Prostate
APCCC 2026 panel opinion on high-risk localised PC: RT + long-term ADT ± ARPI is the plurality pick, while fractionation stays unsettled.
APCCC 2026: High-risk Localised, Locally Advanced, and Biochemically Recurrent PC
TL;DRConsensus (≥75%) reached on 44 of 134 questions (32.8%); fractionation for high-risk localised PC reached no consensus despite 88% favoring some hypofractionation.
HEATENZARADSTAMPEDEHYPO-RT-PCSHARPATLASPEACE-7THUNDER
Fractionation drew 88% for some form of hypofractionation but no consensus on which form, and 44 panellists abstained or declared themselves unqualified. Moderate hypofractionation (2.5–3.4 Gy/fx) is framed as the established option. SBRT for high-risk disease rests on non-randomised SHARP pooling, with 5-yr G2 GU toxicity of 23%, so it stays a trial question.
In very high-risk cN0 PC planned for RT + long-term ADT, panel opinion (65–71%) favors adding 2 yr abiraterone over enzalutamide. This does not settle the choice between ultrahypofractionation and moderate hypofractionation for high-risk disease. The longer read
Fractionation reached no consensus: 88% favored some hypofractionation, and 44 panellists abstained. Moderate hypofractionation (2.5–3.4 Gy/fx) is the established option, while SBRT for high-risk disease rests on non-randomised SHARP pooling. DIL focal boost up to 95 Gy over 77 Gy/35 fx is presented as validated dose escalation.
In very high-risk cN0 disease, 65–71% backed 2 yr abiraterone with RT + long-term ADT, and very few backed enzalutamide, tracking ENZARAD's null MFS (HR 0.88). A combined 83% would stop ADT after 2 yr with abiraterone. ATLAS, PEACE-7, THUNDER and DASL-HiCaP will test other ARPIs.
32–38% favored surgery as part of a multimodal approach for high-risk cN0 disease. The panel reached consensus against perioperative ADT + ARPI before RP, but voted before PROTEUS (pCR/MRD 8.9% vs 1.0%) was presented, so that position may shift.
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Modified Delphi process: 144 international experts drafted 313 multiple-choice questions, 134 on high-risk localised / locally advanced PC, PSA persistence and recurrence. 133 panellists voted by web survey before the conference.
Consensus defined a priori as 75% agreement, strong consensus 90%. Consensus reached on 44 of 134 questions (32.8%), seven of them strong.
No consensus on fractionation (Q19) despite a combined 88% favoring some hypofractionation. Moderate hypofractionation (2.5–3.4 Gy per fraction) is named as an option. MRI-defined DIL focal boost up to 95 Gy over 77 Gy in 35 fractions is described as validated in a randomised trial.
Very high-risk disease: RT + long-term ADT (2–3 yr) with the option of abiraterone for 2 yr. A combined 83% voted ADT can be stopped after 2 yr with abiraterone in most or selected pts (Q7).
The intensification votes follow STAMPEDE over ENZARAD, whose null MFS (HR 0.88, 95% CI 0.67–1.15) came in a lower-risk population. ATLAS, PEACE-7, THUNDER and DASL-HiCaP are testing other ARPIs in this setting.
44 panellists abstained or declared themselves unqualified on fractionation, which shrinks the informed denominator. The Q6 vote against perioperative ADT + ARPI before RP predates PROTEUS, which was presented and published after the conference.
The panel accepts RT and multimodal surgery as defensible for high-risk cN0 disease without settling the comparison. Its abiraterone-not-enzalutamide vote is drug-specific, not a class effect, and the ongoing ARPI trials will decide whether that distinction holds.
| Question | Setting | Panel vote |
|---|---|---|
| Q1–Q2 | High-risk cN0 M0 (conventional or next-gen imaging) | RT + long-term ADT ± ARPI 62–68%; surgery as multimodal 32–38% |
| Q3–Q4 | Very high-risk cN0 M0 | RT + long-term ADT + abiraterone 2 yr 65–71%; very few for enzalutamide |
| Q5 | Neoadjuvant systemic therapy before RT | Selected or most pts, combined 83%+ (87% combined) |
| Q6 | Perioperative ADT + ARPI before RP | Consensus against |
| Q7 | Stop ADT after 2 yr with abiraterone | Most or selected pts, combined 83% |
| Q19 | Fractionation, high-risk localised / locally advanced | No consensus; combined 88% some hypofractionation; 44 abstained / unqualified |
- Can other ARPIs replace abiraterone in very high-risk localised PC? recruiting Relugolix and Enzalutamide in Combination With Radiation Therapy for the Treatment of Very High Risk Prostate Cancer, OPTIMAL Trial Phase 2n=50 · primary completion 2030-11 · ph2 enzalutamide + relugolix + RT, NCCN very-high-risk
- Role of SBRT in high-risk localised PC n=146 · primary completion 2024-02 · randomised ph2 SBRT ± ADT, NCCN IR/HR, PET N0M0n=90 · primary completion 2028-08 · ph2 SBRT ± brachy boost + 6mo ADT in NCCN high-risk
- Does PROTEUS change the stance on perioperative ARPI before RP?