In this UroStream special from the 2025 EAU Congress, Professor Alicia K. Morgans from Dana-Farber Cancer Institute (USA) shares her expert insights into the evolving landscape of metastatic prostate cancer treatment. From addressing disparities in access to care and overcoming hormone resistance, to the critical role of multidisciplinary collaboration and preserving quality of life amid advanced treatment strategies, Professor Morgans presents a comprehensive and human-centered perspective—highlighting the very real challenges faced by clinicians and patients alike.UroStream: What are the current challenges in clinical practice for metastatic prostate cancer, and what breakthroughs have been achieved recently?
Dr. Alicia K. Morgans: I think some of the biggest difficulties that we have in metastatic prostate cancer is actually a disparity in the way that we are able to provide care. That’s going to differ by country, by region within a country, and sometimes by factors related to patients—like their geography, their economic status, their educational status, and others. And I think that these kinds of differences in the way that we apply care are something that we absolutely need to tackle as we continue to try to find new therapies and to find new ways and drugs to take care of people with prostate cancer.
Some of our biggest breakthroughs and successes are that we are finding new ways to treat prostate cancer to keep people alive actually for quite a bit longer, including targeted therapies that target things like PSMA protein. And our radioligand therapies are doing this quite effectively, particularly lutetium PSMA-617.But also we see opportunities for targeted treatments that target patients who have DNA repair defect alterations. And we have PARP inhibitors, and now PARP inhibitor combinations, that can do this.But again, just to circle back, as we think about applying these therapies, it’s really important that we think about ensuring that everybody has access to the amazing breakthroughs that we have.
UroStream: Patients with metastatic prostate cancer often develop resistance to hormone therapy. Based on clinical experience, how do you think we can effectively delay or overcome this resistance problem?
Dr. Alicia K. Morgans:The resistance to hormone treatments is something that we’ve been working on trying to overcome for many years, and at this point in time we still know that patients do develop resistance—even when we use really effective AR pathway inhibitors to prolong the time to progression as compared to androgen deprivation therapy alone.I think there is some suggestion that combinations of PARP and AR pathway inhibitors may allow a prolonged exposure to—and a longer time to resistance on—those AR pathway inhibitors, particularly for patients with HRR mutations. But I don’t think that we really have the cure, the solution at this point in time to hormone resistance.We still need to have other therapies that can come into the place of the AR pathway inhibitors, in particular when they stop being effective on their own with ADT.
UroStream: Advanced treatments (such as chemotherapy or radionuclide therapy) can have a significant impact on patients’ quality of life. How do you balance efficacy and side effects?
Dr. Alicia K. Morgans: I think that the balance between treatment efficacy and side effects is so critically important to the patients who are living under the care of our teams and under the influence of these treatments every day. And treatments only work if the patients are able to take them and tolerate them. And any individual is going to have a bit of a different balance between treatment efficacy and toxicity, so it’s really incumbent upon all of us as physicians and as clinical teams—including our nurses and other members of the team—to ask patients how they’re doing and make sure that we understand the impacts that the therapies are having on their quality of life, including things like fatigue or GI effects and others.
When it comes to things like cytopenias, really we have an obligation to ensure safety, and we balance the effectiveness of treatment with those safety effects on the bone marrow by monitoring and ensuring that we intervene. We reverse things that are reversible, like underlying anemias, and we make sure that we understand how to best support patients with blood transfusions or sometimes changing therapy—if the therapy is somewhat helpful in terms of efficacy but is really causing large amounts of toxicity. It’s always a trade-off. And I think that part of our job is really making sure that we are aware of when that trade-off is benefiting the patient and when it’s time to call it a day on a therapy and say, “This is no longer worth the effort.”
UroStream: In your clinical team, how do you achieve interdisciplinary collaboration among oncology, urology, and radiotherapy? Can you give an example of how this model can improve patient outcomes?
Dr. Alicia K. Morgans:I think multidisciplinary care is both one of the most important things for patients, but also one of the most rewarding aspects of providing clinical care. Because when we work as teams, it’s actually really effective in teaching all of us how to be better doctors as well.
Our team is lucky in that we are co-localized—practicing in the same place as urologists, radiation oncologists, and medical oncologists—sharing the same workroom and space, so that even on the same day when we’re in clinic, we can talk to each other and discuss patient cases and care.
I think also importantly, we have each other’s cell phone numbers, and we can text each other if we don’t see each other in the hallway or if someone is out of town, so that we can always have that support when needed. And I also think that it’s great to have a team that’s very responsive, whether we’re in clinic or not, because questions may come up. A patient may have a new bone metastasis, we may need some metastasis-directed therapy or some palliative radiation that’s unexpected—and my radiation colleagues always respond, come, and help the patient very, very quickly and take things in the right direction.
Or a patient may be developing urinary symptoms, need to have an obstruction that’s relieved, or may have changed his mind and said, “I thought I wanted to do radiation, but now I want to have a prostatectomy.” And always, my urology colleagues step in and just move things forward in a seamless way.
So that collaboration and communication—mutual respect and shared space—I think is something that makes this a wonderful experience and the best way to practice for patients.
