NCCN Guidelines® Insights: Prostate Cancer, Version 3.2024

Computational pathology for breast cancer: Where do we stand for prognostic applications?

The very early days of artificial intelligence (AI) in healthcare are behind us. AI is now spreading in the healthcare sector and is gradually being implemented in routine clinical practice. Driven by the increasing digitization of microscope slides, computational pathology (CPath) is further strengthening the role of AI in the field of oncology. CPath is transforming fundamental research as well as routine clinical practice, both for diagnostic and prognostic applications. In breast cancer, CPath holds the potential to address several unmet clinical needs, particularly in the areas of biomarkers and prognostic tools. Indeed, multiple applications are on their way, ranging from predicting clinically meaningful endpoints to offering alternatives to gene-expression testing and detecting molecular alterations directly from digitized whole slide images. However, to fully harness the potential of CPath, several challenges must be overcome. These include improving the availability of multimodal patient data, advancing the digitalization of pathology laboratories, increasing adoption within the medical community, and navigating regulatory hurdles. This review offers an overview of the current landscape of CPath in breast cancer, highlighting the progress made and the hurdles that remain for its widespread clinical adoption in prognostic applications.

Magnetic Resonance Imaging Versus Computed Tomography Guidance for Stereotactic Body Radiotherapy in Prostate Cancer: 2-year Outcomes from the MIRAGE Randomized Clinical Trial

It has been shown that magnetic resonance imaging (MRI) guidance versus computed tomography (CT) guidance for aggressive margin-reduction (AMR) for stereotactic body radiotherapy (SBRT) in prostate cancer reduces acute toxicity, but the longer-term benefits are unknown. We performed a secondary analysis of MIRAGE, a phase 3 randomized clinical trial of MRI-guided SBRT for prostate cancer, to determine whether AMR with MRI guidance significantly reduced 2-yr physician-scored or patient-reported toxic effects in comparison to CT guidance. The cumulative incidence of 2-yr physician-scored toxicity, defined as grade ≥2 genitourinary (GU) and gastrointestinal (GI) toxic effects according to Common Terminology Criteria for Adverse Events v4.03, were lower with MRI guidance. Cumulative incidence rates of late grade ≥2 toxicity at 2 yr with MRI-guided versus CT-guided SBRT were 27% (95% confidence interval [CI] 19-39%)] versus 51% (95% CI 41-63%) for GU toxicity (p = 0.004), and 1.4% (95% CI 0.2-9.6) versus 9.5% (95% CI 4.6-19) for GI toxicity (p = 0.025). Cumulative logistic regression revealed that MRI-guided SBRT was associated with significantly lower odds of a clinically relevant deterioration in bowel function according to the Expanded Prostate Cancer Index Composite-26 score (odds ratio 0.444, 95% CI 0.209-0.942; p = 0.035) and in the Sexual Health Inventory in Men score (odds ratio 0.366, 95% CI 0.148-0.906; p = 0.03). There were no significant differences in the odds of a deterioration for other quality-of-life metrics. These findings support the hypothesis that aggressive planning for margin reduction for prostate SBRT using MRI leads to continued reductions in toxic effects over 2-yr follow-up. This trial is registered on ClinicalTrials.gov Identifier as NCT04384770.

State of the Art: Personalizing Treatment for Patients With Metastatic Castration-Resistant Prostate Cancer

Until recently, the treatment of metastatic castration-resistant prostate cancer (mCRPC) relied exclusively on hormonal therapies and taxane chemotherapy. The advent of modern molecular profiling methods applied in the clinic, namely, next-generation sequencing and advanced positron emission tomography (PET) imaging, has allowed for the development of biomarker-driven therapeutics including anti-PD-L1 therapy for microsatellite instability-high or tumor mutation burden-high disease, poly(ADP-ribose) polymerase (PARP) inhibitors for patients with DNA damage repair mutations, and lutetium 177 vipivotide tetraxetan (177Lu-PSMA-617) for patients with prostate-specific membrane antigen (PSMA) PET-avid disease. While these targeted therapies have improved outcomes, there is an opportunity to refine biomarkers to optimize patient selection, understand resistance, and develop novel combination strategies. In addition, studies in the laboratory and in patient-derived samples have shown that a subset of mCRPC tumors lose expression of common prostate cancer markers such as prostate-specific antigen and PSMA because of lineage plasticity and the development of non-androgen receptor (AR)-driven disease. Non-AR-driven prostate cancer has been associated with aggressive behavior and poor prognosis, including in some cases histologic transformation to a poorly differentiated neuroendocrine prostate cancer (NEPC). The clinical management of NEPC typically follows the treatment paradigm for small cell lung cancer and increasingly relies on genomic and phenotypic characterization of disease, including loss of tumor suppressors and expression of cell surface markers such as DLL3. Therefore, both genomic subtyping and phenotypic subtyping are important to consider and can guide the clinical management of patients with advanced prostate cancer.

Outcome of Subsequent Therapies After 177Lu-Vipivotide Tetraxetan for Metastatic Castrate-Resistant Prostate Cancer: A Tertiary Cancer Center Experience

BACKGROUND

177Lu-vipivotide tetraxetan (177Lu-PSMA-617, LuPSMA) improves overall survival in patients with metastatic castration-resistant prostate cancer (mCRPC) after at least one taxane chemotherapy and androgen receptor pathway inhibitor. There are limited data on the clinical course and outcomes of patients with mCRPC after receipt of LuPSMA.

METHODS

We queried an IRB-approved prospectively maintained registry of all patients with mCRPC who received standard-of-care LuPSMA at our institution between June 2022 and January 2024. Clinical data about LuPSMA and subsequent therapies were extracted from the electronic medical record, including the type and number of subsequent systemic therapies, reason for treatment cessation, hematologic toxicity and supportive treatment, and PSA50 response to subsequent therapy (defined as a ≥ 50% decrease in PSA).

RESULTS

A total of 146 patients were evaluated; mean age 72 (range 52-87), observed median follow-up 5.9 months (range 0.51-18.7). Forty-four received systemic treatment after LuPSMA. The most common subsequent treatment after LuPSMA was chemotherapy (n = 27), primarily cabazitaxel ± carboplatin/cisplatin (n = 23), and the median number of cycles received was 4 (range 1-7). In 35/44 men with available hematologic toxicity data, 13 developed grade ≥ 3 anemia, 7 had ≥ grade 3 thrombocytopenia, and 16 received hematologic support. PSA50 to post-LuPSMA treatment occurred in 10/36 (28%) evaluable patients. Median overall survival from subsequent systemic therapy was 7.6 months (95% CI 5.81-NR).

CONCLUSIONS

30% of patients receiving standard-of-care LuPSMA received subsequent therapy, mostly cabazitaxel-containing regimens. Post-LuPSMA treatment appeared tolerable and was associated with a PSA50 response rate of 28%. These outcomes may be biased by limited standard-of-care life-prolonging treatment options at the time of LuPSMA FDA approval, but it also highlights the continued need to develop novel therapeutic strategies for mCRPC post-LuPSMA.

Effect of Continuous Nutritionist-led Guidance on Bowel Preparation in Patients Undergoing Prostate Stereotactic Body Radiation Treatment With Endorectal Spacing: A Prospective Pilot Trial

OBJECTIVE

To evaluate the effect of a daily nutritionist consultation on rectal volume, gas, and prostate displacement during Stereotactic Body Radiation Treatment (SBRT) with an endorectal spacer.

METHODS

Twenty-six consecutive patients receiving 5 fraction SBRT with endorectal spacing were prospectively enrolled for an intensive daily nutritionist intervention utilizing biofeedback based on image guidance from each fraction. A retrospective control cohort receiving a standard bowel preparation was compared. Rectal volume, rectal gas, and prostate displacement were assessed by analysis of cone beam computed tomography. Data was analyzed using the SPSS statistics software.

RESULTS

Intense dietary intervention with biofeedback led to a consistently lower rectal gas score over 5 fractions ( P <0.001) and less variability in rectal volume during prostate SBRT indicating a nonsignificant trend for superior preparation in the intervention group compared with controls, particularly for the first 2 fractions. However, there was no significant impact on prostate displacement as measured by couch correction.

CONCLUSIONS

Intense dietary consultations effectively reduce rectal gas and variation of rectal volume during prostate SBRT with endorectal spacing. However, there was no advantage in reducing prostate displacement. Thus, labor-intensive daily nutritionist intervention with biofeedback is not cost-effective in reducing organ motion in patients with endorectal spacers compared with standard pretreatment dietary advice and is not recommended.

Bisphosphonate Bone Imaging Agent [68Ga]Ga-P15-041 for Evaluating Skeletal Metastases in Prostate Cancer: A Comparison With [68Ga]Ga-PSMA-11 PET/CT

BACKGROUND

Accurate diagnosis of bone metastases in prostate cancer is essential for staging, prognosis, and treatment. Although PSMA PET/CT is highly effective, complementary imaging is needed to clarify indeterminate lesions. The novel bisphosphonate-based agent [68Ga]Ga-P15-041 shows superior diagnostic accuracy over conventional SPECT imaging, indicating its potential as an auxiliary diagnostic tool. This study explores its role in detecting and assessing prostate cancer bone metastases.

