The 2026 Pujiang Prostate Cancer Summit was successfully held in Shanghai on June 26–27. Hosted by the Shanghai Anti-Cancer Association and organized by Fudan University Shanghai Cancer Center, the meeting brought together leading experts through keynote lectures, multidisciplinary (MDT) discussions, and live surgical demonstrations to highlight the latest advances in prostate cancer management. Among the meeting's major themes, personalized and precision treatment strategies attracted particular attention.Professor Jianming Guo from the Department of Urology at Zhongshan Hospital, Fudan University, attended the conference and spoke with UroStream about combination endocrine strategies spanning metastatic hormone-sensitive prostate cancer (mHSPC) to metastatic castration-resistant prostate cancer (mCRPC), emerging approaches to overcoming treatment resistance, and the evolving role of cytoreductive surgery for oligometastatic disease. Drawing upon the latest clinical evidence and ongoing research, Professor Guo shared valuable perspectives on current practice and future directions.
Q1. Several novel hormonal therapies and combination regimens have been updated in 2026. Across the continuum from mHSPC to mCRPC, which emerging combination strategies do you find most promising?
Professor Jianming Guo:
The treatment landscape for metastatic prostate cancer has evolved from the traditional concepts of hormone-sensitive prostate cancer (HSPC) and castration-resistant prostate cancer (CRPC), while remaining centered on androgen-targeted therapies.
One important development is a change in disease terminology. According to the latest Prostate Cancer Working Group 4 (PCWG4) recommendations and recent studies published in the New England Journal of Medicine, HSPC and CRPC are increasingly being reclassified as androgen pathway-modulated (APM) disease. Hormone-sensitive disease is now referred to as APMS, whereas resistant disease is termed APMR.
Although clinicians will need time to adapt to this new nomenclature, it reflects a broader conceptual shift: treatment is no longer defined solely by androgen deprivation therapy (ADT) but also by comprehensive androgen receptor pathway inhibition, with second-generation androgen receptor inhibitors now routinely introduced during the hormone-sensitive stage.
As a result, outcomes for patients with mHSPC have improved substantially. Dual- and triple-agent regimens, radioligand therapy, and the incorporation of PARP inhibitors have greatly expanded therapeutic options.
For example, although olaparib recently lost its urologic indication for prostate cancer in China because of less favorable long-term progression-free survival (PFS) data, talazoparib and niraparib have both secured regulatory approval based on positive clinical trial results. Particularly encouraging is the inclusion of the fixed-dose combination of niraparib plus abiraterone in China’s national reimbursement negotiations.
However, once patients progress to the CRPC (APMR) stage, treatment decisions become considerably more challenging. Simply switching to another second-generation androgen receptor inhibitor is generally ineffective because of cross-resistance. Chemotherapy remains an option, although many patients have already received docetaxel during the hormone-sensitive phase or may not tolerate additional chemotherapy.
PARP inhibitors offer another important strategy, but their benefit is largely restricted to patients harboring homologous recombination repair (HRR) mutations, particularly BRCA alterations, which are present in only a minority of advanced prostate cancers.
Another recently approved option is lutetium-177 (^177Lu)-PSMA radioligand therapy (RLT), which currently carries two indications: post-chemotherapy mCRPC based on the VISION trial, and pre-chemotherapy mCRPC based on PSMAfore. Broader clinical adoption, however, will depend in part on cost and accessibility.
Consequently, significant unmet needs remain in APMR. Numerous clinical trials are currently evaluating B7-H3-targeted antibody-drug conjugates (ADCs), dual-target therapies, and androgen receptor degraders, although further clinical evidence is needed to establish their role.
Q2. Endocrine resistance remains one of the greatest challenges in advanced prostate cancer. What strategies show the greatest promise for overcoming resistance?
Professor Jianming Guo:
The introduction of newer therapies has substantially delayed progression from HSPC to CRPC, resulting in meaningful improvements in overall survival (OS). Studies such as ENZAMET have reported median OS approaching eight years from the hormone-sensitive stage, while some patients continue to achieve approximately three years of survival after developing CRPC.
Several promising strategies are being explored to overcome resistance.
The first targets the androgen receptor itself. Novel androgen receptor degraders are being developed to directly eliminate the receptor and circumvent conventional resistance mechanisms.
The second focuses on blocking upstream androgen biosynthesis, similar to the mechanism of abiraterone, with several new agents currently under investigation.
A third approach relies on precision molecular profiling. Patients with BRCA mutations have demonstrated meaningful benefit from combining PARP inhibitors with abiraterone or enzalutamide. Likewise, patients with PSMA-positive disease may derive greater progression-free and overall survival benefit when ^177Lu-PSMA is combined with enzalutamide, compared with radioligand therapy alone.
Equally important is recognizing that the biological characteristics of prostate cancer may evolve following the development of CRPC. Tumors may undergo histologic transformation, progressing from conventional adenocarcinoma to small-cell carcinoma or neuroendocrine prostate cancer.
Whenever feasible, we strongly recommend repeat biopsy and comprehensive genomic profiling following treatment resistance. For example, identification of a PTEN mutation may open the possibility of treatment with capivasertib, a PI3K/AKT pathway inhibitor that has already been approved in other malignancies and is expected to enter the prostate cancer treatment landscape in the near future.
These developments represent important steps toward overcoming resistance in advanced prostate cancer.
Q3. As treatment strategies for oligometastatic prostate cancer continue to evolve, increasing attention is being given to management of the primary tumor. How do you define oligometastatic disease, and what is the clinical value of combining cytoreductive surgery with intensified systemic therapy?
Professor Jianming Guo:
Oligometastatic disease remains metastatic disease by definition. International consensus on its definition is still lacking. Traditionally, it has been defined as five or fewer metastatic lesions, but many contemporary clinical studies involving surgery and radiotherapy adopt a more stringent threshold of three or four lesions.
Personally, I believe defining oligometastatic disease as three or fewer metastatic sites is more appropriate, as the benefit of local therapy tends to diminish when metastatic burden becomes more extensive.
Growing interest in treatment of the primary tumor is driven by two major considerations.
First, cytoreductive surgery reduces overall tumor burden.
Second, removal of the primary tumor provides valuable biological information. Surgical specimens allow more comprehensive genomic profiling while potentially enhancing antitumor immune responses.
Accordingly, perioperative multimodal treatment has become an important area of investigation. The current strategy involves neoadjuvant ADT combined with androgen receptor inhibition to shrink the tumor, followed by resection of the primary lesion and intensified treatment of remaining metastatic sites—for example, radiotherapy for bone metastases.
This integrated approach of systemic therapy, primary tumor surgery, and targeted treatment of metastatic lesions appears more effective than the traditional strategy of relying exclusively on systemic therapy once metastatic disease is diagnosed.
Although current European guidelines have not yet incorporated cytoreductive surgery into standard recommendations, clinical studies across Europe continue to accumulate encouraging evidence demonstrating patient benefit.
I believe that as more high-quality data become available, future guidelines will evolve accordingly, and local treatment of the primary tumor will become an increasingly important component of comprehensive systemic management for selected patients with oligometastatic prostate cancer.
Expert Profile
Professor Jianming Guo Department of Urology, Zhongshan Hospital, Fudan University
