Metastatic HSPC: Insights on Imaging, Genomics, and Treatment Selection

At the 2025 American Society of Clinical Oncology Genitourinary Cancers Symposium, a roundtable of expert panelists convened to discuss the latest research and practice updates related to metastatic hormone-sensitive prostate cancer (mHSPC). Dr. Tanya Dorff of City of Hope Comprehensive Cancer Center was joined by Drs. Dan Childs, Andrew Hahn, Cora Sternberg, and Vadim Koshkin in the discussion.

In the first part of the roundtable, the panel explores the the role of imaging, genomics, and patient factors in the management of mHSPC, covering treatment selection based on age and disease burden, the impact of comorbidities, the use of PSMA PET scans for staging and guiding therapy, and the limitations of extrapolating conventional imaging-based clinical trial data to modern PET-based assessments.

View the next segment on The Role of Genetic and Molecular Testing in Treatment Selection for HSPC.

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Dr. Dorff: We are going to start by discussing mHSPC, focusing on how we use diagnostics like imaging and genomics to categorize patients and select treatments. We recently reviewed the STOPCAP meta-analysis, which primarily examined clinical features. Was there anything new or particularly interesting to you in that analysis?

Dr. Hahn: I thought one of the most interesting aspects of the meta-analysis, as you highlighted, was the role of age in patient outcomes. Specifically, we saw that patients aged over 75 had inferior outcomes with abiraterone compared to younger patients or those treated with AR antagonists.

Dr. Dorff: That raises some concerns. Toward the end of the discussion, the topic of geriatric oncology came up. Is that something either of you utilize in your practice?

Dr. Sternberg: I do not personally use geriatric oncology, but in New York, older patients tend to be very proactive about their care. Many want to pursue all available treatments. However, after listening to the analysis, it does seem that older patients might do just as well with ADT alone and may not necessarily need a second AR pathway inhibitor. That is different from what I saw when I practiced in Rome, Italy.

Dr. Childs: Age is a tricky variable. Sometimes, we meet a 75-year-old who functions more like a 90-year-old, and other times, we see an 80-year-old who is as active as a 50-year-old. So, while age is a factor, I do not think it is the best tool for making decisions about treatment intensification. It is one component, but not the most important one.

Dr. Sternberg: I completely agree. It is really about biological age rather than chronological age.

Dr. Koshkin: Yes, I agree as well. A lot depends on patient preference: how much they are willing to do and what their expectations are. While some of that is age-related, much of it is not.

Dr. Sternberg: Another important consideration is comorbidities. Older patients often have cardiovascular disease, hypertension, diabetes, and are on an average of 10 medications. That needs to be factored into treatment decisions.

Dr. Dorff: That is a great point. The VA developed a simple tool that looks at the number of medications a patient is on, which is highly predictive of longevity. Maybe we should be incorporating that when making treatment decisions.

What about disease burden? If you had an 80- or 85-year-old patient with extensive disease, would that make you more inclined to use a doublet?

Dr. Sternberg: Possibly a doublet, but I would not necessarily use a triplet in an 85-year-old. However, if it were a 60-year-old with high disease burden—especially involving the lungs or liver—or with poor histology, I would strongly consider a triplet.

Dr. Dorff: In Europe, they probably use PSMA PET more frequently than we do. Are you using PSMA PET to assess disease burden in mHSPC patients in New York?

Dr. Sternberg: We use a lot of PSMA PET in New York, particularly for biochemical relapse or in newly diagnosed metastatic patients. However, I do not think there is enough data to justify using it for routine follow-up. Nuclear medicine specialists advocate for PSMA PET in monitoring, but insurance does not cover it, and there is not enough evidence to support that approach. So, I still rely on conventional imaging for follow-up.

Dr. Hahn: I would add that PSMA PET is a useful staging tool, but its impact on management decisions depends on what you find. If conventional imaging already shows high-volume disease, seeing additional metastases on PSMA PET likely will not change my treatment approach. However, when conventional imaging shows only a single lesion, and we are considering options like prostate radiation or metastasis-directed therapy, PSMA PET can clarify whether that lesion is an isolated finding or part of a larger disease process.

Dr. Childs: In my practice, many patients have already undergone PSMA PET as their first staging test by the time they see me. We spend a lot of time interpreting whether a patient has high- or low-volume disease and how to correlate PSMA PET findings with conventional imaging. That said, most patients are not in a diagnostic gray zone. If a PSMA PET shows widespread disease, we recognize it as aggressive biology. If it shows only a few bone lesions, we can reasonably assume they would meet low-volume criteria on conventional imaging.

Dr. Sternberg: That is an important point. The major studies we rely on—like CHAARTED and EMBARK—were all conducted using conventional imaging. So, we cannot directly apply PSMA PET findings to those study criteria.

Dr. Koshkin: Right. We often discuss high- versus low-volume disease based on CHAARTED criteria, but the question is: how do we actually use that information in practice today?

Dr. Dorff: I agree. If a patient appears low-volume on conventional imaging, and we are considering an oligometastatic approach—such as SBRT—PSMA PET can be useful to confirm or refute their oligometastatic status. It makes sense in that context, given that trials like STOMP and ORIOLE used different imaging modalities, including choline PET.