Treatment Sequencing in Metastatic Castration-Resistant Prostate Cancer

Dr. Johann De Bono and Dr. Pedro Barata discuss the evolving role of treatment sequencing and patient selection for radiopharmaceuticals in metastatic castration-resistant prostate cancer (mCRPC). Dr. Barata highlights the growing complexity of integrating radiopharmaceuticals alongside chemotherapy, androgen receptor pathway inhibitors, and PSMA-targeted therapies as new clinical data emerge. The faculty review studies comparing lutetium-based PSMA therapies with taxane chemotherapy and discuss how differences in imaging requirements, tumor burden, PSMA expression, and disease heterogeneity may influence treatment selection in both clinical trials and real-world practice. Dr. Barata also explores how factors such as visceral disease, genomic alterations, and aggressive tumor biology may impact the likelihood of response to PSMA-targeted therapies and guide clinicians toward alternative approaches such as chemotherapy. In addition, the conversation addresses sequencing considerations between radium Ra 223 dichloride and PSMA-targeted therapies, including emerging real-world evidence supporting the feasibility of sequential radiopharmaceutical treatment strategies in mCRPC.