PATIENTS AND METHODS

This prospective study enrolled 35 patients with prostate cancer and skeletal metastases, who underwent both [68Ga]Ga-P15-041 and [68Ga]Ga-PSMA-11 PET/CT within 1 week. Lesions detected by [68Ga]Ga-PSMA-11 PET/CT were classified using Prostate-specific Membrane Antigen Reporting and Data System 2.0.

RESULTS

[68Ga]Ga-P15-041 PET/CT detected more lesions than [68Ga]Ga-PSMA-11 PET/CT (525 vs 509, P < 0.001) and demonstrated significantly higher tracer uptake, with a mean SUV of 20.73 ± 14.67 compared with 11.13 ± 8.12 (P < 0.0001). It detected significantly more osteoblastic lesions (504 vs 391, P < 0.0001). In addition, this study established the Reporting and Data System for [68Ga]Ga-P15-041 (P15-041-RADS), which classifies prostate cancer bone metastases into 5 categories based on SUVmax and morphologic changes. P15-041-RADS reclassified 85.71% of Prostate-specific Membrane Antigen Reporting and Data System category 3 lesions and 95.00% of 5T lesions into higher-confidence categories, offering improved diagnostic clarity. Limitations include small sample size and lack of pathologic gold standards.

CONCLUSIONS

[68Ga]Ga-P15-041 PET/CT is a promising and accessible bone imaging agent that could complement [68Ga]Ga-PSMA-11 PET/CT in the diagnosis and classification of bone metastases in prostate cancer.

Germline Testing for Prostate Cancer Patients: Evidence-Based Evaluation of Genes Recommended by NCCN Guidelines

BACKGROUND

Approximately 50% of prostate cancer (PCa) patients meet the National Comprehensive Cancer Network (NCCN) guidelines for germline testing at diagnosis. However, the selection of genes for testing, their supporting evidence, and clinical interpretation remain poorly understood.

METHODS

An evidence-based evaluation of the recommended genes was conducted using data from the UK Biobank and Johns Hopkins School of Medicine, including 22,052 PCa patients and 191,055 unaffected controls. Association of germline pathogenic/likely pathogenic (P/LP) variants in each gene was tested using logistic regression, adjusting for age and genetic background.

RESULTS

Among the 11 NCCN-recommended PCa-related genes, significant associations (p < 0.0045) were identified between germline P/LP variants of five genes (HOXB13, BRCA2, ATM, CHEK2, and MSH2) and PCa risk. Additionally, BRCA2 and ATM variants were significantly associated with PCa aggressiveness. Of the 19 NCCN-recommended genes related to PARPi sensitivity, consistent evidence supported an enhanced response to PARPi therapy in patients with BRCA2 alterations, with weaker evidence for BRCA1, and limited supporting evidence for the remaining genes. Germline P/LP variants in BRCA2 and BRCA1 were observed in 0.77% and 0.14% of unselected PCa patients, respectively. Notably, no published study specifically assessed the efficacy of germline alterations, which were considerably rarer than somatic mutations.

CONCLUSION

Supporting statistical evidence is available for only a subset of the NCCN-recommended genes for germline testing. This evidence-based analysis may aid urologists-particularly those without specialized genetics training-in understanding germline testing for PCa risk assessment, prognosis, and treatment decision-making in clinical practice.

Current Status and Future Perspectives of Nuclear Medicine in Prostate Cancer from Imaging to Therapy: A Comprehensive Review

Nuclear medicine has emerged as a critical modality in the diagnostic and therapeutic management of urological malignancies, particularly prostate cancer. Advances in single-photon emission computed tomography/computed tomography (CT) and positron emission tomography/CT (PET/CT) have enhanced tumor assessment across staging, treatment response, and recurrence settings. Molecular imaging, which offers insights beyond traditional anatomical imaging, is increasingly integral in specific clinical scenarios. Theranostic nuclear medicine, which combines diagnostic imaging with targeted therapy, has become a well-established treatment option, particularly for patients with metastatic castration-resistant prostate cancer (mCRPC). The development of the prostate-specific membrane antigen (PSMA) radioligands has revolutionized clinical management by enabling precise disease staging and delivering effective radioligand therapy (RLT). Ongoing research aims to refine the role of PSMA PET imaging in staging and treatment monitoring, while optimizing PSMA-targeted RLT for broader clinical use. Given that prostate cancer remains highly prevalent, the anticipated increase in the demand for RLT presents both challenges and opportunities for nuclear medicine services globally. Theranostic approaches exemplify personalized medicine by enabling the tailoring of treatments to individual tumor biology, thereby improving survival outcomes and maintaining patients' quality of life with minimal toxicity. Although the current focus is on advanced disease, future research holds promise for expanding these strategies to earlier stages, potentially enhancing curative prospects. This evolving field not only signifies a paradigm shift in the care of prostate cancer patients but also underscores the growing importance of nuclear medicine in delivering precision oncology.

Muscadine Grape Skin Extract in Biochemically Recurrent Prostate Cancer: A Randomized, Placebo-Controlled, Biomarker-Enriched Trial in Patients With the SOD2 Ala/Ala Variant

BACKGROUND

Many patients with biochemically recurrent prostate cancer (BCRPC) prefer to delay androgen deprivation therapy (ADT) due to its adverse effects, highlighting the need for better-tolerated, effective alternatives. A subgroup analysis of our prior Phase II trial showed that muscadine grape skin extract (MPX) increased PSA doubling time (PSADT) in patients with SOD2 Ala/Ala variant which provided the rationale for this trial.

METHODS

This randomized, double-blind, placebo-controlled trial, conducted at 14 sites, evaluated patients with BCRPC and SOD2 Ala/Ala genotype. Patients received 4000 mg MPX or placebo daily. The primary endpoint was on-study PSA slope with comparisons between treatment arms. Secondary endpoints were PSADT, PSA response (≥ 50% decrease), and PSA progression free survival (PFS). Correlative studies included markers of oxidative stress and gastrointestinal microbiota composition.

RESULTS

At interim analysis, fifty-nine patients were randomized (MPX, n = 29; placebo, n = 30). On-study PSA slopes at 12, 24, 36, and 48 weeks showed no significant differences between the MPX and placebo arms (p = 0.49). The study was stopped due to futility. No significant differences were observed in PSADT, PSA response, median PSA PFS, or oxidative stress biomarkers. MPX was well-tolerated, with no grade 3-4 AEs attributable to the study drug. Microbiome analysis showed no significant differences in alpha diversity but revealed increased relative abundance of Roseburia faecis and Akkermansia muciniphila in the MPX group.

CONCLUSIONS

Although MPX supplementation had no significant effect on PSA slope in men with BCRPC and SOD2 Ala/Ala variant, this study provides a rigorous evaluation of a natural product and highlights the importance of well-designed clinical trials in advancing evidence-based integrative oncology.

TRIAL REGISTRATION

ClinicalTrials. gov, NCT03535675.

Optimizing clinical risk stratification of localized prostate cancer

PURPOSE OF REVIEW

To review the current risk and prognostic stratification systems in localised prostate cancer. To explore some of the most promising adjuncts to clinical models and what the evidence has shown regarding their value.

RECENT FINDINGS

There are many new biomarker-based models seeking to improve, optimise or replace clinical models. There are promising data on the value of MRI, radiomics, genomic classifiers and most recently artificial intelligence tools in refining stratification. Despite the extensive literature however, there remains uncertainty on where in pathways they can provide the most benefit and whether a biomarker is most useful for prognosis or predictive use. Comparisons studies have also often overlooked the fact that clinical models have themselves evolved and the context of the baseline used in biomarker studies that have shown superiority have to be considered.

SUMMARY

For new biomarkers to be included in stratification models, well designed prospective clinical trials are needed. Until then, there needs to be caution in interpretation of their use for day-to-day decision making. It is critical that users balance any purported incremental value against the performance of the latest clinical classification and multivariate models especially as the latter are cost free and widely available.

PSMA PET/CT findings in high-risk biochemical recurrence after local treatment of prostate cancer

Objectives

To describe PSMA PET/CT characteristics of patients with high-risk BCR.

Subjects/patients and methods

This was a retrospective analysis of patients with high-risk BCR prostate cancer (PSA ≥ 2 ng/ml above nadir after radiation therapy [RT] or ≥1 ng/ml after radical prostatectomy [RP] +/- RT) who underwent PET/CT from July 2021-March 2023. Patients with prior cytotoxic chemotherapy, androgen deprivation therapy (ADT) initiated >3 months prior to PET/CT or positive conventional imaging within 3 months of PET/CT were excluded. Neoadjuvant/adjuvant ADT completed ≥9 months prior was allowed. Logistic regression, Pearson's Chi-squared, Wilcoxon rank sum and Fisher's exact tests were used for analysis.

Results

A total of 113 of 145 (77%) included patients in the analysis had ≥1 lesion on PSMA PET/CT. There was no difference in PSMA PET/CT positivity based on age, race, Gleason Grade at initial biopsy or PSA. Overall, 29 (20%) patients had lesions in the prostate/prostate bed only, 31 (21%) had lesions consistent with N1M0 disease and 53 (37%) had lesions consistent with M1 disease. For M1 patients, 21/53 (40%) had oligometastatic disease (1-3 lesions), and 32/53 (60%) had a higher burden (>3 lesions). Local recurrence was more common with RT and nodal recurrence with RP, with no difference in distant metastasis by initial treatment.

Conclusion

Nearly 80% of patients with high-risk BCR after local treatment for prostate cancer with RP and/or RT will have positive findings on PSMA PET/CT. In addition to intensified systemic therapy, up to 55% of the patients may have benefitted from salvage local therapy, nodal pelvic radiation or metastasis-directed therapies for oligometastatic disease.

