# Understanding Management Strategies for Metastatic Hormone-Sensitive Prostate Cancer: A Multidisciplinary Survey in France

Aurélien Gobert, Marc-Olivier Timsit, Pierre Blanchard, Xavier Artignan, Gilles Créhange, Alexandre Ingels, Myriam Chebbah, Solenn Le Clanche, Brigitte Laguerre, Jérome Rigaud, et al.

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## To cite this version:

Aurélien Gobert, Marc-Olivier Timsit, Pierre Blanchard, Xavier Artignan, Gilles Créhange, et al. Understanding Management Strategies for Metastatic Hormone-Sensitive Prostate Cancer: A Multidisciplinary Survey in France. The French Journal of Urology, 2025, pp.103000. 10.1016/j.fjurol.2025.103000. hal-05317289

HAL Id: hal-05317289

https://hal.science/hal-05317289v1

Submitted on 18 Dec 2025

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Original Article

# Understanding management strategies for metastatic hormone-sensitive prostate cancer: A multidisciplinary survey in France

<figure><img src="image_3.png" /></figure>

Comprendre les stratégies de prise en charge du cancer de la prostate métastatique hormonosensible : une enquête de pratique multidisciplinaire en France

Aurélien Gobert<sup>a</sup>, Marc-Olivier Timsit<sup>b,c</sup>, Pierre Blanchard<sup>d</sup>, Xavier Artignan<sup>a</sup>, Gilles Crehange<sup>e</sup>, Alexandre Ingels<sup>f</sup>, Myriam Chebbah<sup>g</sup>, Solenn Le Clanche<sup>g</sup>, Brigitte Laguerre<sup>h</sup>, Jérôme Rigaud<sup>i</sup>, Francois Rozet<sup>j</sup>, Camille Serrate<sup>k</sup>, Stéphane Supiot<sup>l</sup>, Pierre Mongiat-Artus<sup>m,n</sup>, Romain Mathieu<sup>o,*</sup>

ARTICLE INFO

Keywords:

mHSPC

Practice survey

Treatment

Decision-making

France

ABSTRACT

**Introduction:** Metastatic hormone-sensitive prostate cancer (mHSPC) is increasingly diagnosed due to advancements in imaging and screening. Current guidelines recommend intensified androgen deprivation therapy (ADT) as standard of care, with treatment strategies tailored according to disease burden and patient characteristics. This study aimed to explore mHSPC management practices in France through a national clinician survey and multidisciplinary consultation meeting (MCM) discussions, identifying treatment strategies and alignment with guidelines.

**Material and methods:** A two-part questionnaire, developed by a multidisciplinary scientific committee, was distributed to clinicians across France, collecting data on clinician profiles and treatment approaches, including five clinical case scenarios. Additionally, six theoretical cases were discussed in MCMs held across 10 centers to assess collaborative decision-making.

**Results:** Among 143 respondents, 53% were urologists, 22% radiation oncologists, and 25% medical oncologists, with broad regional distribution. Respondents reported managing a median of 30 mHSPC patients annually. Most adhered to national guidelines, though treatment strategies showed variability. Doublet therapy (ADT + ARPI) was widely used, while triplet therapy (ADT + ARPI + docetaxel) was more frequently considered for patients with poor prognostic disease features (e.g., high tumor volume) or younger age. In contrast, ADT alone was typically preferred for frailer patients. MCM discussions promoted greater alignment with guideline-based care.

