Sequencing systemic therapies in advanced prostate cancer: spoiled for choice but not for evidence.

Since 2004, six new life-prolonging systemic therapies have been introduced into clinical practice for patients with metastatic castration-resistant prostate cancer (mCRPC) (Table 1). Five of these have been introduced since 2010 and were developed almost simultaneously and largely in isolation. Thus we have no formal and only limited informal evidence to support the use of these new therapies in sequence with one another, so doctors and their patients must make decisions about treatment sequencing in the absence of significant evidence. In this month’s issue of European Urology, Pezaro et al. present important data from a retrospective analysis of patients who had received cabazitaxel as second-line chemotherapy having previously failed new-generation hormone therapy [1]. These data are important because they justify the use of this potentially toxic agent in a therapeutic era that has changed dramatically since the pivotal TROPIC trial was conducted and support a sequence of therapy commonly used in modern oncology practice.