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Genomic Classifiers and AI for Personalizing Prostate Cancer Radiation Therapy
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Jason Efstathiou, MD, DPhil, FASTRO, FACRO
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| Jason Efstathiou discusses the use of genomic classifiers and AI-based tools in personalizing radiation therapy for prostate cancer.
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| Can Genomics/Artificial Intelligence Help to Minimize Over- or Undertreatment?
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| Jason Efstathiou, MD, DPhil, FASTRO, FACRO
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| Jason Efstathiou argued that genomics and AI can help reduce both overtreatment and undertreatment in prostate cancer, but only when the biomarker matches the clinical question and the endpoint being studied. He emphasized that tools like Decipher and ArteraAI are complementary rather than interchangeable, and that decisions should be guided by absolute benefit, harms, patient preferences, and prospective validation.
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Testosterone Recovery Dynamics After Short-Term ADT for Localized Prostate Cancer
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Bertrand Tombal, MD, PhD
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| Bertrand Tombal outlines testosterone recovery dynamics after short-term ADT with radiation therapy.
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| The Importance of Baseline Testosterone and Testosterone Recovery in High-Risk and Locally Advanced Prostate Cancer
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| Bertrand Tombal, MD, PhD
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| Bertrand Tombal argued that testosterone should be measured before, during, and after ADT because baseline and recovery patterns help inform treatment monitoring and prognosis in high-risk or locally advanced prostate cancer. He highlighted that lower on-treatment testosterone and failure to recover testosterone are generally associated with worse outcomes and slower quality-of-life recovery, although the causal role of recovery in survival remains uncertain.
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| Patients with High-Risk Localized Prostate Cancer Need the Addition of an ARPI to Radiotherapy + Long-Term ADT – Pro the Addition of ARPI to Radiotherapy + ADT
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| Christopher Sweeney, MBBS
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| Christopher Sweeney argued that many men with high-risk localized prostate cancer should receive an ARPI in addition to radiotherapy and long-term ADT, especially when modern PSMA PET staging suggests occult micrometastatic disease. He pointed to STAMPEDE and ENZARAD to show that benefit may be greatest in patients with node-positive or pelvic-node–irradiated disease, while most others may not need enzalutamide.
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| Patients with High-Risk Localized Prostate Cancer Need the Addition of an ARPI to Radiotherapy + Long-Term ADT – Against the Addition of ARPI to Radiotherapy + ADT
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| Jeff Michalski, MD, MBA, FACR, FASTRO
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| Jeff Michalski argued that adding an ARPI to radiotherapy plus long-term ADT should not be routine for all men with high-risk localized prostate cancer, because ENZARAD was negative for metastasis-free survival and overall survival in the overall population. He emphasized selective use instead, mainly for patients with node-positive disease or biomarker-defined high-risk biology, while also weighing toxicity and cost.
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Balancing Treatment Intensification and Quality of Life in Elderly Prostate Cancer Patients
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Rana McKay, MD
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| Rana McKay discusses treating older patients with high-risk and locally advanced prostate cancer. Dr. McKay recommends the Geriatric 8 screening tool, a four-to-five-minute assessment, as a first-line frailty screen, with scores of 14 or below triggering comprehensive geriatric assessment.
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| In Which Patients with High-Risk Disease May Surgery Alone Be Enough and Is There Any Added Value of Surgery If Done as Part of Multimodality Treatment in This Setting?
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| Declan Murphy, MB, BCH, BaO, FRACS, FRCS, Urol
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| Declan Murphy argued that surgery alone is most reasonable for carefully selected high-risk patients with only one high-risk feature, lower-volume disease, no very high-risk biology, and negative metastatic staging. For more advanced cases, he viewed radical prostatectomy as part of a multimodal strategy, with postoperative restaging helping determine whether additional radiotherapy and/or systemic therapy are needed.
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