**Discussion/Conclusion:** This study reveals real-world variability in mHSPC management in France, driven by clinical judgment and patient-specific factors. Multidisciplinary collaboration was critical for consistency and

<footnote><sup>a</sup>Department of Radiation Oncology, CHP St Grégoire, St Grégoire, France</footnote>

<footnote><sup>b</sup>Université de Paris, service urologie, cancérologie génito-urinaire et transplantation rénale, Paris, France</footnote>

<footnote><sup>c</sup>Hôpital européen Georges-Pompidou, service d'urologie, Paris, France</footnote>

<footnote><sup>d</sup>Department of Radiation Oncology, Oncostat U1018 Inserm, Université Paris-Saclay, Gustave-Roussy, Villejuif, France</footnote>

<footnote><sup>e</sup>Department of Radiation Oncology Curie Institute, Paris, France</footnote>

<footnote><sup>f</sup>AP-HP, Department of Urology, Henri-Mondor University Hospital, Créteil, France</footnote>

<footnote><sup>g</sup>Public Health Expertise, Medical Affairs Department, 75004 Paris, France</footnote>

<footnote><sup>h</sup>Department of Medical Oncology, Eugene-Marquis Center, Rennes, France</footnote>

<footnote><sup>i</sup>Departments of Urology and Renal Transplantation, Nantes University Hospital Center, Nantes, France</footnote>

<footnote><sup>j</sup>Department of Urology, Institut Mutualiste Montsouris, Paris, France</footnote>

<footnote><sup>k</sup>Groupe hospitalier Diaconesses Croix Saint-Simon, service d'oncologie médicale, Paris, France</footnote>

<footnote><sup>l</sup>Department of Radiotherapy, Institut de Cancérologie de l'Ouest René-Gauducheau, Saint-Herblain, France</footnote>

<footnote><sup>m</sup>Université Paris Cité, Paris, France</footnote>

<footnote><sup>n</sup>Urology Department, Saint-Louis Hospital, Assistance publique-Hôpitaux de Paris, Paris, France</footnote>

<footnote><sup>o</sup>Department of Urology, University of Rennes, Rennes, France</footnote>

<footnote>* Corresponding author.</footnote>

<footnote>E-mail address: Romain.MATHIEU@chu-rennes.fr (R. Mathieu).</footnote>
Mots clés :

mHSPC

Enquête de pratique

Traitement

Prise de décision

France

personalized care. Ongoing efforts should focus on addressing practice variability, incorporating patient preferences, and integrating emerging therapies to improve outcomes while minimizing loss of therapeutic opportunity.

Level of evidence: (HAS): 4 (descriptive studies, surveys, expert opinions)

RÉSUMÉ

**Introduction** : Le cancer de la prostate métastatique hormonosensible (mHSPC) est de plus en plus fréquemment diagnostiqué grâce aux progrès de l'imagerie et du dépistage. Les recommandations actuelles préconisent une intensification de l'hormonothérapie (ADT) comme standard de traitement, avec des stratégies adaptées en fonction de la charge tumorale et des caractéristiques des patients. Cette étude avait pour objectif d'explorer les pratiques de prise en charge du mHSPC en France à travers une enquête nationale auprès des cliniciens et des discussions lors de réunions de concertation pluridisciplinaire (RCP), afin d'identifier les stratégies thérapeutiques et leur alignement avec les recommandations.

**Matériel et méthodes** : Un questionnaire en deux parties, élaboré par un comité scientifique multidisciplinaire, a été diffusé auprès des cliniciens à travers la France. Il recueillait des données sur le profil des cliniciens et leurs approches thérapeutiques, incluant cinq scénarios cliniques. Par ailleurs, six cas théoriques ont été discutés lors de RCP organisées dans 10 centres afin d'évaluer les prises de décision collaboratives.

**Résultats** : Parmi les 143 répondants, 53 % étaient des urologues, 22 % des oncologues radiothérapeutes et 25 % des oncologues médicaux, représentant une répartition régionale large. Les participants ont rapporté prendre en charge en moyenne 30 patients atteints de mHSPC par an. La majorité suivait les recommandations nationales, bien que des variations dans les stratégies thérapeutiques aient été observées. La bithérapie (ADT + ARPI) était largement utilisée, tandis que la trithérapie (ADT + ARPI + docétaxel) était plus souvent envisagée pour les patients présentant des caractéristiques de mauvais pronostic (par exemple, un volume tumoral élevé) ou dans les groupes d'âge plus jeunes. À l'inverse, l'ADT seule était généralement préférée pour les patients plus fragiles. Les discussions en RCP ont favorisé un meilleur alignement avec les soins basés sur les recommandations.

