Optimal systemic therapy in men with low-volume prostate cancer

Area of Science:

• Urology
• Oncology
• Medical Imaging

Background:

• Low-volume prostate cancer is a prognostic category in metastatic hormone-sensitive prostate cancer.
• The definition of low-volume disease is often inconsistently applied across various prostate cancer states.
• This review examines the evolving definitions, biology, and treatment evidence for low-volume prostate cancer.

Approach:

• Exploration of current definitions and biological underpinnings of low-volume prostate cancer.
• Review of existing therapeutic strategies and evidence.
• Investigation into the impact of advanced imaging, specifically PSMA PET scans, on patient stratification and treatment paradigms.

Key Points:

• Advanced imaging, particularly PSMA PET, enhances metastatic detection, potentially altering conventional low-volume disease definitions.
• Prognosis and treatment for low-volume prostate cancer depend on the timing of metastatic presentation.
• Biomarker-directed therapy, metastasis-directed therapy (MDT), and de-escalation of systemic therapies are emerging strategies, especially for metachronous disease.

Conclusions:

• Management of low-volume prostate cancer (CHAARTED criteria) may rely on metastatic timing in the absence of validated biomarkers.
• Recommendations include novel hormonal therapy (NHT) doublets with or without MDT for metachronous disease, and NHT doublets with or without MDT and prostate-directed radiation for synchronous disease.
• Future strategies may involve MDT without systemic therapy for oligometastatic disease identified by genomics and PSMA PET imaging.