Conventional wisdom says chemotherapy leads every treatment plan. That view is outdated. Modern prostate cancer drugs have expanded the toolkit in India with targeted hormone agents, precision radiopharmaceuticals, and selected immunotherapy strategies. I will set out the current options, what the newer agents actually add, who benefits, and how to manage trade-offs. Clear, practical, and usable for treatment discussions.

Current Prostate Cancer Drugs Available in India

1. Androgen Receptor Pathway Inhibitors

Prostate cancer depends on androgen signalling. That is why androgen receptor pathway inhibitors sit at the core of effective care. In India, daily practice now includes several modern agents that complement or follow androgen deprivation therapy. These prostate cancer drugs are used from high-risk non-metastatic disease through metastatic castration-resistant disease, depending on timing and prior exposure.

Agent	Where it typically fits
Enzalutamide	Non-metastatic CRPC and metastatic settings as an oral androgen receptor inhibitor with broad use.
Apalutamide	Non-metastatic CRPC and selected metastatic hormone-sensitive cases with ADT.
Darolutamide	Non-metastatic CRPC and, increasingly, combination in metastatic hormone-sensitive disease.
Abiraterone acetate	Metastatic hormone-sensitive and metastatic castration-resistant disease with corticosteroid co-therapy.

The practical distinctions matter. Enzalutamide, apalutamide, and darolutamide block the receptor directly, while abiraterone acetate suppresses androgen synthesis upstream. Choice depends on clinical stage, comorbidities, prior therapies, and patient goals. In practice, I prioritise schedule simplicity, central nervous system tolerability, and the likely duration of benefit. It is basically matching mechanism to a patient’s day-to-day reality.

• When bone disease dominates, I consider radiopharmaceutical add-ons downstream. See below.

• When rapid control is required, oral AR inhibitors are often faster to start than chemotherapy.

• Where cost sensitivity exists, generics improve access to several prostate cancer drugs.

Evidence from second-generation antiandrogens shows clinically meaningful metastasis-free survival gains when combined with ADT. The direction is consistent across agents, though absolute benefit varies by setting and study design. The takeaway is simple. Potent AR inhibition with continued ADT remains a reliable backbone.

2. Chemotherapy Options

Chemotherapy retains a defined role, particularly for symptomatic, high-volume, or rapidly progressive disease. Two agents dominate in India for advanced settings.

• Docetaxel: Often paired with ADT in metastatic hormone-sensitive disease when disease burden is high. It reduces early progression risk and can debulk symptom load.

• Cabazitaxel: Commonly used post-docetaxel or after AR pathway inhibitors in metastatic castration-resistant disease. It remains effective when cross-resistance is suspected.

I introduce chemotherapy when the disease biology signals urgency or when patients plateau after oral agents. Some will argue for earlier chemotherapy in most cases. The counterpoint is patient preference and tolerability, which frequently favour oral prostate cancer drugs first, then a timed escalation.

3. Immunotherapy Advances

Classical immune checkpoint inhibition benefits a subset of prostate cancers, particularly where mismatch repair deficiency or high microsatellite instability is present. Broader use is evolving through trials. As Mayo Clinic highlights in its treatment overview, combination strategies are under active evaluation to enhance immunotherapy responsiveness.

Emerging approaches include cellular therapies and vaccine concepts. In a number of ongoing studies, researchers are testing CAR-T constructs and DNA vaccine platforms to prime more durable immune responses and, in some protocols, to prevent recurrence after systemic control. The trend is steady. Immunotherapy is moving from a narrow biomarker-defined niche to earlier settings through combination designs.

Results to date show promise when immune agents are integrated with AR pathway inhibitors or targeted therapies. But this is not uniform. Patient selection still drives outcomes, and careful toxicity management is essential.

4. Radiopharmaceutical Therapies

Radiopharmaceuticals matter when disease is bone-dominant or when previous lines of therapy have stalled. These prostate cancer drugs deliver targeted radiation to cancer cells while limiting exposure to surrounding tissue.