The outcomes of salvage robotic radical prostatectomy following radiation versus focal therapy: Does the primary treatment modality matter?

Objectives

We aim to compare salvage robotic radical prostatectomy (sRRP) for recurrent prostate cancer (PCa) after primary radiation (RT) versus focal therapy (FT).

Materials and Methods

Patients who underwent sRRP following primary local therapy for PCa were identified. Perioperative findings and functional/oncologic outcomes were compared in RT versus FT groups.

Results

Overall, 112 patients were included, with 84 receiving RT and 28 FT as primary treatment. Median age and PSA were 68 years and 5.4 ng/mL, respectively. There was one rectal injury in the RT group. The overall 90-day complications were significantly higher in RT group (33% vs. 11%, p = 0.03). On multivariable analysis, history of RT and prolonged operative time were associated with a higher rate of 90-day complications. The 6- and 12-month continence rates were higher in FT group (50% vs. 20%, p = 0.02 and 69% vs. 33%, p = 0.03). Potency at 12 months was better preserved in FT group (46% vs. 12%, p = 0.01). On final sRRP pathology, the rates of grade group ≥ 4 (51% vs. 36%, p = 0.2), pT3 (69% vs. 75%, p = 0.6), positive nodes (30% vs. 18%, p = 0.2) and positive margins (33% vs. 39%, p = 0.5) were similar for RT versus FT, respectively. The 3-year biochemical recurrence-free survival was 86% for RT versus 94% for FT (p = 0.6).Conclusion: sRRP for recurrent PCa after FT is associated with lower complications and higher urinary continence and potency rates than patients who received primary RT.

Treatment Landscape of Prostate Cancer in the Era of PSMA Radiopharmaceutical Therapy

The treatment landscape of prostate cancer is quite complex because of the many therapeutic options available in different disease settings (hormonal treatments, chemotherapy, poly(adenosine diphosphate ribose) polymerase inhibitors, radiopharmaceutical therapy). Since in most cases we do not have comparative studies between these different agents, the best therapeutic sequence in patients with prostate cancer remains unsolved. In this review, we describe the different systemic therapeutic options available in each disease setting from localized disease to metastatic castration-resistant disease. We also indicate when to use each of these therapeutic options in the therapeutic sequence on the basis of the results of the available studies. A special focus of this review is the place of prostate-specific membrane antigen radiopharmaceutical therapy in the treatment algorithms.

Prospective Evaluation of Supplemental External Beam Radiation Therapy With Palladium-103 Prostate Brachytherapy: Long-Term Results of the 44/20/0 Trials

PURPOSE

The 44/20 and 20/0 randomized trials evaluated whether different external beam radiation therapy (EBRT) dosing regimens prior to brachytherapy affected biochemical failure (BF). We report long-term outcomes of both trials and evaluate whether biological equivalent dose (BED) was associated with reduced BF in the combined trial cohort.

METHODS AND MATERIALS

Both trials enrolled patients with clinical T1c to T2b, Gleason scores 7 to 9, and/or a pretreatment prostate-specific antigen (PSA) 10 to 20 ng/mL disease. The 44/20 trial randomized patients to 44 Gy EBRT with 90 Gy palladium (Pd)-103 versus 20 Gy EBRT with 115 Gy Pd-103. The subsequent 20/0 trial randomized patients to the 20 Gy arm versus monotherapeutic 125 Gy Pd-103. For each trial, univariate Fine-Gray analysis evaluated whether the treatment arm was associated with BF for the entire cohort and the unfavorable intermediate-risk (UIR) subgroup. For the combined trial cohort, multivariate Fine-Gray analysis evaluated whether BED was associated with BF while adjusting for clinical factors.

RESULTS

There were 247 analyzable patients in the 44/20 trial. At a median follow-up of 13.7 years, there were no differences in BF for the entire cohort (subdistribution hazard ratio [sHR] 0.99; 95% CI, 0.43, 2.276; P = .97) or the UIR subgroup (sHR 0.72; 95% CI, 0.25, 2.08; P = .55). There were 383 analyzable patients in the 20/0 trial. At a median follow-up of 10.4 years, there were no differences in BF for the entire cohort (sHR 0.42; 95% CI, 0.13-1.80; P = .15) or the UIR subgroup (sHR 0.81; 95% CI, 0.16-4.03; P = .80). For the combined cohort (630 patients), BED was not associated with BF (1.00; 95% CI, 0.98-1.02; P = .88) on multivariate analyses while adjusting for androgen deprivation therapy utilization, 4-tiered National Comprehensive Cancer Network category, and year of treatment.

CONCLUSIONS

Brachytherapy monotherapy should be a standard-of-care treatment for clinically localized, intermediate-risk prostate cancer, including UIR disease.

Beyond fluorodeoxyglucose: Molecular imaging of cancer in precision medicine

Cancer molecular imaging is the noninvasive visualization of a process unique to or altered in neoplasia, such as proliferation, glucose metabolism, and receptor expression, which is relevant to patient management. Several molecular imaging modalities are now available, including magnetic resonance, optical, and nuclear imaging. Nuclear imaging, particularly using fluorine-18-fluorodeoxyglucose positron emission tomography, is widely used in the staging and response assessment of multiple cancer types. However, at this writing, new nuclear medicine probes, especially positron emission tomography tracers, are increasingly used or are being investigated for cancer evaluation. This review focuses on these probes, their biologic targets, and the applications or potential applications for their use in the assessment of various neoplasms, including both probes available for commercial use-such as somatostatin receptor ligands in neuroendocrine tumors, prostate-specific membrane antigen ligands in prostate cancer, norepinephrine analogs in neural crest tumors like neuroblastoma, and estrogen analogs in breast cancer-and others in clinical development, such as fibroblast-activating protein inhibitors, C-X-C chemokine receptor type 4 ligands, and monoclonal antibodies targeting receptor tyrosine kinases, CD4-positive or CD8-positive tumor-infiltrating lymphocytes, tumor-associated macrophages, and cancer stem cell biomarkers. These developments represent a major step toward the integration of molecular imaging as a powerful tool in precision medicine, with an expectedly significant impact on patient management and outcome.

Current role of salvage radiotherapy in oligometastatic prostate cancer at the time of recurrence

PURPOSE OF REVIEW

To review the evidence for metastasis-directed therapy (MDT) in oligometastatic (OM) prostate cancer (PC) and future directions in this clinical setting.

RECENT FINDINGS

The indications for radiotherapy in PC have significantly increased over the last decade. The treatment of OM disease has been gaining popularity thanks to new molecular imaging techniques that allow more accurate identification of OM patients who may benefit from MDT. stereotactic body radiation therapy can offer potentially curative treatment with low toxicity rates. Although most published MDT studies focus on hormone-sensitive (HS) PC in the setting of recurrence, promising results have emerged in recent years even in patients with castration resistance.

SUMMARY

MDT has emerged as an effective treatment option for OM PC patients with favorable oncological outcomes and a low toxicity profile. Evidence suggests that MDT can be used to delay androgen deprivation therapy or in combination with systemic therapy to potentially improve efficacy outcomes. Molecular stratification is needed to determine who will benefit from treatment intensification with MDT +/- systemic therapies.

Genomic and transcriptomic sequencing in prostate cancer

PURPOSE OF REVIEW

Genomic and transcriptomic sequencing technologies have revolutionized our ability to characterize prostate cancer at the molecular level. The underlying premise of next-generation sequencing technologies and their current and evolving applications in prostate cancer management are provided in the review.

RECENT FINDINGS

Improved methodologies are allowing timely sequencing of the coding regions or both the coding and noncoding regions of the genome to help identify potential mutations and structural variations in the prostate cancer genome, some of which are currently also targetable therapeutically. DNA microarray- based differential gene expression has been supplanted by RNA sequencing (RNA-seq), which not only allows for more accurate quantitation but also nucleotide-level resolution to investigate the entire transcriptome, including alternative gene spliced transcripts and noncoding RNA transcripts, whose full clinical implications have yet to be fully understood and realized. Gene classifier platforms that predict risk of recurrence or metastasis are being incorporated into prostate cancer management algorithms. In the appropriate clinical context, not only somatic but also germline mutation testing is being recommended.

SUMMARY

Continued clinical integration of sequencing technologies and ongoing research will lead to improved understanding of prostate cancer biology and prostate cancer treatment.

Trends in Surgical Overtreatment of Prostate Cancer

Importance

Overtreatment of prostate cancer is a public health concern that undermines prostate cancer screening efforts.

Objective

To assess trends in pathologic grade on prostatectomy during the past 2 decades as a surrogate for overtreatment.

Design, Setting, and Participants

This retrospective cohort study examined the grade of prostate cancer on final pathology reports among patients undergoing prostatectomy between January 1, 2010, and September 1, 2024, in 2 parallel cohorts: Surveillance, Epidemiology, and End Results (SEER), a nationwide cancer registry, and Michigan Urological Surgery Improvement Collaborative (MUSIC), a statewide clinical registry. The presence of higher-risk features among patients who underwent grade group 1 prostatectomy during this period was also assessed.

Exposures

The primary exposure of interest was year of radical prostatectomy.

