As 2024 draws to a close, the field of oncology celebrates the year’s grand finale with the ESMO ASIA Annual Meeting. The conference not only attracted top scholars and researchers from across Asia and the global oncology community but also showcased numerous breakthroughs in urologic oncology. On-site at the conference, Urology Frontier invited Professor Xuefeng Qiu from Nanjing Drum Tower Hospital，The Affiliated Hospital of Nanjing University Medical School to summarize this year’s advancements in the field of prostate cancer, share his team’s research selected for ESMO ASIA, and discuss future trends in the field.

Urology Frontier：This year, major breakthroughs in urologic oncology were unveiled at international conferences like ESMO and ESMO ASIA. How have these advancements influenced the diagnosis and treatment of prostate cancer and other urologic malignancies?

Professor Xuefeng Qiu：In 2024, significant progress has been made in prostate cancer diagnosis and assessment, particularly with the growing application of multiparametric MRI (mpMRI), prostate biopsy techniques, and PSMA PET/CT. These advancements have improved diagnostic accuracy and staging precision, potentially altering clinical decision-making for patients.

1. mpMRI and Prostate Biopsy For patients suspected of clinically significant prostate cancer, mpMRI and prostate biopsy are commonly recommended. Over the years, targeted biopsy combined with systematic biopsy has been the standard approach, but cognitive fusion biopsy has now been increasingly integrated. Studies have shown that experienced physicians using cognitive fusion techniques can achieve results comparable to those of software fusion methods, with the added benefit of lower equipment requirements, though it demands higher technical expertise from the physician.

Additionally, new biopsy techniques, such as targeted biopsy combined with peri-lesional biopsy, have been proposed to reduce the number of biopsy needles and lower complication rates. However, the evidence supporting peri-lesional biopsy remains relatively weak, and various protocols have been suggested by different researchers. Determining the most clinically appropriate method still requires further exploration.

1. PSMA PET/CT PSMA PET/CT has been a hot topic in prostate cancer research. Numerous recent studies have demonstrated its pivotal role in reassessment for patients with post-surgical recurrence. Compared to traditional imaging modalities like ECT bone scans, CT, and mpMRI, PSMA PET/CT exhibits higher sensitivity and specificity, enabling the detection of recurrence sites that conventional tools may miss. This allows physicians to reassess disease status and adjust treatment plans accordingly.

As a result, several guidelines, including those by ESMO, recommend PSMA PET/CT for patients with recurrence, albeit with a Grade C recommendation. While PSMA PET/CT facilitates early detection and intervention, the long-term benefit evidence is not robust. Thus, its application should be decided based on individual circumstances and shared decision-making between patients and physicians.

1. Genetic Testing The application of genetic testing in prostate cancer treatment has also garnered increasing attention. While standardized protocols have been established abroad, China mainly relies on expert consensus. This year, relevant guidelines updated recommendations for genetic testing, including the scope of testing, target populations, and testing methods such as HRR testing and TMB detection. For advanced-stage patients, where obtaining samples from primary or metastatic lesions is challenging, studies have shown that ctDNA testing based on serum is also an effective alternative.

Treatment Advancements

With ongoing research, treatment approaches for prostate cancer at different stages have also evolved. Below, I highlight two stages that I am particularly focused on: the biochemical recurrence (BCR) stage and the metastatic hormone-sensitive prostate cancer (mHSPC) stage.

1. Biochemical Recurrence Stage Treatment for patients experiencing biochemical recurrence of prostate cancer primarily revolves around salvage therapies, often combined with ADT (androgen deprivation therapy). Recent studies have explored this stage further, with the EMBARK study establishing the role of enzalutamide monotherapy in treating high-risk BCR patients. Current guidelines and expert consensus recommend enzalutamide monotherapy or its combination with ADT for high-risk BCR patients.

This also reflects trends in drug development, as enzalutamide is transitioning from use in mCRPC patients to mHSPC and now high-risk BCR patients. In the future, it might even be utilized in adjuvant or neoadjuvant settings for postoperative high-risk patients.

1. mHSPC Stage Significant advancements have also been made in treating advanced prostate cancer, particularly in the mHSPC stage. This year’s ESMO and ESMO ASIA meetings reported numerous studies on dual and triple combination therapies for mHSPC. Current findings suggest that triple therapies (e.g., ADT combined with darolutamide and docetaxel, or ADT combined with abiraterone and docetaxel) may have specific advantages for younger patients with high tumor burden, high-risk disease, and good tolerance for docetaxel. These approaches have been endorsed by guidelines and consensus.

However, some patients still refuse chemotherapy. Identifying suitable candidates who can achieve long-term benefits remains a key focus for the future. Currently, there is a lack of related biomarkers for treatment in this field, making the development of molecular imaging tools a future priority. While there has been much research in the mCRPC stage, breakthrough findings remain relatively scarce.

Urology Frontier：Can you introduce the related research achievements of you and your team, as multiple studies from the urology department at Nanjing Drum Tower Hospital were selected for the ESMO ASIA conference this year?

