(UroToday.com) The 2026 ASCO GU Annual Symposium was host to a prostate cancer poster session. Dr. Rana McKay presented the results of an international, real-world study evaluating the sequencing of therapeutic agents before and after the diagnosis of metastatic castration-resistant prostate cancer (mCRPC).
Over the last decade, the management of mCRPC has evolved substantially with the introduction of multiple life-prolonging systemic therapies. However, real-world data describing how these agents are sequenced before and after mCRPC diagnosis across international practice settings remain limited. In this real-world evidence study, investigators utilized the international IRONMAN advanced prostate cancer registry to provide an overview of treatment use and sequencing patterns surrounding the transition to mCRPC.
Using the international IRONMAN registry (NCT03151629), which includes patients from 15 countries, investigators analyzed data from men newly diagnosed with mCRPC between January 2018 and December 2021 with follow-up through July 2022. Patients may have had prior metastatic hormone-sensitive prostate cancer (mHSPC) or non-metastatic CRPC before progression to mCRPC. Demographic and clinical characteristics were recorded along with treatments administered before mCRPC diagnosis, therapies initiated after progression to mCRPC, and treatment sequencing between the last pre-mCRPC therapy and first-line mCRPC treatment. Androgen deprivation therapy (ADT) was considered backbone therapy in this analysis, with ADT monotherapy specifically distinguished when given alone.
A total of 520 men were identified, primarily from the United States (24%), Spain (20%), Canada (19%), and the United Kingdom (12%). At mCRPC diagnosis, median age was 72 years (IQR 67–78), 73% of participants were White, and median PSA was 9.15 ng/mL (IQR 2.57–41.49).
Before development of mCRPC, ADT monotherapy was the most common treatment approach (57%), followed by ADT combined with chemotherapy (23%) or androgen receptor pathway inhibitors (ARPIs) (11%). Among patients receiving ARPIs prior to mCRPC (n=59), abiraterone (51%) and enzalutamide (47%) were most frequently used.
Following progression to mCRPC, ARPIs were the most commonly prescribed therapy (79%), followed by chemotherapy (34%). Among patients treated with ARPIs after mCRPC diagnosis (n=413), abiraterone (51%) and enzalutamide (55%) remained the predominant agents, noting that some patients received more than one ARPI.
The most common treatment sequence from pre-mCRPC to first-line mCRPC therapy was ADT monotherapy followed by an ARPI (37%), followed by chemotherapy transitioning to an ARPI (15%).
Among 190 patients who transitioned from ADT monotherapy to ARPI therapy, most were ≥75 years (54%), had non-metastatic disease at initial diagnosis (83%), and were commonly from Canada (29%), Spain (23%), or the United States (21%). Among 78 patients receiving chemotherapy followed by ARPI therapy, many were aged 65–74 years (44%), frequently presented with de novo metastatic disease (54%), and were often from the United Kingdom (38%).
During the study period, ADT monotherapy remained the most frequently prescribed treatment prior to mCRPC diagnosis, with relatively limited early ARPI use. After the development of mCRPC, ARPIs became the dominant treatment approach. Treatment patterns varied by geographic region, highlighting international differences in therapy sequencing. Overall, the findings suggest an ongoing unmet need for earlier optimization of life-prolonging therapy use in advanced prostate cancer.
Presented by: Rana R. McKay, MD, Associate Professor of Medicine, Department of Medicine, University of California San Diego Moores Cancer Center, La Jolla, CA, USA
Written by: Rashid K. Sayyid, MD, MSc, Assistant Professor, Urologic Oncologist, Department of Urology at The University of Arizona and Banner University Medical Center, Tucson, AZ – @rksayyid on X during the 2026 Genitourinary (GU) American Society of Clinical Oncology (ASCO) Annual Meeting, San Francisco, CA, Thurs, Feb 26 – Sat, Feb 28, 2026.