Main Outcomes and Measures

The primary outcome was the proportion of all prostatectomies that were pathologic grade group 1 (pGG1) on final pathology reports. The secondary outcome was the proportion of pGG1 prostatectomies with a higher-risk preoperative feature, assessed as a binary variable and including at least 1 of the following: more than 50% of biopsy cores positive, prostate-specific antigen of 10 ng/mL or higher, or grade group 2 on biopsy.

Results

A total of 162 558 male patients in SEER (median [IQR] age, 63 [57-67] years) and 23 370 in MUSIC (median [IQR] age, 64 [59-69] years) underwent prostatectomy. The proportion of radical prostatectomies resulting in pGG1 on final pathology reports decreased from 32.4% (5852 of 18 071) to 7.8% (978 of 12 500) between 2010 and 2020 in SEER and from 20.7% (83 of 401) to 2.7% (32 of 1192) between 2012 and 2024 in MUSIC. A more recent prostatectomy was associated with a lower likelihood of a pGG1 prostatectomy while controlling for age and race within SEER (odds ratio [OR] per 5 years, 0.41; 95% CI, 0.40-0.42; P < .001) and MUSIC (OR per 5 years, 0.39; 95% CI, 0.36-0.43; P < .001). Within a subset analysis of those prostatectomies that were final pGG1, a more recent prostatectomy was associated with the presence of a higher-risk preoperative feature, including more than 50% of biopsy cores positive, prostate-specific antigen of 10 ng/mL or higher, and grade group 2 on prior biopsy within SEER (OR per 5 years, 1.60; 95% CI, 1.54-1.67; P < .001) and MUSIC (OR per 5 years, 1.60; 95% CI, 1.34-1.90; P < .001).

Conclusions and Relevance

This cohort study found that since 2010, the frequency of pGG1 prostatectomies markedly decreased, and those few that were performed were more likely to have a higher-risk feature. This reduction in the proportion of prostatectomies that are pGG1 likely reflects improved diagnostic pathways, adherence to active surveillance protocols for low-risk cases, and ongoing efforts at both the state and national levels to minimize unnecessary surgical interventions in patients diagnosed with clinically insignificant prostate cancer.

Exploring the Molecular Mechanism and Role of Glutathione S-Transferase P in Prostate Cancer

Aims: To investigate the effect of Glutathione metabolism in prostate cancer pathogenesis. Background: There is growing evidence that Glutathione metabolism plays an important role in prostate cancer, with genes encoding key enzymes in this pathway potentially serving as diagnostic or prognostic biomarkers. Objective: To explore whether there is a causal relationship between key enzymes in the Glutathione metabolism and prostate cancer, and to further investigate the molecular mechanisms and roles of the genes encoding their proteins in relation to prostate cancer. Method: Transcriptomic datasets from the Gene Expression Omnibus (GEO) database were analyzed to identify differentially expressed genes (DEGs) and enriched pathways in prostate cancer versus normal tissues. Two-sample bidirectional Mendelian randomization (MR) was employed to assess causal relationships between Glutathione metabolic enzymes (exposure) and prostate cancer risk (outcome). Immune infiltration analysis and LASSO regression were performed to construct a diagnostic model. Single-cell RNA sequencing (scRNA-seq) data were utilized to elucidate cell-type-specific expression patterns and functional associations of target genes. Result: The results of two-sample bidirectional MR showed that Glutathione S-transferase P (GSTP) in Glutathione metabolism could reduce the risk of prostate cancer. The Glutathione S-transferase Pi-1 (GSTP1) gene was lowly expressed in prostate cancer and was able to diagnose prostate cancer more accurately. Single-cell analysis showed that the high expression of GSTP1 in prostate cancer epithelial cells was closely associated with the upregulation of the P53 pathway and apoptosis. Conclusions: Our study reveals that GSTP in Glutathione metabolism reduces the risk of prostate cancer and further analyzes the genetic association and mechanism of action between GSTP1 and prostate cancer.

Case Report: Two cases of chemotherapy refractory aggressive variant prostate cancer with extreme durable response to PARP inhibitor

Background

Aggressive variant prostate cancer (AVPC) represents a distinct clinical subset characterized by resistance to novel hormone therapies and an unfavorable prognosis, frequently associated with the concurrent loss of tumor suppressor genes (TSG) such as PTEN, RB1, and TP53. While the progression-free survival (PFS) and overall survival (OS) of AVPC are relatively short, the optimal first-line treatment remains unclear.

Presentation

In this case report, we presented two de novo AVPC cases who have ultimately benefited from the usage of PARP inhibitors. The first patient was a 64-year-old male who was diagnosed during prostate biopsy featured by mutations in PTEN, and loss of RB1, BRCA2, ATM, and FANCA. He was treated with docetaxel/albumin-bound paclitaxel and cisplatin in the first line. Second-line therapy was applied with radiotherapy and Olaparib after failure of first-line therapy, resulting in a PSA response sustained for three years. The second case was a 75-year-old male with localized neuroendocrine feature and mutations in TP53, loss of RB1 and HDAC2. He was treated with sustained ADT and chemotherapy in the first-line treatment. Radiotherapy and Fluzoparib + abiraterone was applied as subsequent treatments with a PSA response for 2 years.

Conclusions

These two cases demonstrating a satisfactorily durable response to PARP inhibitors indicating its clinical benefit in AVPC population with detected DNA damage response (DDR) defects. The survival improvement with PARP inhibitors observed in our clinical experiences, along with current advances in tumor sequencing provide more information on future clinical trials and explorations of innovative therapies in AVPC population.

Homologous recombination repair gene alteration is strongly associated with more prostate-specific membrane antigen-positive metastases in newly diagnosed hormone-sensitive prostate cancer with ≤5 conventional imaging defined distant metastases

BACKGROUND

The differences in imaging between prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) and conventional imaging (CI) significantly impact disease staging, subsequently influencing the scope and clinical efficacy of stereotactic body radiotherapy (SBRT). In this multicenter retrospective study, we aimed to explore the effect of homologous recombination repair (HRR) gene status on the imaging differences between PSMA PET/CT and CI, which may have important implications for treatment selection.

PATIENTS AND METHODS

A total of 1214 newly diagnosed hormone-sensitive prostate cancer (HSPC) patients with ≤ 5 CI-defined distant metastatic lesions were included. All patients underwent PSMA PET/CT, CI, and circulating tumor DNA testing for 19 HRR genes. The PSA response was defined as achieving a PSA level of < 0.1 ng/ml after 6 months.

RESULTS

The median PSA level was 22.7 ng/ml. In the comparison of bone metastasis detection rates, the proportion of patients with higher detection rates on PSMA PET/CT than on CI was similar between BRCA mutation carriers and those with other HRR gene mutations (43.6% vs. 39.3%, p = 0.554), yet significantly higher in both groups compared to non-mutation carriers (20.5%, p = 0.00001). Similar results were observed in the analysis of metastasis detection rates for distant lymph nodes and regional lymph nodes. In non-metastatic HSPC patients without PSMA-positive distant disease who accepted radical prostatectomy (RP), patients without HRR gene mutations exhibited a significantly higher PSA response rate compared to HRR gene mutated patients (96.9% vs. 90.2%, p = 0.003).

CONCLUSIONS

HRR gene alterations were significantly associated with a higher number of PSMA-positive metastases in newly diagnosed HSPC with ≤ 5 CI-defined distant metastases and worse outcomes in non-metastatic HSPC accepting RP. This finding suggests that HRR gene status should be considered as a potential indicator for recommending PSMA PET/CT in the design of clinical trials involving SBRT and in shaping imaging strategies.

The Health Inequality Impact of Darolutamide for Non-Metastatic Castration-Resistant Prostate Cancer in the United States: A Distributional Cost-Effectiveness Analysis

OBJECTIVES

Non-Hispanic (NH) Black patients are disproportionally affected by nonmetastatic castration-resistant prostate cancer (nmCRPC). The objective was to quantify the health inequality impact of darolutamide + androgen deprivation therapy (ADT) relative to ADT for nmCRPC in the United States using a distributional cost-effectiveness analysis.

METHODS

With a health economic model, quality-adjusted life years (QALYs) and costs were estimated for NH-White, NH-Black, NH-Asian, and Hispanic patients. Given the lifetime risk of nmCRPC and assuming equally distributed opportunity costs, the incremental net health benefits of darolutamide were calculated, which were used to estimate general population quality-adjusted life expectancy at birth (QALE) by race and ethnicity with and without darolutamide. The extent of QALYs and QALE differences between race and ethnicity subgroups with each strategy was quantified with an inequality index, and their difference defined as the inequality impact of darolutamide.

RESULTS

Darolutamide + ADT resulted in an additional 1.04 (95% uncertainty interval 0.56-1.51) QALYs per treated patient relative to ADT, with the greatest gain observed among NH-Black patients (1.48 [0.48-2.71]). The relative inequality in QALYs among patients reduced by 66%, from an inequality score of 0.033 (0.004-0.082) with ADT to 0.011 (0.000-0.051) with darolutamide + ADT. Factoring in disease risk and health opportunity costs, nmCRPC treatment with darolutamide resulted in the largest net gain in QALYs among the NH-Black population, thereby having a favorable impact on inequalities in QALE.

CONCLUSIONS

Darolutamide + ADT results in greater and a more even distribution of QALYs than ADT for nmCRPC. The greatest gains among NH-Black individuals implies a favorable health inequality impact with darolutamide.

