Chemotherapy, not androgen receptor-targeted therapy should be used upfront for metastatic hormone-sensitive prostate cancer. PRO: docetaxel chemotherapy should be the default consideration in metastatic hormone-sensitive prostate cancer.

In the past five years, multiple studies have established docetaxel chemotherapy and androgen receptor-targeted therapies as alternate standardof-care treatments for patients commencing continuous androgen deprivation therapy (ADT) for metastatic hormone-sensitive prostate cancer (mHSPC), demonstrating profound improvements in overall survival whilst delaying both disease related complications and the development of metastatic castration-resistant prostate cancer (mCRPC). Despite this, no prospective trials currently exist comparing chemotherapy to androgen receptor-targeted therapy, leaving clinicians with the dilemma of selecting between two distinct management pathways. Although administration of highly efficacious and well-tolerated androgen receptor pathway inhibitors represents an attractive option, we will argue that failure to administer upfront chemotherapy in select patients may represent a lost opportunity to capitalize on the patient and cost benefits of docetaxel for mHSPC.