The Evolving Landscape of Prostate Cancer: Risk, Treatment, and the Role of the Care Team

Prostate cancer is the most common cancer in American men, with an estimated 333,000 cases and 400,000 deaths in 2026 alone.¹ It represents a significant burden for patients, particularly those with metastatic and advanced disease. Proper diagnosis and screening are growing ever more crucial to identify prostate cancer in earlier stages when prognoses are favorable with better responses to therapy.

At the 2026 Community Oncology Alliance (COA) Annual Meeting, pharmacists discussed the current prostate cancer landscape with an emphasis on the importance of structured communication between neurologists and oncologists to ensure coordinated care.

The Prostate Cancer Landscape

Most men with prostate cancer are diagnosed with localized or regional disease, which is generally highly curable with survival rates exceeding 99%. However, patients with metastatic disease have significantly lower 5-year survival outcomes. Improvements have been made over time with the advent of novel therapeutic approaches from about 55% in the mid-2000s to approximately 66% by 2020.²

Risk factors for prostate cancer are comprised of modifiable and non-modifiable risk factors. Patients can reduce their risk and prevent disease through smoking cessation and following healthy lifestyle choices such as implementing a nutritional diet and engaging in physical activity.²

Regarding nonmodifiable risk factors, risk significantly increases with age, particularly for Black men who have the highest incidence and mortality compared with other racial groups. Family history also has a role to play in the development of prostate cancer. First‑degree relatives such as fathers, brothers, and sons have an increased risk, which is raised further when multiple family members are affected. Interestingly, family history of breast cancer may also relevant—potentially due to BRCA1/BRCA2 alterations which are present in both prostate and breast cancers.²

Screening and Diagnosis

Across disease states, screening is critical to diagnose patients in early disease stages when treatment success is more likely. All major organizations agree that screening should be a joint decision between provider and patient. Discussion should cover the potential benefits of early detection for preventing metastatic disease.²

For men at average risk, screening typically begins somewhere between the ages of 45 and 55 years, with the exact timing individualized based on a man's overall health and personal preferences. Men at higher risk, however, may benefit from earlier and more frequent screening, often starting around 40 to 45 years of age. High-risk groups include Black and African American men, those with a first-degree relative who has had prostate cancer or multiple affected family members, and men with known germline mutations.²

The primary screening tool is the PSA (prostate-specific antigen) blood test, though a digital rectal exam may also be used as a complementary measure. How often a man is screened depends on his individual risk and initial PSA results—some guidelines recommend annual testing, while others suggest screening every 2 to 4 years. Screening is generally discontinued around 70 to 75 years of age, or earlier if a man's life expectancy is less than 10 years.²

Treating Prostate Cancer Across the Spectrum

Treatment of prostate cancer depends on stage, risk category, and patient life expectancy/performance status. Androgen deprivation therapy (ADT) is the cornerstone of treatment for patients as prostate cancer is an androgen-driven disease. These agents aim to lower or block testosterone and related androgens to slow or stop cancer growth, typically reducing testosterone levels to less than 50 ng/dL.²

Beyond ADT, androgen receptor pathway inhibitors (ARPIs)—including enzalutamide (Xtandi; Astellas Pharma US, Inc), apalutamide (Erleada; Janssen Products, LP), darolutamide (Nubeqa, Bayer Healthcare Pharmaceuticals Inc), and abiraterone (Zytiga; Centocor Ortho Biotech Inc)—have entered the prostate cancer treatment landscape.²

Localized Disease

Localized prostate cancer is grouped into risk categories based on the likelihood of recurrence, and these categories directly guide treatment decisions. The factors used to determine risk include T stage, PSA level, Gleason score or grade group, and the percentage of positive biopsy cores. Together, these factors place a patient into one of several categories: low risk, favorable intermediate risk, unfavorable intermediate risk, or high/very high risk. These risk groups, combined with a patient's life expectancy—whether greater than 10 years, 5 to 10 years, or less than 5 years—form the foundation of recommended management.

Metastatic Disease

Metastatic prostate cancer is broadly divided into two phases based on how the disease responds to testosterone suppression. In metastatic castration-sensitive prostate cancer, the cancer has spread beyond the prostate but remains responsive to lowering testosterone. Once the disease progresses despite castrate levels of testosterone—meaning ADT is already in place and testosterone is very low—it is classified as metastatic castration-resistant prostate cancer. Across both phases, ADT remains the backbone of treatment, with additional agents layered on top.

