Medical Oncology Perspective on Integration of Molecular Imaging and Treatment for mCRPC

 

How to cite: Bastos DA. Medical Oncology Perspective on Integration of Molecular Imaging and Treatment for mCRPC. Grand Rounds in Urology.  September 15, 2025. Accessed Oct 2026. https://grandroundsinurology.com/medical-oncology-perspective-on-integration-of-molecular-imaging-and-treatment-for-mcrpc/

Summary

Diogo A. Bastos, MD, PhD, Clinical Oncologist, Hospital Sírio-Libanês, São Paulo, Brazil, provides an in-depth oncologic perspective on how molecular imaging, particularly prostate-specific membrane antigen (PSMA) positron emission tomography (PET), informs sequencing and selection of systemic treatments for metastatic castration-resistant prostate cancer (mCRPC).

Dr. Bastos emphasizes that treatment sequencing in mCRPC cannot follow a single universal algorithm. Therapy must be individualized, considering comorbidities, frailty, prior treatments, concurrent medications, histology, and biomarker status. He explains that intensified strategies in castration-sensitive disease, such as triplet therapy with androgen receptor pathway inhibitors (ARPIs) and docetaxel, directly affect options in the resistant setting.

Dr. Bastos reviews systemic options, including ARPIs (abiraterone, enzalutamide), chemotherapy (docetaxel, cabazitaxel), radium-223, PARP inhibitors for homologous recombination repair (HRR) alterations, immunotherapy for select patients, and Lutetium-177 PSMA. He focuses on PSMA-targeted therapy, citing the TheraP trial, which showed that Lutetium-PSMA achieved higher prostate-specific antigen (PSA) declines and radiographic progression-free survival (rPFS) compared to cabazitaxel, although without an overall survival benefit.

He summarizes findings from the VISION trial, in which Lutetium-PSMA, combined with the standard of care, significantly improved rPFS and overall survival, leading to global regulatory approval. Safety was favorable, with most adverse events being grade 1 or 2. Patients with higher PSMA uptake demonstrated greater benefits, although efficacy was observed across PSMA-positive groups.

Dr. Bastos also highlights the PSMAfore trial, the first Phase III study testing Lutetium-PSMA before taxane chemotherapy, which shows a rPFS benefit over an ARPI switch, although overall survival data remain limited due to crossover.

Dr. Bastos argues that all patients with mCRPC should undergo both germline and somatic genomic testing, and PSMA PET should be standard for therapy eligibility. Treatment should prioritize life-prolonging options, avoid back-to-back ARPI use, and strongly consider Lutetium-PSMA for PSMA-positive patients.

The Global Summit on Precision Diagnosis and Treatment of Prostate Cancer is a unique multi-disciplinary forum organized to inform the key health care stakeholders about the emerging advances in clinical case and research and create a consensus-based vision for the future of precision care and educational and research strategy for its realization. The mission of the Summit is to fill the currently existing gap between the key experts of in vivo imaging, the world authorities in the in vitro fluid- and tissue-based molecular diagnostics, including genomics, and thought leaders in the development of novel observation strategies (e.g., active surveillance, or AS) and therapeutic interventions.