In this study, Taich and colleagues describe the most common patterns of radium-223 administration in a diverse cohort of male veterans with metastatic bone-predominant hormone-resistant prostate cancer. There are several important findings in this study that should be highlighted. First, the sequence and pattern of treatments may alter tumor biology and correlate with disease aggressiveness.1,2 The authors found that novel androgen-targeted therapies followed by docetaxel prior to radium-223 were associated with worse survival (HR 2.02, 95 C11.34, 3.04) when compared the other treatment combinations. Tissue biopsies and molecular analysis of tumors from men with varying patterns of care will help us understand how therapies affect the biological evolution of a tumor and provide us with insight as to which therapies may be more effective as a next line of treatment. Secondly, this study highlights the need to understand how new therapies may impact the utilization and efficacy of current therapies. In this analysis, the introduction of a novel androgen blockade in 2015 led to a decrease of radium-223 utilization from 52 in 2015 to 2 in 2017. With such a
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