The management of metastatic hormone sensitive prostate cancer (mHSPC) has evolved dramatically over the last decade. There has been a shift in the treatment paradigm towards earlier treatment intensification including the androgen receptor pathway inhibitors (ARPIs): apalutamide, enzalutamide and darolutamide with standard of care androgen deprivation therapy (ADT). However, the uptake of ARPI has been poor among urologists, and remains predominately in the realm of medical oncology. This narrative review aims to summarise the real-world utilisation and limitations to the prescription of ARPI among urologists and highlight the importance of overcoming this.

A systematic search was conducted through Embase, Medline and Pubmed by two independent reviewers, with a third to resolve any conflicts. Only original articles pertaining to the real-world utilisation of ARPI among urologists and the major limitations preventing their uptake were considered, resulting in a review of 35 articles.

In the United States, data from Swami et al. (2022) and Heath et al. (2021) highlight that while ARPIs are increasingly used by oncologists for mHSPC, urologists’ patients are frequently not receiving the new standard of care treatment. This is despite 85% of the panel at the Advanced Prostate Cancer Consensus Conference 2019 agreeing that treatment intensification including ARPIs is warranted regardless of disease volume. Promisingly, Barata et al. (2023) analysed the treatment intensification trends for mHSPC across five European countries (United Kingdon, France, Germany, Spain and Italy) and the United States between the periods of 2016-2018 and 2019-2020. They found an overall trend towards initial management including ARPI and decreased time to treatment intensification between these times periods in Europe and the US. Barriers to ARPI uptake by urologists include prescriber confidence, concerns about drug tolerability, questions about treatment intensification timing, lack of clinical evidence impacting overall survival and patient’s financial constraints. Medlinskiene et al. (2021) outline that barriers to uptake of new therapeutics can be overcome by continuing medical education and influence by opinion leaders.

Lagging uptake of ARPIs for mHSPC has been observed internationally, particularly among urologists. This is due to a complex interplay of local, physician, patient and disease factors affecting ARPI adoption. Research and education are required to address the barriers that urologists face in initiating ARPI for mHSPC.