The management of metastatic hormone sensitive prostate cancer (mHSPC) has evolved dramatically over the last decade to include the use of androgen receptor pathway inhibitors (ARPI): apalutamide, enzalutamide and darolutamide. However, the uptake of ARPI prescribing has been poor among urologists and remains predominately in the realm of medical oncology. The primary aim of this study is to evaluate prescribing patterns and identify limitations to Australian and New Zealand urologists initiating ARPI for mHSPC.

A cross-sectional survey of Australian consultant urologists was conducted. The survey consisted of questions related to the current volume of ARPI prescribing, in which clinical circumstances they are prescribed, and level of comfort in managing side-effects and interactions of ARPI. Following this, an educational workshop run by a high prescriber urologist familiar with ARPI was conducted for interested urologists. Descriptive analysis formed the basis of assessing the primary aim.

Of the 50 respondents to the survey, 47 (194%) were Australian and 3 (6%) were New Zealand practising urology consultants. Despite 88% of urologists having prostate cancer patients comprise at least 10% of their practice and 74% deeming ARPI prescription by urologists as moderately to very important, only one in three felt comfortable or very comfortable prescribing the medication. Therefore, 2 out of 3 urologists opted to rely on medical or radiation oncology to choose and commence treatment with ARPI for patients with low or high-volume metastatic disease. The most common limitations to urologists initiating ARPI prescription include: limited consulting time to follow-up and manage medication side effects (20%), lack of familiarity regarding procedures to prescribe the medications (20%), limited knowledge about side-effects and drug interactions (19%), ARPI prescription deemed not within the urologist’s scope of practice (18%) and uncertainty about the timing of initiating treatment (13%). The urologists that commenced ARPI treatment most commonly chose darolutamide (34%) over apalutamide (17%) and enzalutamide (7%). When choosing treatment, familiarity with the medication (31%), knowledge of side effects (25%) and drug interactions (17%) were deemed more important than perceived efficacy (15%) and financial costs to patients (13%).

Two-thirds of Australian and New Zealand urologists are not comfortable initiating prescription of ARPI for metastatic prostate cancer despite almost three-quarters claiming that this is an important role for urologists. Addressing and overcoming the barriers that limit urologists writing the first prescription is required to improve the appropriate and timely prescription of ARPI and reduce fragmentation in their patients’ treatment.