Intensified approaches with surgery and RT: Standard of care for locally advanced PCa?
What will be the standard of care in the management of locally advanced prostate cancer in 2025? The Thematic Session “Clinically relevant questions in the management of advanced, hormone-sensitive prostate cancer” provided answers to this question. Led by Chairs Prof. Dr. Derya Tilki (DE) and Assoc. Prof. Roderick Van Den Bergh (NL), the session featured enhanced strategies through surgery and radiation therapy.
In his presentation “Intensified approaches with surgery”, Dr. Brian Chapin (US) concluded that locally advanced prostate cancer (PCa) has lethal potential. He added that there is a lack of high-level data supporting surgery. Surgery as the initial step in multimodality therapy may provide informed application of subsequent adjuvant or salvage treatments. Dr. Chapin also stated that intensified therapies with surgery using systemic approaches are promising with trials underway.
On behalf of Prof. Nicholas James (GB) who could not attend due to the Heathrow Airport airport closure, Prof. Noel Clarke (GB) presented the lecture “Intensified approaches with radiation therapy”. The key takeaways on ADT and RT were that ADT improves the outcomes with RT, and vice versa; and more ADT is better than less ADT for long-term PCa outcomes. However, lower grade and lower stage PCa have excellent prognosis, more ADT is more toxic and may increase death rates from non-cancer causes.
The lecture also covered prostate RT, which remains part of the standard therapy in low-volume metastatic hormone-sensitive prostate cancer (mHSPC) in the era of Androgen Receptor Pathway Inhibitors (ARPi)-based intensification. Furthermore, the effects on urinary complications justify the use in high-volume mHSPC as well. The toxicity shown in both the STAMPEDE and PEACE1 trials is acceptable.
Regarding low-volume M1 and M0 disease, Prof. Clarke stated, “There is good evidence to treat the primary in low-volume M1 HSPC but bear in mind that evidence sits with standard imaging. There is also good evidence for combining RT, abiraterone and ADT in high-risk M0 disease. The effect of docetaxel on M0 disease is less pronounced than that of abiraterone. Many cases of high-risk M0 disease will be low-volume M1 on prostate-specific membrane antigen-positron emission tomography (PSMA-PET). This suggests we may need to reassess the need for long-term ADT in all cases, given how good the M0 outcomes are.”
Webcasts, videos, posters, and full-text abstracts are accessible via the EAU25 Resource Centre.