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Drs. Benjamin Garmezy & Manojkumar Bupathi

Urology

Drs. Manojkumar Bupathi and Benjamin Garmezy are expert healthcare providers in oncology and genitourinary cancers. Dr. Garmezy, of Sarah Cannon Research Institute, serves as the Associate Director of Genitourinary Research for the national network as well as the Co-Chair of the Executive Research Committee where he oversees investigational therapy trials for GU cancers, including prostate, kidney, testicular, and bladder cancers. Dr. Bupathi is a board-certified medical oncologist specializing in genitourinary cancers including adrenal, bladder, kidney, penile, prostate, and testicular. He was recently elected practice president for Rocky Mountain Cancer Centers and serves as the Co-Chair for US Oncology Genitourinary Cancer Research Program.

Treatment of Oligometastatic Prostate Cancer

Dear readers,

What is the definition of oligometastatic prostate cancer? How do we best treat patients in this disease state? The true answer is that we don’t fully know. There is always the risk of over- vs. under-treatment. However, we do not always have the luxury of high-quality data to guide us, and we need to make decisions for the patient in front of us today.

At ASCO GU 2025, Dr. Niazi presented phase II data from the GROUQ-PCS 9 trial. This trial looked at patients with front-line mCRPC with 1-5 metastases who had not seen a prior androgen receptor pathway inhibitor (but could have seen docetaxel in the mHSPC setting). In essence, these were patients with progression on ADT monotherapy who had a few sites of metastatic disease. Patients were randomized to receive ADT + enzalutamide vs. ADT + enzalutamide + metastasis-directed therapy (MDT) with radiation (SBRT). The addition of SBRT to ADT + enzalutamide resulted in a 52% reduction in radiological progression or death (HR 0.48; p=0.014). rPFS was dramatically different: 4.6 vs. 2.3 months. There was also an improvement in biochemical progression-free survival and time to subsequent line of therapy, but overall survival was not significantly different.

This data adds to the STOMP and ORIOLE datasets, both phase II studies. In STOMP, patients with up to 3 metastases were randomized to either surveillance or MDT after recurrence following curative-intent therapy. Five year ADT free survival was 34% vs. 8% (MDT vs surveillance). The five-year CRPC survival was 76% vs. 53%. ORIOLE had a similar trial design, including men with up to three metastatic lesions. Progression at six months was 19% vs. 61%. Dr. Deek and colleagues published genetic predictors of response to STOMP and ORIOLE and suggested that patients with mutations in one of ATM, BRCA1/2, RB1, or TP53 were most likely to derive benefit from MDT.

So how do we translate this data into clinical practice? I think a lot of us are starting to use MDT in mHSPC and in some cases in mCRPC. The goal in mHSPC is to further debulk the tumor and treat with ADT + ARPI, and then try and pull of therapy. For mCRPC, the goal could be to delay castration or to prolong time until castration resistance. The caveat here is we do not have high-level evidence to support this paradigm, and there is a risk of harm with MDT.

In the Oncology Decoded podcast, we further discuss oligometastatic prostate cancer and its therapy in the community (with guests Dr. David Morris and Dr. Tanya Dorff). Please listen and subscribe to Oncology Decoded on Apple or Spotify (or using the link below)!

Best,

Benjamin Garmezy, MD & Manojkumar Bupathi, MD

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