I have been struck in the past few weeks by the number of patients in my practice who have advanced metastatic CRPC who were diagnosed more than 15 years ago and had, on their original biopsy specimen, ONLY a Gleason 6 pattern prostate carcinoma.
Welcome to my blog on UroToday!  I am a genitourinary medical oncologist at the University of California – San Francisco and specialize in the management of advanced prostate cancer. I maintain a specific focus on androgen and androgen receptor (AR) interactions in the tumor as well as in the patient. The science of testosterone and prostate cancer have both exploded in the last decade, and one of my goals is to help navigate these findings through both a scientific and a patient oriented perspective. 
I have spent the better part of the last 20 years thinking about testosterone and the androgen receptor (AR) and its effect on prostate cancer. I started by applying synthetic testosterone to cancer cells in the laboratory at the University of Wisconsin, progressed to studying the effect of retained androgen receptor signaling in human prostate tumors at Memorial Sloan Kettering and finally studied the clinical effects of abiraterone, apalutamide, ketoconazole and other drugs as therapies for prostate cancer here at UCSF. One of the best pieces of career advice that I ever got was a very simple: Follow the AR.
In the last two weeks I’ve had one patient refuse ADT because of his history of depression, another who has been on ADT for 10 months asked me to refer him to a psychiatrist, and another, with CRPC who has been on ADT for 4 years, told me his depression is finally under control. This leaves a lot of issues to confront.