Advances in Current Treatment Paradigms for Metastatic Hormone-Sensitive Prostate Cancer

Metastatic hormone-sensitive prostate cancer (mHSPCa) presents de novo or represents significant disease progression and requires systemic treatment. However, progression to castration resistance is inevitable. The treatment landscape has evolved with the introduction of intensified systemic therapy, including androgen deprivation therapy (ADT) combined with either androgen receptor signaling inhibitors (ARSIs) or cytotoxic chemotherapy (doublet therapy) or combined therapy with both agents (triplet therapy). Landmark trials such as CHAARTED, STAMPEDE, LATITUDE, ENZAMET, and TITAN have established combination therapies as the standard of care, demonstrating significant overall survival benefits. More recently, triplet therapy-integrating ADT, docetaxel, and an ARSI-has emerged as an effective approach, particularly in high-volume metastatic disease, as supported by ARASENS and PEACE-1. Advances in imaging, such as PSMA PET-CT, have improved disease detection, allowing earlier detection of metastasis and appropriate therapy. Similarly, genomic profiling has enabled biomarker-driven, personalized treatment strategies. The role of treatment of the primary tumor, by either radiation therapy or cytoreductive prostatectomy, in low-volume disease continues to be explored. As novel therapies, targeted agents, and immunotherapies undergo investigation, optimizing treatment selection based on disease burden, molecular characteristics, and patient factors will be essential. The future of mHSPCa management lies in multidisciplinary, precision-based approaches to improve patient outcomes while balancing treatment efficacy and tolerability.

The association of where patients with prostate cancer live and receive care on racial treatment inequities

BACKGROUND

Black individuals are less likely to be treated for prostate cancer even though they are more than twice as likely to die compared with White individuals. The complex causes of these inequities are influenced by social and structural factors, including racism, which contribute to the differential delivery of care. This study investigates how factors related to the location of where individuals live and receive care affect treatment inequities for prostate cancer between Black and White individuals. We hypothesize that both location and race independently influence treatment inequities.

METHODS

We used data from the Surveillance, Epidemiology, and End Results (SEER) cancer registry linked to Medicare claims to estimate the treatment inequity, as defined by differences in radiation or radical prostatectomy. Fixed effects at the physician, hospital, and patient ZIP code levels were incorporated to adjust for all time-invariant factors at these levels.

RESULTS

The results indicate that residential location-related factors explain only half of the treatment inequity, whereas provider- and hospital-level factors do not significantly account for disparities. Even after accounting for all time-invariant factors, significant differences in treatment rates persist.

CONCLUSIONS

The study highlights the importance of understanding race as a social construct and racism as a systemic and structural phenomenon in addressing treatment inequities. These findings provide a necessary step toward understanding equitable care and designing interventions to solve this inequity.

When You Get to the Fork in the Road, Take It: The Challenges in Managing Patients With Advanced Prostate Cancer

As is the case with most solid tumors, the heterogeneity of the disease biology of prostate cancer presents clinicians managing this disease with daily challenges. However, in contrast to other common cancers such as breast, lung, and colorectal cancers, there are unique challenges in prostate cancer management, including the variety of clinicians who manage aspects of the disease (urologists, medical oncologist, radiation oncologists) and the striking absence of prospective comparative data to inform the optimal sequence of systemic therapy in patients with metastatic castration-resistant disease. The purpose of this review is to attempt to assist practicing oncologists with sorting through the myriad of prostate cancer disease subsets and the challenges in making therapeutic decisions in multiple data-free zones given the absence of level 1 comparative clinical trials in the metastatic hormone-sensitive and castration-resistant states.

Gleason scores provide more accurate prognostic information than grade groups

Prostate cancer grade is currently often reported both by Gleason scores and by grouping of the scores into five so-called International Society of Urological Pathology (ISUP) grades (also known as grade groups). Using population-based registry data from 172,112 men diagnosed with prostate cancer on needle biopsy, we recently investigated the outcome of Gleason score 8-10 prostate cancer with death due to prostate cancer and death from any cause as endpoints. There was a prognostic heterogeneity between Gleason scores 3+5, 4+4 and 5+3 (ISUP grade 4) and between Gleason scores 4+5, 5+4 and 5+5 (ISUP grade 5). This heterogeneity was lost when the grades collapsed into ISUP grades 4 and 5, respectively. On the other hand, there was also a prognostic overlap between these ISUP grades. The outcome of Gleason score 5+3 and 4+5 cancers was very similar. The prostate-specific mortality of Gleason scores 5+3 and 4+5 was 0.32 (95% confidence interval 0.27-0.36) and 0.30 (0.29-0.31), respectively, after 5 years and 0.44 (0.39-0.49) and 0.45 (0.44-0.46), respectively, after 10 years. The findings emphasise the importance of reporting the Gleason grades and scores for more accurate prognostic information of highly heterogeneous high-grade prostate cancers. It also questions the clinical value of the current recommendations of grouping of Gleason scores into ISUP grades or grade groups.

Artificial intelligence in digital pathology - time for a reality check

The past decade has seen the introduction of artificial intelligence (AI)-based approaches aimed at optimizing several workflows across many medical specialties. In clinical oncology, the most promising applications include those involving image analysis, such as digital pathology. In this Perspective, we provide a comprehensive examination of the developments in AI in digital pathology between 2019 and 2024. We evaluate the current landscape from the lens of technological innovations, regulatory trends, deployment and implementation, reimbursement and commercial implications. We assess the technological advances that have driven improvements in AI, enabling more robust and scalable solutions for digital pathology. We also examine regulatory developments, in particular those affecting in-house devices and laboratory-developed tests, which are shaping the landscape of AI-based tools in digital pathology. Finally, we discuss the role of reimbursement frameworks and commercial investment in the clinical adoption of AI-based technologies. In this Perspective, we highlight both the progress and challenges in AI-driven digital pathology over the past 5 years, outlining the path forward for its adoption into routine practice in clinical oncology.

Hypofractionated radiotherapy for prostate cancer (HYDRA): an individual patient data meta-analysis of randomised trials in the MARCAP consortium

BACKGROUND

Trials comparing moderately hypofractionated radiotherapy (MHFRT) to conventionally-fractionated radiotherapy (CFRT) for prostate cancer have varied considerably in intent (non-inferiority vs superiority) and MHFRT dose. We compare the efficacy and toxicity profiles of isodose MHFRT and dose-escalated MHFRT.

METHODS

This was an individual patient data meta-analysis that identified randomised phase 3 trials of CFRT versus MHFRT that had published individual patient-level data on efficacy and late toxicity. A systematic literature search using MEDLINE, Embase, trial registries, the Web of Science, Scopus, and relevant conference proceedings was initially conducted on Dec 15, 2023, and was re-conducted on Jan 8, 2025. Trials that did not publish efficacy data, did not publish late toxicity data, or did not use modern dose radiotherapy (≥70 Gy in 2 Gy equivalents) in the CFRT group were excluded. Individual patient data were provided to MARCAP by study investigators. Three separate meta-analyses were designed to compare efficacy (primary endpoint was progression-free survival), physician-scored late toxicity (co-primary endpoints were late grade 2 or higher genitourinary and late grade 2 or higher gastrointestinal toxic effects), and patient-reported outcomes (co-primary endpoints were clinically-significant decrements in patient-reported urinary or bowel quality of life) between patients receiving CFRT versus MHFRT.

FINDINGS

We identified 1696 records for review. Seven phase 3 trials comparing MHFRT with CFRT were eligible for inclusion in our analysis. Individual patient data were obtained from these seven studies (3454 patients from three trials comparing CFRT with isodose MHFRT and 2426 patients from four trials comparing CFRT with dose-escalated MHFRT). At a median follow-up of 5·4 years (IQR 4·6-7·2) for isodose MHFRT and 7·1 years (5·7-8·4) for dose-escalated MHFRT, no differences in progression-free survival were detected (hazard ratio 0·92, 95% CI 0·81-1·05; p=0·21 and 0·94, 0·82-1·09; p=0·43 respectively). No increased odds of grade 2 or higher genitourinary toxic effects were identified for either isodose (odds ratio [OR] 1·16, 95 CI% 0·86-1·57; p=0·32) or dose-escalated MHFRT (1·20, 0·95-1·51; p=0·13). The odds of grade 2 or higher gastrointestinal toxic effects were significantly higher with dose-escalated (OR 1·48, 95% CI 1·14-1·92; p=0·0035) but not isodose MHFRT (1·30, 0·59-2·87; p=0·51). Isodose MHFRT was not found to show different odds of urinary quality-of-life decrement (OR 1·03, 95% CI 0·51-2·09; p=0·93) or bowel quality-of-life decrement (0·76, 0·40-1·43; p=0·39). Dose-escalated MHFRT was associated with greater odds of bowel quality-of-life decrement (OR 1·68, 95% CI 1·07-2·61; p=0·023), but no evidence of greater urinary quality-of-life decrement was found (1·57, 0·87-2·85; p=0·13).

INTERPRETATION

Isodose MHFRT and dose-escalated MHFRT both have similar efficacy compared with CFRT, but dose-escalated MHFRT is associated with higher physician-scored and patient-reported bowel toxicity. Isodose regimens, eg, 60 Gy in 20 fractions, should be the standard MHFRT regimen for localised prostate cancer.

FUNDING

None.