Professor Xuefeng Qiu：At this year’s ESMO ASIA conference, our team had nine studies accepted, including eight posters and one oral presentation. Based on my area of expertise and focus, I would like to highlight two prostate cancer-related studies.

Testosterone Levels and Long-Term Prognosis

The first study is a retrospective, single-center research project that has been ongoing for several years. It analyzed the relationship between testosterone levels during androgen deprivation therapy (ADT) and long-term prognosis in prostate cancer patients. The results demonstrated that lower testosterone levels (as defined by the 2024 EAU guideline threshold for deep testosterone suppression, <20 ng/dl) were associated with better long-term survival outcomes.

The study also emphasizes the importance of monitoring testosterone levels in patients undergoing endocrine therapy. Despite most patients receiving standard medical castration, some do not achieve ideal testosterone suppression, which may lead to PSA progression or disease worsening. We need to further explore whether such progression is due to drug resistance or insufficient drug efficacy. While similar studies have been reported internationally, this type of research is relatively rare in China. Therefore, being selected for ESMO ASIA provides valuable insights for clinical practice in our country.

Survival Analysis of Relugolix + ADT in mHSPC Across Different Age Groups

The second study focuses on relugolix, a domestically developed second-generation androgen receptor (AR) inhibitor. The drug was featured in The Lancet Oncology in 2022 and is recommended by the CSCO guidelines for treating high-burden metastatic hormone-sensitive prostate cancer (mHSPC). This study conducted a stratified post-hoc analysis to evaluate the efficacy of combining relugolix with ADT across different age groups. Results showed comparable benefits in overall survival (OS), radiographic progression-free survival (rPFS), and time to PSA progression across all age groups. Additionally, the incidence and severity of side effects associated with ADT combined with relugolix were similar across age groups when compared to the control group.

In summary, the combination of ADT and relugolix is effective for treating high-burden mHSPC and demonstrates consistent safety and efficacy across different age groups. This conclusion was shared through an oral presentation at the conference, where we also engaged in in-depth discussions with international colleagues about the potential of relugolix in future triple therapy regimens. Furthermore, domestic researchers are currently investigating its use in low-burden patients and its role in triple therapy combinations. With more evidence and data, we anticipate that ADT combined with relugolix will play an increasingly significant role in mHSPC treatment.

Urology Frontier：Based on these studies and the latest treatment strategies, how do you foresee changes in the clinical practice of prostate cancer treatment in the future?

Professor Xuefeng Qiu：Each year, academic conferences present multiple advancements in the diagnosis and treatment of prostate cancer. By participating in large-scale clinical conferences and summarizing high-level clinical evidence, we aim to standardize and advance progress in the field of prostate cancer treatment. As a prostate cancer surgeon, I believe the future of clinical practice may see the following changes:

Diagnosis

Advancements in diagnostic methods, such as cognitive fusion biopsy and targeted biopsy combined with perilesional puncture, may lead to significant changes. Many centers in China are conducting relevant clinical studies. For instance, our hospital is undertaking a study on biopsy techniques, with enrollment expected to conclude by the end of 2024 and results to be published in 2025.

BCR Treatment

High-risk localized prostate cancer patients face a high probability of biochemical recurrence (BCR) post-radical surgery. Selecting subsequent treatment plans remains a challenging issue in China. International guidelines often recommend salvage radiotherapy with or without endocrine therapy. However, due to fear of radiotherapy among Chinese patients, its acceptance remains low.

In recent years, novel endocrine therapies such as enzalutamide or enzalutamide combined with ADT have been shown to benefit high-risk biochemical recurrence patients, providing new treatment options for this population. With more clinical evidence emerging, physicians will gain greater confidence in choosing these treatment regimens.

mHSPC Treatment

Treatment for advanced prostate cancer, especially at the mHSPC stage, has undergone significant changes over the past decade. It has evolved from standalone ADT to a variety of drug options, including dual and triple therapies. Selecting the most suitable treatment for patients is now a critical issue. Currently, stratification tools for mHSPC are limited, relying primarily on traditional imaging and pathological features. However, with advancements in molecular profiling technologies, future treatment decisions are likely to be guided by imaging or molecular-based stratification models.

While genetic testing or Decipher testing packages are increasingly recommended internationally, their application in China is still limited. This represents a potential area for future development in research and clinical practice.

Professor Xuefeng Qiu

• Associate Chief Physician, Department of Urology, Nanjing Drum Tower Hospital, Affiliated Hospital of Nanjing University Medical School
• Associate Professor, Nanjing University Medical School; M.D.
• Master’s Supervisor (Nanjing University, Nanjing Medical University, Nanjing University of Chinese Medicine)
• Postdoctoral Fellow, University of California, San Francisco (UCSF) and Nanjing University School of Life Sciences
• Selected for Jiangsu Province’s “333” High-Level Talent Training Program
• Selected for Nanjing Young Talent Program
• Working Secretary, Medical Robotics Committee, Jiangsu Medical Association