<p>Innovations in imaging technologies, molecular biomarkers, and genomic classifiers are providing new ways to risk stratify patients with prostate cancer. Our featured experts share their thoughts on these developments, how they have influenced their clinical practice, and the future of prostate cancer risk stratification.</p>

My urology practice is completely different now than it was 10 years ago in the sense that, 10 years ago, we did not use prostate magnetic resonance imaging (MRI) for workup in patients with an elevated prostate-specific antigen. We did not have any molecular biomarkers available or the ability to use prostate-specific membrane antigen positron emission tomography (PSMA PET) scans for staging. So, there have been a lot of changes, starting in advanced prostate cancer around 2010 and continuing in localized disease with the introduction of novel imaging agents and biomarkers.

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The use of prostate MRI has gotten so popular that it is now sometimes difficult to access. At my institution, it can sometimes take 6 to 8 weeks for someone to get on the schedule for an MRI. Further, because its use has proliferated across centers, sometimes there are some quality assurance issues with community-based MRI programs in that you may not get the same reading that you would get at a tertiary care center. However, that is often the case with any new technology.

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As a urologist, I would love for some technology to become available that could tell me who should have surgery and who should have radiation. I see patients with intermediate- and high-risk prostate cancer, and I might recommend surgery for someone in this group, whereas a radiation oncologist might recommend radiation for that same patient. At Duke, we typically have a genitourinary medical oncologist see these patients in a multidisciplinary oncology clinic, and we joke that they are the tiebreaker. Having sophisticated risk stratification in the future could potentially help us make determinations on some really fundamental questions about surgery vs radiation.

In localized prostate cancer, we have seen a paradigm shift in how we use genomic classifiers such as Decipher (Veracyte, Inc) and Oncotype DX (Exact Sciences Corporation) to determine whether patients need hormonal therapy, how long they should get it after radiation therapy, and how long they are likely to have benefit from hormonal therapy. A recent study was presented at the 2025 American Society of Clinical Oncology (ASCO) Annual Meeting by Wolfgang Peter Fendler, MD, one of the leaders of the PROMISE registry, which collected data from more than 6000 patients with prostate cancer across all different stages. We are looking forward to seeing the published article, but the results presented at ASCO 2025 showed that patients could be separated into low, intermediate, and high risk based on their PSMA PET scan across all stages of prostate cancer. In localized prostate cancer, PSMA PET scan–based prognostication seems to outperform traditional risk prognostication or modeling. I think that this is just a start, and I remain very optimistic about how these tools are going to help us better define the aggressiveness of the disease and improve management.

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I like the ArteraAI Prostate Test (Artera) because many of my patients would love to avoid ADT when they are receiving radiation therapy, and many intermediate-risk patients can avoid ADT or castration. If some high-risk patients can avoid the extra 2 years of ADT, that would be a big deal for them. I think that it is quite exciting to have tools available in the clinic that not only help with initial decision making but also help guide how long patients should remain on ADT and whether they really need to be on ADT.

I think that early on after the introduction of PSMA PET/computed tomography scans in the United States, there was some resistance from people who would say, “We don’t know what to do with this information. It has not been cross validated against conventional imaging.” However, practically speaking, the technology is here, it is highly sensitive and specific, and we are acting on it clinically. It has allowed us to be more precise in our management of prostate cancer.

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Moreover, in the distant past, we used to think of prostate cancer as being either localized or metastatic, and management was very different for each. However, because of the remarkable progress in prostate cancer management and now that we can see gradations in the disease and have greater precision in defining it, there can be a lot of treatment overlap between localized and metastatic disease. For example, there are now patients with localized disease for whom we might intensify systemic therapy, and, conversely, there are those with metastatic disease for whom we might choose to treat the primary tumor. These things were not done in the past. I think that the field has moved forward and has adopted these approaches, and there is really no going back, which is a very good thing.