PRIMARY scoring in 68Ga-PSMA PET/CT: correlation with prostate cancer risk groups and its potential impact on active surveillance

OBJECTIVE

The PRIMARY scoring system is a scale designed to identify clinically significant intraprostatic malignancies on 68Ga-PSMA PET/CT images. Active surveillance is a management method for patients with low-risk prostate cancer. In this study, we aimed to assess the efficacy of PRIMARY scoring in identifying appropriate candidates for active surveillance based on the distribution within prostate cancer risk groups.

METHODS

The data of 134 patients diagnosed with PCa by biopsy who underwent 68Ga-PSMA PET/CT imaging for post-diagnostic staging purposes were retrospectively analyzed. Age, total PSA, ISUP grade, prostate lesion SUVmax values, PI-RADS scores, and PRIMARY scores were recorded. Patients were classified into low-risk and intermediate/high-risk groups.

RESULTS

In the intermediate/high-risk group, the PRIMARY score was 1-2 in 17.6% and 3-5 in 82.4% of patients. In the low-risk group, the PRIMARY score was 1-2 in 34.7% and 3-5 in 65.3% of patients. None of the patients in the low-risk group had a PRIMARY score of 5. The most frequent PRIMARY score in both groups was 4, and there was a significant difference between the average SUVmax values of the intermediate/high and low-risk groups with a PRIMARY score of 4 (p = 0.018). The sensitivity of PRIMARY scoring in detecting patients in the intermediate/high-risk group was 82.3%, the specificity was 34.6%, and the positive predictive value (PPV) was 68.6%. When a cut-off SUVmax value 5.0 was used for the PRIMARY score of 4, the sensitivity was 67.0%, the specificity was 65.3% and the PPV was 77.0%. In the ROC analysis, the area under the curve was 0.727 for PRIMARY scoring, 0.662 for PI-RADS, and 0.744 for their combined mean.

CONCLUSION

The PRIMARY scoring system can complement PI-RADS scoring in mpMRI for selecting patients suitable for active surveillance. Revising the PRIMARY score 4 with an SUVmax cut-off value may increase the specificity.

Integrating Prostate Specific Membrane Antigen-PET into Clinical Practice for Prostate Cancer

Prostate surface membrane antigen (PSMA)-PET imaging has significantly shaped the clinical management of prostate cancer, from localized to metastatic disease. It outperforms conventional imaging in both primary staging and detecting recurrence. PSMA-PET incorporation into the clinical workflow can alter treatment decisions, though the impact of observed stage migration on patient outcomes has yet to be well-characterized. There is growing interest in using PSMA-PET to predict treatment response across all stages of prostate cancer, and to select patients for PSMA radioligand therapy. Use of PSMA-PET will continue to expand for clinical applications as its role becomes better defined through prospective studies.

Comparative Cardiovascular Safety of Gonadotropin-releasing Hormone Antagonists and Agonists Among Patients Diagnosed with Prostate Cancer: A Systematic Review and Meta-analysis of Real-world Evidence Studies

BACKGROUND AND OBJECTIVE

Gonadotropin-releasing hormone (GnRH) antagonists and agonists are cornerstone treatments in prostate cancer. However, evidence regarding the comparative cardiovascular safety of these drugs from clinical trials is inconclusive. The objective of this study was to systematically assess the risk of adverse cardiovascular events of GnRH antagonists compared with GnRH agonists across real-world evidence studies.

METHODS

We conducted a systematic search of PubMed, Embase, Cochrane Library, Scopus, and Web of Science (2008-2023). We included real-world evidence studies comparing the risk of cardiovascular outcomes of GnRH antagonists with those of GnRH agonists among patients with prostate cancer. We conducted a meta-analysis of effect estimates across studies at a low or moderate risk of bias, assessed via the Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) tool, using random-effect models.

KEY FINDINGS AND LIMITATIONS

Among ten included studies, four were classified as having a moderate and six as having a serious risk of bias. Across three studies at a moderate risk of bias in the primary analysis, degarelix was associated with an increased risk (pooled relative risk [RR]: 1.31, 95% confidence interval [CI]: 1.14-1.51) of major adverse cardiovascular events (MACEs). An augmented risk was observed in two studies among patients with a history of cardiovascular disease (pooled RR: 1.31, 95% CI: 1.11-1.56) compared with one study among patients without a history of cardiovascular disease (RR: 1.15, 95% CI: 0.83-1.59).

CONCLUSIONS AND CLINICAL IMPLICATIONS

Real-world evidence studies indicate that degarelix, compared with GnRH agonists, is associated with a modest increased risk of MACEs, particularly among patients with a history of cardiovascular disease. However, residual confounding due to the treatment of high-risk patients with degarelix may account for these findings. Additional large studies with detailed data on tumor characteristics and cardiovascular risk factors are needed to confirm these findings.

PATIENT SUMMARY

In this systematic evaluation of evidence among patients diagnosed with prostate cancer in routine care, degarelix was associated with higher cardiovascular adverse outcomes than gonadotropin-releasing hormone agonists.

Risk of Biochemical Recurrence and Metastasis in Prostate Cancer Patients Treated with Radical Prostatectomy After a 10-year Disease-free Interval

BACKGROUND AND OBJECTIVE

Prostate-specific antigen (PSA) testing is used to follow up prostate cancer (PCa) patients treated with radical prostatectomy (RP). Research on PSA thresholds for identifying PCa patients with biochemical recurrence (BCR) who are at a higher risk of progression yielded inconclusive results. This study aims to investigate the risk of late BCR in PCa patients treated with RP and long postoperative (120 mo) undetectable PSA follow-up, and to identify prognostic factors for late BCR within this patient cohort.

METHODS

PCa patients treated with curative RP (1992-2012) and free of BCR during the first 120 mo following RP were retrospectively identified within five European tertiary centers; BCR was defined as two consecutive PSA values of ≥0.2 ng/ml. Kaplan-Meier and Cox regression models tested for an association between BCR and patient or tumor characteristics.

KEY FINDINGS AND LIMITATIONS

The study cohort consisted of 4639 patients, of whom 243 (5.2%) developed BCR at a medium follow-up of 147 mo. Of those with BCR, 23 (9.5%) subsequently developed metastatic progression. In Kaplan-Meier models, BCR-free survival differed according to advanced tumor status. In multivariable Cox regression models, pT stage (pT3a: hazard ratio [HR]: 1.46; pT3b: HR: 2.42), pathological Gleason score (pGS 3 + 4: HR: 1.71; pGS ≥4 + 3: HR: 2.47), surgical margin (R1/Rx: HR: 1.72), and pNx stage (pNx: HR: 0.72) represented independent predictors for BCR (all p < 0.05). Conversely, age, PSA at diagnosis, and year of surgery failed to achieve independent predictor status for BCR.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Among PCa patients with an uneventful follow-up of at least 10 yr after RP, still one in 20 patients subsequently develop late BCR. Nevertheless, late BCR and subsequent progression to metastasis (0.3%) rates in patients with pT2 stage and pGS ≤3 + 4 were strikingly low, implicating that abandoning follow-up beyond an uneventful period of 10 yr is justifiable within this cohort of patients.

PATIENT SUMMARY

In this study, prostate cancer patients treated with a radical prostatectomy and at least 10 yr of uneventful prostate-specific antigen testing were identified within five European centers. Relying on these patients, the rate of subsequent late biochemical recurrence was calculated and risk factors were identified for biochemical recurrence following 10 yr of uneventful prostate-specific antigen testing.

Prospective observational study on the relationships between genetic alterations and survival in Japanese patients with metastatic castration-sensitive prostate cancer: the impact of IDC-P

BACKGROUND

Intraductal Carcinoma of the Prostate (IDC-P) is a significant prognostic indicator for prostate cancer, which demonstrates significant associations with homologous recombination repair gene mutations (HRRm) and alterations in tumor suppressor genes. However, no study in Japan has investigated the association between IDC-P and genetic mutations in men with metastatic castration-sensitive prostate cancer (mCSPC).

METHODS

This prospective observational study enrolled 102 de novo mCSPC (LATITUDE high-risk) patients diagnosed between 2018 and 2021, with subsequent monitoring of survival outcomes. A single genitourinary pathologist evaluated all needle biopsy slides. Genetic analyses were performed using the Myriad myChoice HRD plus™. These genetic analyses covered 108 genetic loci, including 15 HRRm genes, with a success rate of 91%.

RESULTS

Genetic alterations were observed in 79 patients (77.5%), with 20 exhibiting HRRm (19.6%). Common genetic alterations included FOXA1 (29.4%) and TP53 (17.6%) mutations; BRCA (9.8%) mutations were the most frequent HRRm (BRCA1:2 cases, BRCA2:8 cases, including 6 biallelic). IDC-P-positive patients demonstrated a significantly higher frequency of genetic aberrations (82.6% vs. 50%, p = 0.0082). Patients with biallelic BRCA2, TP53, and PTEN mutations exhibited significantly poorer cancer-specific survival. Multivariate analysis identified lactate dehydrogenase (LDH) (HR 1.005, p = 0.035), TP53 mutations (HR 5.196, p < 0.001), biallelic BRCA2 mutations (HR 10.686, p = 0.005), and IDC-P as independent predictors of poor cancer-specific survival. No cancer-related deaths occurred in IDC-P-negative cases.

CONCLUSION

Our study emphasizes the significant association between IDC-P and an elevated incidence of genetic alterations in Japanese mCSPC patients, emphasizing the need for early genetic testing to guide therapeutic decision-making.