• Radium-223: Alpha-emitting agent focused on bone metastases in castration-resistant disease. It offers pain relief and survival benefit in appropriately selected patients. As Theranostics Centre reports, India’s first Radium-223 therapy access marked a practical step-change for bone-predominant cases.

• Lutetium-177 PSMA: A targeted beta emitter linked to PSMA ligands for PSMA-positive disease. It is used after AR inhibitors and taxanes, with growing real-world experience. Cost per cycle in India is typically between $7,000 and $9,000, as Dr. Ankur Bahl notes, which is significantly lower than many Western centres.

Global forecasts suggest radiopharmaceuticals will expand quickly this decade, with prostate-focused agents leading clinical demand. As Express Pharma estimates, revenue could reach $6.3 billion by 2030, reflecting increased adoption of PSMA-directed therapies.

The operational point is practical. If PSMA imaging is positive and prior systemic lines have failed, Lutetium-177 can be decisive. Not a cure-all. But often the right next step.

New Generation Hormone Therapy Options

1. Enzalutamide: Mechanism and Availability

Enzalutamide is a direct androgen receptor inhibitor that blocks receptor signalling and prevents nuclear translocation. The result is reduced transcription of growth-driving genes and, in many cases, durable control. In India, multiple manufacturers supply enzalutamide, and it is widely available through oncology centres and specialist pharmacies.

Where I place it:

• Non-metastatic castration-resistant disease when delaying metastasis is the priority.

• Metastatic settings where an oral, chemotherapy-sparing approach is warranted.

• Patients with prior docetaxel, depending on response duration and comorbidities.

The clinical appeal is straightforward. Enzalutamide harmonises with ADT and suits patients who prefer a home-based regimen. Still, dose holds are sometimes needed for fatigue or hypertension. I discuss seizure risk in advance even when risk is low. Precision helps here. It sets patient expectations early and reduces unnecessary discontinuations linked to manageable enzalutamide side effects.

2. Apalutamide: Treatment Applications

Apalutamide works along the same axis with distinct pharmacologic nuances. It consistently delays radiographic progression in non-metastatic castration-resistant disease, with combination strategies in metastatic hormone-sensitive disease. In India, access is good in tertiary centres, and uptake is steady where doctors prioritise early metastasis control.

• Strengths: clear metastasis delay, predictable adverse event pattern, compatible with ADT.

• Watchpoints: rash, thyroid function changes, falls in older patients.

My selection logic often hinges on comorbidity fit and work-life demands. Some patients accept dermatologic monitoring for the benefit of longer metastasis-free intervals. Others prefer an alternative with fewer cutaneous events. Either path can be defensible.

3. Darolutamide: Latest Approvals and Uses

Darolutamide offers potent receptor inhibition with relatively limited central nervous system penetration in comparative studies. That feature can be useful for patients sensitive to fatigue or cognitive effects. In India, darolutamide is available through larger cancer centres and distributors. Clinically, it is a strong choice in non-metastatic castration-resistant disease and in some metastatic hormone-sensitive regimens with ADT and docetaxel.

Two practical advantages stand out. Fewer drug-drug interactions than some peers, and a tolerability profile that suits patients working full-time. But still, liver function and blood pressure deserve routine monitoring.

4. Abiraterone Acetate: Generic Availability and Cost

Abiraterone acetate inhibits CYP17 to suppress androgen synthesis, and it is co-prescribed with a corticosteroid. Its versatility across metastatic hormone-sensitive and castration-resistant disease makes it foundational in India. Generic abiraterone acetate is widely available locally, with multiple brands offering competitive pricing.

• Advantages: oral dosing, broad indications, strong evidence base with ADT.

• Monitoring: liver function, potassium, blood pressure, fluid balance.

• Access: generics reduce the cost burden in many states and hospital systems.

Where patients ask about affordability, I advise pharmacy comparisons and hospital procurement schemes. Prices can vary by strength and manufacturer, and patient-assistance programmes sometimes narrow the gap further. For value-conscious care, it remains one of the most accessible prostate cancer drugs.