**Discussion/Conclusion** : Cette étude met en évidence une variabilité dans les pratiques réelles de prise en charge du mHSPC en France, influencée par le jugement clinique et des facteurs spécifiques aux patients. La collaboration multidisciplinaire a joué un rôle clé dans l'harmonisation des pratiques et la personnalisation des soins. Des efforts continus doivent être menés pour réduire les variations de pratique, intégrer les préférences des patients et incorporer les nouvelles thérapies afin d'améliorer les résultats tout en minimisant les opportunités thérapeutiques

**Niveau de preuve** : (HAS): 4 (études descriptives, enquêtes, avis d'experts)

# 1. Introduction

Prostate cancer is a significant global health concern, particularly in developed countries where the aging population is more prominent [1]. According to the Global Cancer Observatory, it was the second most commonly diagnosed cancer and the 5th leading cause of cancer-related deaths among men in 2020 [2]. In France, prostate cancer remains the most prevalent cancer in men, accounting for 25% of all new male cancer diagnoses [3], with over 66,000 new cases reported in 2020 [4]. Hormone-sensitive prostate cancer (HSPC) refers to cases that have either not been treated with androgen deprivation therapy (ADT) or remain responsive to this treatment [5]. Since 2013, the diagnosis of mHSPC has become increasingly common, driven by advancements in imaging techniques, more widespread PSA testing, and improved awareness of early diagnostic methods among general practitioners. This has also been accompanied by a rise in the detection of non-metastatic cases [5]. Treatment strategies have evolved, with upfront docetaxel introduced in 2014 and current guidelines recommending intensified androgen deprivation therapy (ADT) as the standard of care [5,6]. Doublet therapy, combining ADT with androgen receptor pathway inhibitors (ARPIs), is advised for synchronous (metastases present at initial diagnosis) and metachronous (metastases developing after initial treatment) mHSPC due to its survival benefits and good tolerability [6,7]. More recently, triplet therapy (ADT, darolutamide or abiraterone/prednisone, in combination with docetaxel) is an option for fit patients [6,7]. Personalized approaches consider disease burden, patient fitness, and molecular characteristics, with ADT alone reserved for those unable to tolerate intensified treatment [6].

The study aimed to examine current mHSPC treatment practices in France through a survey on clinical decision-making and the analysis

of theoretical patient cases discussed in multidisciplinary consultation meetings (MCM), highlighting real-world practices across patient profiles and healthcare professionals.

# 2. Material and methods

Following a comprehensive literature review aiming to identify relevant clinical guidelines for the management of mHSPC, a multidisciplinary scientific committee (SC) composed of 17 French experts (urologists, radiation and medical oncologists) managing mHSPC in their daily clinical practice developed a 2-section questionnaire (Appendix A1). The first section consisted of 8 questions aiming to characterize the respondents' professional profile and their approach to managing mHSPC patients at their respective institutions. The second section focused on the strategic therapies used in the treatment of patients with distinct types of mHSPC. This section included 5 clinical case scenarios (Appendix A1 – question 13) to assess preferred treatment strategies, with 3 mandatory and 2 optional cases. This was a self-administered questionnaire hosted online on a secure platform between August 29th, 2023, and February 29th, 2024. The questionnaire link was distributed by the SC members via their professional networks and through French learned societies, including the Association française d'urologie (AFU) and the Société française de radiothérapie oncologique (SFRO).

The scientific committee also presented 6 theoretical patient cases with the aim to identify the treatment strategies that healthcare professionals would have proposed for these patients. Patient cases were presented to volunteer members by the MCM coordinator. An identical form was provided for each MCM along with the cases to collect the proposed responses homogeneously and avoid bias in the
way to analyze the results. The 6 patient cases are presented in Appendix A2 A–F.