Long noncoding HOXD-AS1: a crucial regulator of malignancy

Long non-coding RNAs (lncRNAs) play a crucial role in the occurrence and progression of various cancers. HOXD-AS1, an antisense RNA 1 of the lncRNA HOXD cluster, (also known as HAGLR, MIR7704HG, Mdgt, and STEEL), is located at human chromosome 2q31.1. Recent studies have demonstrated that the abnormal expression of HOXD-AS1 is significantly correlated with the clinicopathological features of patients with various tumors. The expression of HOXD-AS1 is abnormal in various tumors, affecting tumor cell proliferation, apoptosis, metastasis, invasion, metabolism, and drug resistance. HOXD-AS1 is important for cancer diagnosis and prognosis evaluation. Detecting its expression level helps judge cancer progression and predict patient survival. It is a therapeutic target and biomarker for early diagnosis and prognosis, with good clinical application prospects. This article reviews the role, molecular mechanisms, and potential clinical value of HOXD-AS1 in malignant tumor development.

Comparative therapeutic efficacy and safety of first-line and second-line therapies for metastatic castration-resistant prostate cancer: a systematic review and network meta-analysis

Background

There is no cross-sectional comparison on therapeutic and adverse effects for treatments of metastatic castration-resistant prostate cancer (mCRPCa). We aimed to horizontally compare them for all common first-line and second-line therapies.

Methods

We conducted a network meta-analysis with a systematic review in four databases (Pubmed, Web of Science, Embase, and Cochrane Library) up to January 5th, 2025. All randomized controlled trials (RCT) related to mCRPCa treatments with a clear description in study design were included. Endpoints included the radiographic progression-free survival (rPFS), overall survival (OS), time to PSA progression (TTPP), PSA progression rate (PSARR), and adverse events. All data was extracted by two researchers and analyzed with Gemtc package in R and Stata15. This NMA protocol was registered online (ID: CRD42025633178).

Findings

After screening among 33,694 articles, 24 RCTs involving 13,059 cases were included. For first-line treatments, combination therapies with second-generation androgen receptor inhibitors (ARIs) showed superior efficacies in OS [HR of poly(ADP-ribose) polymerase inhibitors (PARPi) + ARI: 0.63 (0.32,1.25)], TTPP [HR of Lu177 + ARI: 0.07 (0.01,0.87)] and PSARR [RR of Lu177 + ARI: 33.02 (15.56,71.62)] with the highest SUCRA (Surface under the Cumulative Ranking Curve) (72%, 91% and 97% respectively). PARPi + ARI also performed best for rPFS (SUCRA: 85%, with an insignificant HR [0.12 (0.02,2.35)]. For post-docetaxel second-line treatments, ARI also emerged as the preferred option. Efficacies of post-ARI second-line treatments were not evaluated due to the lack of related RCTs. No obvious heterogeneity and publication bias was detected during the therapeutic comparison.

Interpretation

This study provided comparative evidence for first-line and post-chemotherapy second-line mCRPCa treatment options. Second-generation ARIs exhibited good efficacy, particularly when combined with other treatments. However, the safety analysis necessitated balance between benefits and adverse events, especially for combination therapies. Stronger evidence is needed through direct comparisons in future clinical trials.

Funding

The study was supported by The National Natural Science Foundation of China (No. 82172568).

PCBP2 promotes immune evasion via cGAS-STING pathway in biochemical recurrence of prostate cancer

Immunotherapy resistance is a significant obstacle in the treatment of prostate cancer (PCa), primarily due to immune evasion mechanisms. This study aims to explore cancer-intrinsic immune evasion-related genes (CIERGs) in PCa and develop a predictive signature for biochemical recurrence (BCR). Bulk RNA-seq data and single-cell RNA-sequencing (scRNA-seq) were obtained from TCGA and Gene Expression Omnibus database. The scRNA-seq data analysis revealed higher immune evasion scores in tumor cells compared to normal cells. Differentially expressed genes from TCGA-PRAD and GSE70769 cohorts were intersected with 182 core immune evasion genes, followed by univariate Cox regression, identifying 48 CIERGs significantly associated with BCR. Nonnegative matrix factorization (NMF) clustering revealed two immune evasion-related PCa subtypes. A risk signature based on CIERGs was developed using LASSO regression, and a nomogram was created to predict BCR-free survival. Among the 48 identified CIERGs, poly(C)-binding protein 2 (PCBP2) emerged as a key risk factor associated with poor prognosis in PCa, and its function was validated in vitro. NMF clustering identified two subtypes, with the C1 subtype having a poorer prognosis. Gene Set Variation Analysis highlighted enrichment in cell cycle, extracellular matrix receptor interaction, and transforming growth factor-beta signaling pathways in the C1 subtype. A CIERGs-based risk signature, including six key genes, was developed and validated, with the nomogram showing high predictive accuracy. In vitro experiments showed PCBP2 promotes PCa cell proliferation, migration, and invasion by inhibiting the cyclic GMP-AMP synthase-STING pathway. The CIERGs signature provides a precise prediction of BCR, with PCBP2 emerging as a potential therapeutic target due to its inhibition of the cGAS-STING pathway in PCa.

Current insights on PSMA PET/CT in intermediate-risk prostate cancer: a literature review

The purpose of this systematic review was to evaluate the role of PSMA PET/CT in intermediate-risk prostate cancer (PCa) patients, to determine whether it could help improve treatment strategy and prognostic stratification. A systematic literature search up to May 2024 was conducted in the PubMed, Embase and Scopus databases. Articles with mixed risk patient populations, review articles, editorials, letters, comments, or case reports were excluded. The quality of the papers was assessed by using the CASP criteria. The literature search returned 1111 studies; however, 1105 articles were excluded, and therefore 6 full-text papers were retrieved for the final analysis. Three out of six papers focused on the utility of SUVmax in identifying high ISUP grade in patients with intermediate-risk PCa. The latest three papers discussed the controversial role of PSMA PET/CT in predicting the lymph node involvement, mainly in the case of favorable subset. PSMA PET has completely changed the management of patients with PCa; indeed its role is still undefined in patients with intermediate-risk disease. Future perspective is to investigate larger cohorts of intermediate-risk PCa patients, to fully recognize the added value offered by PSMA PET in this category of subjects.

Molecular Landscape of Aggressive Histologic Subtypes of Localized Prostate Cancer

Despite incredible progress in describing the molecular underpinnings of prostate cancer over the last decades, pathologic examination remains indispensable for predicting aggressive behavior in the localized setting. Beyond pathologic grade, specific histologic findings have emerged as critical prognostic or predictive indicators. Here, the authors review molecular correlates of aggressive histologic subtypes of prostate cancer in the localized setting, demonstrating that many of the signature molecular alterations found in metastatic disease-such as tumor suppressor gene loss and DNA repair defects-are enriched in primary disease with adverse histologic features, presaging aggressive behavior, and presenting opportunities for earlier germline screening or targeted therapies.

Deciphering Complexity: The Molecular Landscape of Castration-Resistant Prostate Cancer

Despite improvements in diagnosis and treatment approaches, prostate cancer (PC) remains a leading cause of cancer-related death in men. PC progresses through various stages, mostly driven by androgen receptor signaling. However, after androgen deprivation therapies, in a significant portion of patients, several different molecular mechanisms contribute to the development of castration resistance. Delving deeply into the molecular landscape of castration-resistant PC, grasping the selective pressures exerted by therapies, and understanding the drivers of lineage plasticity is pivotal to prevent progression. Targeting genetic and epigenetic alterations that drive this transition will guide clinical management strategies and possibly prevent and/or treat lethal disease.

Comparison of two alternative sequences with cabazitaxel and 177Lu-PSMA-617 in metastatic castration-resistant prostate cancer: A retrospective multicenter study (LuCaS)

BACKGROUND

Cabazitaxel and 177Lu-PSMA-617 have been shown to improve survival in patients with metastatic castration-resistant prostate cancer (mCRPC) previously treated with docetaxel and androgen receptor pathway inhibitors (ARPI). we aimed to evaluate the impact of sequencing cabazitaxel and 177Lu-PSMA-617 on survival outcomes in patients with mCRPC.

PATIENTS AND METHODS

This is a retrospective, multicenter, cohort study which included patients with mCRPC who received sequential treatment with 177Lu-PSMA-617 and cabazitaxel between January 2015 and December 2023. Primary outcome was progression-free survival-2 (PFS-2) RESULTS: A total of 68 patients with mCRPC who received sequential 177Lu-PSMA-617 and cabazitaxel were included in the study. The primary outcome, progression-free survival-2 (PFS-2), was similar in patients treated with 177Lu-PSMA-617 first (LU-CA) and those receiving cabazitaxel (CA-LU) first (10.8 and 11.7 months, respectively; p = 0.422). The median overall survival (OS) was also similar in the LU-CA and CA-LU groups (16.6 and 19.9 months, respectively; p = 0.917). The objective response rate (ORR) for 177Lu-PSMA-617 was 23.1 % when used first and 16.1 % after cabazitaxel. ORR for cabazitaxel was 25.6 % and 31.3 % when used as the first agent and when used after 177Lu-PSMA-617, respectively.

CONCLUSIONS

In conclusion, treatment sequencing between cabazitaxel and 177Lu-PSMA-617 did not significantly affect survival outcomes in patients with mCRPC. These findings suggest that both drugs can be effectively integrated into the mCRPC treatment paradigm without concerns about the effect of sequencing. However, prospective data are needed to optimize sequencing strategies and explore their impact on specific patient subgroups for more personalized care.