PARP Inhibitors and Targeted Therapies

1. Olaparib: BRCA-Mutation Targeted Treatment

Olaparib targets tumours with homologous recombination repair defects, notably BRCA1 or BRCA2 alterations. The mechanism exploits synthetic lethality by inhibiting PARP and overwhelming DNA repair capacity in susceptible cells. In practice, this matters most for metastatic castration-resistant disease after progression on AR pathway inhibitors.

Two imperatives precede prescribing:

• Confirm a qualifying HRR mutation through germline or tumour testing.

• Integrate cardiovascular and haematologic baselines, since anaemia emerges frequently.

When genomic testing flags a BRCA alteration, olaparib is often the first targeted option I consider beyond hormone therapy for prostate cancer. The clinical signal is stronger in BRCA2 than in non-BRCA HRR genes, though exceptions exist.

2. Rucaparib: Clinical Applications

Rucaparib is also a PARP inhibitor with activity in BRCA-altered disease. Access in India is more variable and may involve named-patient import pathways, depending on institution and up-to-date regulatory status. If both olaparib and rucaparib are options, selection typically hinges on prior lines, tolerability profile, and logistical availability.

There is a nuance worth noting. Cross-toxicity patterns across PARP inhibitors are similar, yet individual patients tolerate one better than another. I keep that flexibility open when planning second choices.

3. Niraparib and Combination Therapies

Niraparib has attracted interest for combination strategies with AR pathway inhibitors or with other targeted agents. Combination approaches seek to widen benefit beyond classic BRCA mutations and extend durability. Results vary by trial and biomarker definition, so a conservative stance is appropriate until stronger consensus emerges.

Where trial access exists, I discuss combinations early, especially after deep but finite responses to AR inhibitors. The aim is to prolong control without immediate chemotherapy, where feasible.

4. Patient Selection Criteria

Selection is the hinge on which targeted therapy outcomes turn. I use a simple framework for prostate cancer drugs in this class:

1. Biomarker fit

   • BRCA1/2 or other HRR gene alteration confirmed by a validated test for PARP therapy.

   • PSMA expression on imaging for Lutetium-177 PSMA therapy.

2. Clinical trajectory

   • Rate of progression and symptom burden to determine urgency.

   • Prior exposure to AR inhibitors and chemotherapy to map resistance patterns.

3. Organ function and interaction profile

   • Haematologic reserve for PARP inhibitors.

   • Hepatic function for abiraterone acetate regimens.

4. Patient preference

   • Oral versus infusion, visit frequency, and monitoring appetite.

This structure avoids misaligned expectations and reduces unforced errors. Right drug, right biomarker, right moment.

Side Effects Management and Treatment Considerations

Hormone Therapy Side Effects

Potent AR pathway blockade is effective, and it carries a consistent side effect set. I prepare patients for the following, and I plan proactive mitigation. It keeps adherence high.

• Fatigue and reduced energy. Encourage structured activity and sleep hygiene; consider brief dose holds if severe.

• Hypertension and fluid changes. Monitor blood pressure regularly, optimise antihypertensives, and check electrolytes.

• Metabolic shifts. Track glucose and lipids, reinforce diet and weight management.

• Falls and fractures. Bone health planning with vitamin D, calcium, and DEXA where indicated.

• Hot flushes and mood changes. Non-hormonal agents or targeted counselling can help.

Specific enzalutamide side effects often include fatigue, hypertension, and rare seizure risk. For apalutamide, rash is more prominent. For darolutamide, central nervous system effects appear lower in comparative experience. These differences guide my first-line choice when efficacy is broadly similar.

Managing PARP Inhibitor Toxicities

PARP inhibitors share several class effects. The key is early lab surveillance and patient education. Small habits prevent big problems.

• Anaemia and thrombocytopenia: Full blood counts every 2 to 4 weeks early on, then space out once stable. Use dose modifications promptly.

• Gastrointestinal symptoms: Nausea, decreased appetite, constipation. Simple antiemetics and hydration usually suffice.

• Fatigue: Multi-factorial; address sleep, anaemia, mood, and activity levels.

