Conclusion future directions

It is clear from the foregoing discussion that increased biological knowledge and drug development technologies has resulted in a vast number of agents for clinical trial testing. However, it is paramount that judicious trial designs are employed and match the drug to the tumor by ensuring that the target is present. It is also quite certain that no single drug will work given the inherent multiple redundant survival pathways. This is probably more apparent for castration resistant disease. Therefore, one can argue that waiting for metastatic disease or castrate resistant disease to assess a new drug is a defeatist approach, and that an assessment earlier in the disease spectrum to prevent the emergence of resistance is a more proactive and promising approach to improve outcomes in prostate cancer. The conduct of a study in patients with a biochemical relapse after definitive localized therapy provides a major opportunity for drug development. This approach allows the analysis of a drug in isolation and as well as an assessment and effective triage of the numerous new agents that are now available for testing. Also the primary pathology can be interrogated to look for activation of the pathway and provides an opportunity to biologically direct the evaluation of drugs relevant to a given a pathway in an individual's cancer. Ultimately, key combinations simultaneously targeting the essential and multiply redundant pathways driving cancer survival and resistance mechanisms can be developed. This has been a successful strategy for treatment of HIV and AIDS where the early use of Highly Active Anti-retroviral Therapy (HAART) has made major advances. With time and judicious clinical development, it is possible to develop a similar strategy such as Highly Effective Early Prostate Cancer Therapy (HEEPT) for patients with rapidly progressive PSA rises after definitive local therapy and have a long life expectancy. Early use of a highly effective combination therapy will hopefully eradicate the disease and prevent patients from dying from recurrent disease that may otherwise have been lethal and more difficult to treat if waited until later in the disease

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