Expanding the Scope of Interventional Oncology: Locoregional Therapies in Extrahepatic Malignancies

BACKGROUND/OBJECTIVES

Locoregional therapies (LRTs), including transarterial embolization (TAE), transarterial chemoembolization (TACE), and transarterial radioembolization (TARE), have become integral in the management of hepatocellular carcinoma (HCC) in recent decades and continue to shape evolving treatment strategies. While their role in liver tumor management is well established, their potential for treating extrahepatic malignancies is gaining increasing attention. Notably, growing research has highlighted the promising applications of TAE, TACE, and TARE in extrahepatic cancers such as glioblastoma (GBM), soft tissue sarcomas (STSs), prostate cancer (PCa), pancreatic cancer, and renal cell carcinoma (RCC). This review aims to explore these novel applications, providing a comprehensive summary of the current literature, examining clinical outcomes, and discussing future directions for integrating these techniques into broader oncologic treatment strategies.

METHODS

A systematic literature review was conducted focusing on LRTs such as TAE, TACE, and TARE in extrahepatic malignancies. Studies published between May 1998 and December 2024 were included, emphasizing outcomes in GBM, STS, PCa, pancreatic cancer, and RCC. Data extraction prioritized clinical outcomes, safety profiles, and procedural efficacy.

RESULTS

LRTs demonstrated significant potential in managing extrahepatic malignancies, with TAE, TACE, and TARE showing promising results in palliative management and tumor control. Across studies, these therapies exhibited varying degrees of success in improving progression-free survival and overall survival, with minimal systemic toxicity.

CONCLUSIONS

The expanding application of LRTs in extrahepatic malignancies highlights their transformative potential in interventional oncology. By offering targeted, minimally invasive treatment options, these modalities bridge critical gaps in managing tumors refractory to conventional therapies. Future research should focus on standardizing protocols, optimizing patient selection, and exploring combination therapies to maximize their clinical efficacy.

Overcoming drug resistance in castrate-resistant prostate cancer: current mechanisms and emerging therapeutic approaches

Metastatic castration-resistant prostate cancer (mCRPC) is driven by a complex network of resistance mechanisms against standard-of-care therapies, resulting in poor long-term outcomes. This review offers a uniquely comprehensive and integrative perspective on these resistance pathways, systematically examining both androgen receptor (AR)-dependent factors (including AR overexpression, point mutations, glucocorticoid receptor signaling, splice variants, post-translational modifications, altered coregulators, and intratumoral hormone biosynthesis) and AR-independent pathways (such as neuroendocrine differentiation, lineage plasticity, and alternative growth factor signaling). We also highlight resistance mechanisms influencing immunotherapy, chemotherapy, radiopharmaceutical therapy and targeted therapy. By synthesizing emerging insights across these domains, this review not only clarifies the underlying biology of mCRPC resistance but also identifies key leverage points for more effective interventions. Building on this foundation, we propose a forward-looking framework for overcoming mCRPC drug resistance, emphasizing the importance of biomarker-guided patient selection, combination strategies that simultaneously target multiple resistance mechanisms, and novel therapies under investigation. These recommendations are intended to guide future clinical trial designs and research priorities that move beyond incremental improvements. Ultimately, this comprehensive synthesis aims to serve as a resource for clinicians and researchers to accelerate the development of durable, precision-based treatment strategies in mCRPC.

Prospective Head-to-Head Comparison of 18F-PSMA PET/CT and 18F-NaF PET/CT for Assessing Bone Metastases in 160 Patients with Newly Diagnosed High-Risk Prostate Cancer

Prostate-specific membrane antigen (PSMA) PET/CT is increasingly used for primary staging in prostate cancer (PC), mainly because of its improved accuracy in detecting lymph node metastases compared with conventional imaging. However, the diagnostic benefit of PSMA PET/CT for detecting bone metastases is less well established. This study compares the diagnostic accuracy of 18F-PSMA PET/CT and 18F-NaF PET/CT for detecting bone metastases in patients newly diagnosed with PC. Methods: This prospective study included patients with histologically confirmed high-risk PC. All participants were referred from the department of urology to 18F-NaF PET/CT and underwent 18F-PSMA PET/CT within 3 weeks. Images were reviewed by 2 nuclear medicine physicians unaware of the results of the other imaging modality. Presence or absence of bone metastases and number of metastatic lesions were recorded. A reference standard was established at the patient level based on agreement between the 2 imaging modalities. In cases of concordance, both modalities were deemed correct. In cases of discordance, additional follow-up scans were performed. Diagnostic performance metrics, including sensitivity, specificity, and accuracy, were calculated. Results: In total, 160 participants were included. Sensitivity, specificity, and accuracy for detecting bone metastases at the patient level were 0.98, 0.99, and 0.99, respectively, for 18F-PSMA PET/CT, and 0.91, 1.00, and 0.97, respectively, for 18F-NaF PET/CT. No significant differences were found. The concordance rate of bone metastases between 18F-NaF and 18F-PSMA PET/CT at the patient level was observed in 154 patients (96.3%). 18F-PSMA PET/CT tended to identify more bone metastases per patient than 18F-NaF PET/CT. Conclusion: Both 18F-NaF and 18F-PSMA PET/CT exhibit high diagnostic accuracy for detecting bone metastases in newly diagnosed high-risk PC patients. 18F-PSMA PET/CT may detect additional metastatic lesions compared with 18F-NaF PET/CT. Subsequent 18F-NaF PET/CT may be redundant if no bone metastases are found on 18F-PSMA PET/CT.

Management of Patients with Advanced Prostate Cancer. Report from the 2024 Advanced Prostate Cancer Consensus Conference (APCCC)

BACKGROUND AND OBJECTIVE

Innovations have improved outcomes in advanced prostate cancer (PC). Nonetheless, we continue to lack high-level evidence on a variety of topics that greatly impact daily practice. The 2024 Advanced Prostate Cancer Consensus Conference (APCCC) surveyed experts on key questions in clinical management in order to supplement evidence-based guidelines. Here we present voting results for questions from APCCC 2024.

METHODS

Before the conference, a panel of 120 international PC experts used a modified Delphi process to develop 183 multiple-choice consensus questions on eight different topics. Before the conference, these questions were administered via a web-based survey to the voting panel members ("panellists").

KEY FINDINGS AND LIMITATIONS

Consensus was a priori defined as ≥75% agreement, with strong consensus defined as ≥90% agreement. The voting results show varying degrees of consensus, as discussed in this article and detailed in the Supplementary material. These findings do not include a formal literature review or meta-analysis.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The voting results can help physicians and patients navigate controversial areas of clinical management for which high-level evidence is scant or conflicting. The findings can also help funders and policymakers in prioritising areas for future research. Diagnostic and treatment decisions should always be individualised on the basis of patient and cancer characteristics, and should incorporate current and emerging clinical evidence, guidelines, and logistic and economic factors. Enrolment in clinical trials is always strongly encouraged. Importantly, APCCC 2024 once again identified important gaps (areas of nonconsensus) that merit evaluation in specifically designed trials.

The Role of Prostate-Specific Membrane Antigen-Radioligand and Magnetic Resonance Imaging in Patients with Prostate Cancer Biochemical Recurrence

A significant proportion of men with prostate cancer will experience biochemical recurrence (BCR), which is characterized by an elevation in prostate-specific antigen (PSA) levels after receiving treatment with curative intent. Imaging plays an important role in the management of patients with BCR. It can help identify sites of recurrence to determine the most appropriate management strategies, ranging from salvage treatment for local recurrences to systemic treatments for those with advanced, distant disease. PET/CT with prostate-specific membrane antigen (PSMA)-radioligands is the most sensitive method for the detection of prostate cancer recurrence, with significantly higher cancer detection rates compared to conventional imaging techniques such as bone scan and computed tomography, even at lower PSA levels. Nevertheless, interpretation of PSMA PET/CT images can be challenging, particularly for the evaluation of local recurrence due to urinary activity that can mimic or mask the presence of cancer. Furthermore, some prostate cancers may not express PSMA and have false negative results. Multiparametric prostate MRI is an excellent method for the evaluation of local recurrence and can overcome some of the limitations of PSMA PET/CT. In this review, we discuss the role of imaging in managing patients with prostate cancer BCR and describe the potential benefits of MRI in the PSMA-radioligand imaging era, emphasizing the assessment of local recurrence.

Convergence of evolving artificial intelligence and machine learning techniques in precision oncology

The confluence of new technologies with artificial intelligence (AI) and machine learning (ML) analytical techniques is rapidly advancing the field of precision oncology, promising to improve diagnostic approaches and therapeutic strategies for patients with cancer. By analyzing multi-dimensional, multiomic, spatial pathology, and radiomic data, these technologies enable a deeper understanding of the intricate molecular pathways, aiding in the identification of critical nodes within the tumor's biology to optimize treatment selection. The applications of AI/ML in precision oncology are extensive and include the generation of synthetic data, e.g., digital twins, in order to provide the necessary information to design or expedite the conduct of clinical trials. Currently, many operational and technical challenges exist related to data technology, engineering, and storage; algorithm development and structures; quality and quantity of the data and the analytical pipeline; data sharing and generalizability; and the incorporation of these technologies into the current clinical workflow and reimbursement models.