When to start: receptor-positive disease with clinical indication (adjuvant, biochemical recurrence, metastatic control) and a plan for duration.
When to stop: radiologic/biochemical progression despite adequate suppression; or severe irreversible toxicity.

Severe irreversible toxicity (CTCAE v5.0 anchors):

  • Grade 3–4 hepatotoxicity (AST/ALT > 5× ULN) unresponsive to dose changes/support.

  • Thromboembolism requiring long-term anticoagulation (e.g., tamoxifen).

  • Fragility fracture on therapy-related bone loss.

  • Persistent severe mood/cognitive impairment impacting daily function.

Bone health (pair with strong anti-estrogen/ADT):

  • Indications for prophylaxis: DEXA T-score ≤ −2.0, or ≥5% annual BMD loss, or FRAX 10-yr risk >20% (major) or >3% (hip).

  • Zoledronic acid: 4 mg IV every 6–12 months (renal-adjust).

  • Denosumab: 60 mg SC every 6 months (no renal adjustment).

  • Supplements: Calcium ~1200 mg/day + Vitamin D 800–1000 IU/day; DEXA every 2 years.

  • Dental precautions (ONJ risk): dental check before first antiresorptive dose; avoid dental implants/extractions during therapy. If unavoidable, consider temporary hold and resume after mucosal healing.

Metabolic & cardiovigilance (especially with ADT/AIs):
Check BP, lipids, fasting glucose periodically; manage lifestyle, statins/metformin as indicated.

Reproductive medicine & contraception:

  • Before therapy: offer fertility preservation (sperm cryopreservation; oocyte/embryo cryopreservation; in some chemo settings, ovarian suppression).

  • Contraception: endocrine agents are teratogenic—use non-hormonal methods, preferably Copper Intrauterine Device (IUD) or barrier methods.

  • Supplements to avoid: DiHydroEpiAndrosterone (DHEA), “testosterone boosters,” phytoestrogens.

  • Tamoxifen washout: stop 2–3 months before attempting conception.

Quality of Life (QoL) tools you can actually use:

  • EORTC QLQ-C30 (oncology general).

  • SF-36 (global health).

  • FACT-P (prostate-specific).

  • International Prostate Symptom Score (IPSS): 0–7 mild, 8–19 moderate, 20–35 severe (track urinary impact during pelvic RT/ADT).

Supportive “crosswalk” (match risk → prevention):

  • Aromatase inhibitors / long-term ADT → osteoporosis → bisphosphonate/denosumab + exercise.

  • Abiraterone → hypertension, hypokalemia, LFT ↑ → prednisone, monitor BP/K+/LFTs.

  • Tamoxifen → thrombosis/endometrial ca → assess VTE risk; evaluate abnormal bleeding.

  • Fulvestrant → injection pain → rotate sites, local measures.

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