The 2026 Pujiang Prostate Cancer Conference was held in Shanghai on June 26–27, 2026, under the theme "Standardization, Precision, Chinese Innovation, and Global Collaboration." The meeting brought together leading experts in uro-oncology from across China to showcase advances in standardized prostate cancer management and cutting-edge research.During the conference, Prof. Yong Yang from the Department of Urology, Peking University Cancer Hospital, presented his lecture titled “Prognostic Impact of Maximal tPSA Decline Following Treatment for Newly Diagnosed Metastatic Prostate Cancer.”
At the meeting, UroStream conducted an exclusive interview with Prof. Yang to discuss the prognostic significance of PSA response, its role in risk stratification and treatment assessment, and strategies for optimizing therapy in patients who fail to achieve a deep PSA response.
UroStream:
Do you believe that the assessment of deep PSA response is limited by pathological subtype? What is the relationship between PSA levels—or the magnitude of PSA decline—and patient prognosis?
Prof. Yong Yang:
In metastatic hormone-sensitive prostate cancer (mHSPC), regardless of the first-line treatment regimen used, the extent of PSA decline is a reliable predictor of prognosis. However, there is one important prerequisite: the patient’s pathology must be prostatic acinar adenocarcinoma.
If the tumor exhibits neuroendocrine differentiation, its biological behavior is fundamentally different. In essence, it represents a distinct disease entity, and PSA is no longer an appropriate prognostic biomarker in that setting. Fortunately, more than 95% of patients encountered in clinical practice have prostatic acinar adenocarcinoma, making this principle broadly applicable.
Overall, the greater the PSA decline and the more rapidly PSA reaches a low level, the longer the patient’s overall survival and the lower the risk of death.
UroStream:
There is currently no universally accepted definition of an ultra-low PSA level. Based on available evidence and your clinical experience, what role should deep PSA response play in evaluating treatment efficacy and guiding therapeutic decisions in mHSPC?
Prof. Yong Yang:
During the initial treatment phase for mHSPC—particularly throughout the first six months—it is essential to monitor total PSA (tPSA) monthly to track its dynamic changes.
As for the optimal PSA threshold, evidence dates back more than 20 years to the SWOG study, which demonstrated that patients whose tPSA rapidly declined below 0.2 ng/mL experienced substantially improved outcomes.
More recently, post hoc analyses of multiple Phase III trials evaluating novel hormonal therapies have shown that achieving an even deeper response—specifically reducing PSA below 0.02 ng/mL—is associated with additional survival benefits.
Therefore, in clinical practice, we should not be satisfied simply because PSA reaches the conventional target level. Instead, we should continue monitoring until the patient’s PSA nadir is reached.
For patients who fail to achieve an optimal deep PSA response, treatment intensification should be initiated promptly. If a patient has received ADT alone, a novel androgen receptor pathway inhibitor should be added. If ADT plus novel hormonal therapy still fails to achieve the desired response, docetaxel chemotherapy should ideally be incorporated to further intensify treatment.
UroStream:
For patients whose tPSA does not decline sufficiently and who fail to achieve a deep response, which high-risk features concern you most? Would you consider early treatment intensification or modifying therapy to delay progression to metastatic castration-resistant prostate cancer (mCRPC)?
Prof. Yong Yang:
This is a very practical clinical question.
For patients who present with clearly identifiable high-risk features at diagnosis, there is no need to wait for the PSA response before adjusting treatment. These patients should receive intensified therapy from the outset.
Which high-risk features warrant particular attention? Patients with high tumor burden, diffuse bone metastases, visceral metastases, or a Gleason score of 8 or higher all fall into the high-risk category. For these patients, treatment should be maximally intensified from the beginning.
At present, the strongest evidence supports triplet therapy consisting of ADT, novel hormonal therapy, and docetaxel, a regimen that has demonstrated a clear overall survival benefit.
Of course, we also encounter patients who receive intensified therapy upfront but still fail to achieve the desired PSA target after six months. In such cases, further escalation of cytotoxic therapy may be considered. For example, docetaxel combined with cisplatin for three to four cycles may help drive PSA down to the desired level.
However, whether to pursue more intensive treatment must always be determined by considering the patient’s overall condition, age, and ability to tolerate therapy. Clinical decisions should not be based solely on PSA values.
Prof. Yong Yang
