Conclusion

In patients with PDA, the longer duration of ADT monotherapy compared with ARPI or chemotherapy likely reflects the disease state (HSPC) at the time of therapy initiation rather than inherent treatment superiority. The shorter durations associated with ARPI/chemotherapy may reflect the shift to CRPC, more aggressive tumor biology, and prior selection of high-risk patients. The distinct biology of PDA therefore justifies future prospective studies incorporating early systemic treatment intensification and molecular characterization to better refine therapeutic sequencing and improve patient outcomes. However, given the rarity of PDA, randomized controlled trials are unlikely to be feasible. As a pragmatic alternative, large multicenter retrospective cohort studies with standardized data collection and advanced statistical methodologies, such as propensity score matching across extended (ideally international) datasets, may represent a realistic next step toward generating higher-level evidence for optimal treatment strategies in this patient population.

Given the limited cohort size and follow-up duration, survival and regression analyses should be interpreted as exploratory and hypothesis-generating rather than providing definitive prognostic or clinically actionable conclusions.