• Hypertension: Particularly with certain combinations. Standard antihypertensive optimisation applies.

Before starting, I confirm renal and hepatic baselines and review concurrent medications. It is basic, and it prevents avoidable interruptions.

Drug Interactions and Contraindications

Drug interactions can blunt efficacy or raise toxicity. I keep a short checklist for prostate cancer drugs when reconciling medicines.

• Enzalutamide: Induces hepatic enzymes and can reduce exposure to several concomitant drugs. Review anticoagulants, antiepileptics, and cardiovascular agents.

• Apalutamide: Similar interaction profile; pay attention to thyroid function and falls risk in the elderly.

• Darolutamide: Fewer interactions reported, yet I still screen for P-gp and moderate CYP effects.

• Abiraterone acetate: Requires corticosteroid co-therapy; monitor for hypokalaemia, hypertension, and fluid retention. Use caution in significant hepatic impairment.

• PARP inhibitors: Additive myelosuppression when combined with other marrow-suppressive agents. Plan haematology monitoring.

• Radiopharmaceuticals: Coordinate timing with marrow-impacting treatments to preserve counts.

One insider term worth recalling is DDI, or drug-drug interaction. It sounds dry. It decides whether a regimen is smooth or chaotic.

Future of Prostate Cancer Treatment in India

The trajectory is clear. More precision, more combination therapy, and better sequencing. Genomic profiling and PSMA imaging are becoming routine in major centres, with trickle-down adoption to regional hospitals. Generics and local manufacturing continue to expand access to core prostate cancer drugs, while hospital-based financing and government schemes, to an extent, soften cost barriers.

Two developments deserve particular attention:

1. Earlier use of targeted agents: Moving PARP and PSMA-directed therapies closer to the front for biomarker-selected patients.

2. Data-driven sequencing: Real-world datasets that clarify the order of AR inhibitors, chemotherapy, PARP inhibitors, and radiopharmaceuticals.

And yet, gaps remain. Diagnostics unevenly distributed, financial toxicity for some families, and variable awareness of clinical trials. The work now is about scale and consistency as much as innovation. Maybe that is the point. Innovation matters only if access follows.

Frequently Asked Questions

What is the cost of generic abiraterone acetate in India?

Prices vary by manufacturer, strength, and region. Generic abiraterone acetate is typically substantially lower than imported brands, and hospital procurement or patient-assistance schemes can reduce costs further. The most reliable method is to request written quotes from two to three oncology pharmacies and compare monthly totals, including the required corticosteroid.

Which PARP inhibitors are currently available for prostate cancer patients in India?

Olaparib has the broadest availability for BRCA or other homologous recombination repair alterations. Rucaparib access is more variable and can involve named-patient or import pathways, depending on the treating centre. Availability evolves, so I advise confirmation with the hospital pharmacy and the treating oncologist at the time of decision.

How effective is Lutetium-177 PSMA therapy compared to traditional treatments?

For PSMA-positive metastatic castration-resistant disease after AR inhibitors and taxanes, Lutetium-177 PSMA often achieves meaningful responses and symptom relief. It is not a replacement for hormone therapy or chemotherapy in earlier lines, but rather a targeted option when those have plateaued. Effectiveness depends on PSMA expression, disease distribution, prior treatments, and bone marrow reserve.

What are the major side effects of enzalutamide treatment?

Commonly reported enzalutamide side effects include fatigue, hypertension, falls, and, rarely, seizures. Some patients also experience hot flushes and mild cognitive effects. Most issues are manageable with monitoring, dose adjustments, and supportive care. Pre-emptive counselling reduces anxiety and improves adherence.

Can hormone therapy and PARP inhibitors be used together?

Yes, they can, in selected settings. Combined approaches are used when patients have qualifying HRR mutations and remain candidates for continued androgen pathway suppression. The decision hinges on biomarkers, prior exposure to AR inhibitors, and the patient’s haematologic profile. Shared planning between medical oncology, cardiology, and supportive care improves outcomes and safety.