Chemotherapy for prostate cancer: when should a urologist refer a patient to a medical oncologist?

The last few years have seen considerable evolution in treatment options and therapeutic strategies for patients with castrate-resistant prostate cancer (CRPC). One major change was the expansion of chemotherapeutic options with the approval of cabazitaxel, representing the first chemotherapeutic therapy after docetaxel to demonstrate improved survival in patients with CRPC. A number of other noncytotoxic therapies have either recently been approved or are in advanced development for treating this patient population. Offering novel mechanisms of action, these new agents make considerably more expansive and complex the decisions regarding when to treat, which agents to use, and the order in which they are administered. A pivotal decision point for urologists who treat patients with advanced prostate cancer has been timing the patient's referral to an oncologist for chemotherapy. Although clinical guidelines regard chemotherapy as only appropriate for prostate cancer patients with symptomatic metastatic disease, increasing evidence points to the possibility that a subgroup of patients may benefit from an earlier introduction of chemotherapy. At the same time, additional treatment options that may either precede chemotherapy or follow initial chemotherapeutic failure mean that urologists must closely monitor their patients' health status to match specific clinical profiles with specific treatment options. With the increase in number and variety of therapeutic approaches, the role of the urologist has been expanded, in part, owing to the opportunity for urologists to administer treatments previously unavailable, and also owing to the growing importance of working cooperatively with oncologists and as a member of a multidisciplinary team.