Updates on prostate cancer

Background:
Prostate cancer remains one of the most prevalent malignancies in men, significantly contributing to global morbidity, mortality, and healthcare costs. Advances in diagnostics and treatment over the past decade have reshaped management strategies.

Methods:
A literature review was conducted using PubMed and major conference proceedings from the past ten years.

Results:
Prostate-specific membrane antigen (PSMA) positron-emission tomography (PET) has redefined prostate cancer imaging. Conventional imaging is no longer required before PSMA PET, which offers superior sensitivity and specificity. However, its cost-effectiveness remains debated across different healthcare systems. For localized disease, radiotherapy is an appropriate option in select patients with comorbidities, Gleason 7 (3+4), and <50% positive biopsy cores, particularly when dose escalation is feasible. The PACE trials established that stereotactic radiotherapy—often guided by PSMA PET—achieves outcomes comparable to surgery or conventional radiotherapy. Pelvic nodal radiotherapy provides a survival benefit, and adding a brachytherapy boost improves control, potentially reducing or even avoiding androgen deprivation therapy (ADT) in intermediate-risk cases. In high-risk disease, short-term (six-month) ADT may suffice, as extended exposure to gonadotropin-releasing hormone (GnRH) agonists increases cardiac risk. For unfavorable intermediate-risk patients, prostatectomy or radiotherapy with 4–6 months of ADT is recommended. Androgen receptor pathway inhibitors (ARPIs) are indicated for node-positive cases. Compared with GnRH agonists, GnRH antagonists (e.g., degarelix, relugolix) yield better oncologic outcomes and fewer adverse effects. Total androgen blockade with a GnRH agent plus an anti-androgen remains the standard for high-risk, nodal, or metastatic disease, while intermittent ADT is discouraged in advanced stages. In oligometastatic and castration-resistant prostate cancer (CRPC), multimodal strategies are used. These include radiopharmaceuticals (radium-223, lutetium-177 PSMA), stereotactic body radiotherapy, chemotherapy, and immunotherapy. Triplet therapy or early radiopharmaceutical use benefits younger, fit patients. Pembrolizumab and PARP inhibitors are now standard in metastatic CRPC with MSI-H/dMMR or BRCA/ATM mutations. Recurrence is typically identified through PSA testing, defined by the Phoenix criterion (2 ng/mL above nadir). PSMA PET surpasses CT and bone scans for restaging accuracy, while circulating tumor DNA (ctDNA) remains investigational but promising. Prostatectomy after radiotherapy or reirradiation is technically demanding due to fibrosis and should be performed in expert centers. Genomic profiling is central to precision oncology, identifying actionable mutations that guide targeted therapy. Tissue biopsy remains standard, though liquid biopsy and ctDNA testing are emerging tools under clinical evaluation. Supportive measures, including sexual health counseling, are vital for maintaining adherence and quality of life.

Conclusions:
Major progress has been achieved in imaging, systemic therapy, and radiotherapy for prostate cancer. Continuous research in molecular profiling and novel therapeutics is essential to further improve early detection, personalization, and survivorship outcomes.

Dr. Drilon Bytyçi is a medical doctor from Kosovo who graduated from the University of Prishtina. He also holds a Bachelor’s degree in Radiologic Technology (2022). His main interests include radiology, otorhinolaryngology, oncology, and medical research. He is skilled in academic writing, medical imaging interpretation, and structured clinical reasoning. Dr. Bytyçi is strongly motivated to engage in new research initiatives, applying evidence-based medicine and integrating current literature into practice to contribute to data analysis and systematic reviews.