Disease volume also plays an important role in guiding treatment intensity. High-volume disease is commonly defined as four or more bone metastases with at least one outside the spine or pelvis, and/or the presence of visceral metastases such as liver or lung involvement. Low-volume disease involves fewer metastases and no visceral involvement. Volume, alongside performance status and comorbidities, helps determine how aggressively to treat.

Supportive Care and Adverse Event Management

Although ADT forms the backbone of treatment across many stages, it carries wide-ranging systemic effects. As one way to frame it: ADT doesn't deliver something to the body, it takes something away, and that loss manifests in several important ways.

On the musculoskeletal side, ADT increases the risk of osteopenia and osteoporosis, raises fracture risk, and leads to loss of muscle mass alongside an increase in fat mass. Metabolically, it can alter body composition, affect lipids and glucose regulation, and contribute meaningfully to cardiometabolic risk. Men on ADT also commonly experience fatigue, depression or mood changes, sleep disturbances, and hot flashes and other vasomotor symptoms.

Bone health deserves particular attention in this patient population. ADT itself increases the risk of osteoporosis and fractures, and in advanced disease, bone metastases add further skeletal risk on top of that. For all men on ADT, calcium and vitamin D supplementation is recommended, along with encouragement of weight-bearing exercise, healthy diet, smoking cessation, and alcohol moderation. Bone density assessment is appropriate where indicated. In the setting of metastatic castration-resistant disease or established osteoporosis, bone-modifying agents such as denosumab or zoledronic acid should be used more routinely as bone supportive therapies.

ARPIs can add fatigue, hypertension, and cardiovascular risks, with abiraterone in particular carrying notable cardiac considerations. Drug-drug interactions are also an important concern with this class. Chemotherapy agents such as docetaxel and cabazitaxel bring their own toxicity profile, including myelosuppression (neutropenia and anemia), peripheral neuropathy, hair loss, and fatigue.

Fatigue is best addressed through lifestyle interventions, particularly physical activity and exercise, while also evaluating for contributing causes such as anemia, depression, or sleep disorders. Mood changes and depression should be actively screened for, with mental health support provided when needed. Sleep disturbances benefit from sleep hygiene education and attention to contributing factors like nocturia.

Body composition changes—such as muscle loss and weight gain—are best countered through a combination of resistance and aerobic exercise and healthy nutrition, with ongoing monitoring of weight and metabolic markers. For hot flashes and vasomotor symptoms, nonhormonal approaches and selected pharmacologic options such as certain antidepressants or gabapentin may be considered, carefully weighing their own adverse event (AE) profiles.

Coordinating Care for Patients With Prostate Cancer

Treatment guidelines for prostate cancer are constantly evolving, with new therapies and sequencing strategies emerging. Pharmacists play a pivotal role in care coordination with urologists and oncologists to ensure patients receive the best possible care. On the education side, pharmacists can explain the expected AEs of ADT, ARPIs, chemotherapy, and radiopharmaceuticals, and provide patients and caregivers with written documentation outlining what to expect and who to contact with concerns.

“Structured communication is really essential to ensure that we are providing guideline‑driven care and commonly delivered care to these patients,” Sherry Vogt, PharmD, BCOP, system clinical pharmacy manager at Hollings Cancer Center at the Medical University of South Carolina in Charleston, said during the COA presentation.

In terms of care coordination, pharmacists with access to the same electronic health record as the broader care team can review provider notes, track upcoming appointments, monitor adherence, and use internal alerts to flag patients.

As the prostate cancer treatment landscape continues to evolve, staying current with rapidly shifting guidelines and an expanding therapeutic arsenal has never been more important. From early detection and risk stratification to the nuanced sequencing of ADT, ARPIs, chemotherapy, PARP inhibitors, and radioligand therapies, pharmacists today are navigating a level of complexity that demands both specialized knowledge and coordinated team-based care.

REFERENCES

1. Key Statistics for Prostate Cancer. American Cancer Society. Accessed April 29, 2026. January 13, 2026. https://www.cancer.org/cancer/types/prostate-cancer/about/key-statistics.html

2. Vogt S, Ewing J. Communication in action: Empowering community oncology pharmacists to optimize prostate cancer care across urology & oncology. Presented at: 2026 COA Annual Meeting. April 28-29, 2026. Orlando, FL.