Selection and Management for Locally Advanced Disease Declining Clinical Trials

How to cite: Taplin ME. Selection and Management for Locally Advanced Disease Declining Clinical Trials. Grand Rounds in Urology. February, 2026. Accessed Oct 2026. https://grandroundsinurology.com/selection-and-management-for-locally-advanced-disease-declining-clinical-trials/

Summary

Mary-Ellen Taplin, MD, Professor of Medicine, Dana-Farber Cancer Institute, Boston, presents a medical oncology perspective on the selection and management of patients with localized high-risk and locally advanced prostate cancer. She defines this population based on clinical and pathologic features, including high Gleason score, elevated prostate-specific antigen, and lymph node involvement. She emphasizes that most patients are diagnosed with localized or regional disease and have long survival, making treatment-related side effects a critical consideration.

Dr. Taplin highlights the importance of comprehensive diagnostic assessment, including prostate magnetic resonance imaging, prostate-specific membrane antigen positron emission tomography, biologic tumor profiling, and germline testing, with approximately 10 percent of patients harboring DNA repair gene mutations. Multidisciplinary evaluation and careful assessment of comorbidities are essential for treatment planning.

She reviews comparative data demonstrating no significant difference in prostate cancer-specific mortality between prostatectomy and radiation with androgen deprivation therapy when guideline-directed multimodality treatment is applied. This underscores the importance of individualized decision-making based on life expectancy, comorbidities, and patient preferences. Patients undergoing prostatectomy should be counseled regarding the potential need for adjuvant or salvage therapy and the risks of urinary and sexual side effects.

The PROTEUS trial is presented as a pivotal ongoing phase 3 study evaluating neoadjuvant and adjuvant apalutamide plus androgen deprivation therapy in high-risk patients undergoing prostatectomy. Accrual exceeded expectations, and results are anticipated soon, with metastasis-free survival as a key endpoint.

For patients treated with radiation, Dr. Taplin reviews data from the STAMPEDE trial demonstrating improved outcomes with the addition of abiraterone to androgen deprivation therapy. She also discusses the ENZARAD trial, which did not show a benefit for enzalutamide, highlighting the need for better patient selection.

She underscores that active surveillance is not appropriate in this population and that treatment should follow established guidelines while ongoing trials refine optimal strategies.

 

The International Prostate Cancer Update (IPCU), is a multi-day, CME-accredited conference focused on new developments in prostate cancer treatment, diagnosis, and prevention. IPCU 36 will feature lectures, interactive discussions, panel roundtables, debates, and case reports. This conference is led by expert physicians and is designed for urologists, medical oncologists, radiation oncologists, and other healthcare professionals involved in the diagnosis and treatment of prostate cancer.

The goal of this educational program is to equip healthcare professionals involved in the diagnosis and treatment of prostate cancer with the up-to-date clinical knowledge and tools they need to best treat their patients. The program will discuss the treatment of prostate cancer from diagnosis to treating advanced and metastatic disease. The conference aims to give physicians exposure to a comprehensive review of treating prostate cancer patients and to give them a chance to discuss the issues with peers and experts.