Since guidelines recommend a multidisciplinary approach to treating advanced prostate cancer [5], the target respondent population consisted of urologists, medical oncologists, and radio-therapists managing mHSPC patients.

Data collection was conducted through the online platform, ensuring both anonymity and confidentiality. The aggregated responses were analyzed and are presented descriptively.

# 3. Results

## 3.1. Respondents' characteristics

A total of 143 respondents participated in the survey, comprising 53% urologists (n = 76), 22% radiation oncologists (n = 32), and 25% medical oncologists (n = 35) (Table 1). The majority worked in private practice (54%) and 46% in public hospitals. The respondents had a median professional experience (corresponding to the number of years of practice after internship) of 17 years (minimum: 1; maximum: 45), including 18 years for urologists, 16 years for radiation oncologists, and 15 years for medical oncologists. The sample represented all regions of France, including Corsica and Guadeloupe, ensuring broad geographical coverage. In median, respondents managed 30 mHSPC patients annually (minimum: 1; maximum: 500). Regarding treatment protocols, 43% followed the 3C

network protocol (a French regional adaptation of national guidelines), while 34% had no specific protocol for mHSPC management in their center. In parallel, 85% of respondents adhered to the ccAFU recommendations for mHSPC treatment selection. Additionally, 66% indicated adherence to European Guidelines (ESMO, EAU-EANM-ESTRO-ESUR-ISUP-SIOG), and 28% referenced International Guidelines (ASCO, NCCN). PET scans were commonly used for biochemical recurrences (94%), initial assessments in high-risk patients (78%), and castration-resistant recurrences (73%).

## 3.2. Therapeutic strategies in patients with mHSPC

Respondents reported that, among the mHSPC patients they are managing in daily clinical practice, an average of 40% had synchronous disease and 60% had metachronous disease.

For synchronous patients, the main criteria used by respondents to identify poor prognostic features were the presence of visceral metastases (97%), the International Society of Urological Pathology (ISUP) score (78%), and the location of bone metastases (60%) (Fig. 1A).

In metachronous cases, poor prognostic features were primarily assessed based on the presence of visceral metastases (88%), the interval between cessation of hormone therapy and recurrence (74%), and prostate specific antigen (PSA) doubling time (73%) (Fig. 1B).

Regarding treatment decisions, 94% of respondents indicated that the initiation of ARPI is systematically discussed in MCM.

<table><caption>**Table 1**

Characteristics of respondents.</caption><thead><tr><th>Characteristics</th><th>Total respondents<br>n = 143</th><th>Urologists<br>n = 76</th><th>Radiation oncologists<br>n = 32</th><th>Medical oncologists<br>n = 35</th></tr></thead><tbody><tr><td>Practitioner specialty, n (%)</td><td>143 (100%)</td><td>76 (53%)</td><td>32 (22%)</td><td>35 (25%)</td></tr><tr><td>Place of practice, n (%)</td><td></td><td></td><td></td><td></td></tr><tr><td>Private</td><td>77 (54%)</td><td>38 (50%)</td><td>20 (63%)</td><td>19 (54%)</td></tr><tr><td>Private clinic</td><td>42 (29%)</td><td>28 (37%)</td><td>11 (34%)</td><td>3 (9%)</td></tr><tr><td>Private hospital except CLCC</td><td>13 (9%)</td><td>9 (12%)</td><td>0 (0%)</td><td>4 (11%)</td></tr><tr><td>CLCC</td><td>22 (15%)</td><td>1 (1%)</td><td>9 (28%)</td><td>12 (34%)</td></tr><tr><td>Public</td><td>66 (46%)</td><td>38 (50%)</td><td>12 (38%)</td><td>16 (46%)</td></tr><tr><td>Public hospital</td><td>24 (17%)</td><td>16 (21%)</td><td>4 (13%)</td><td>4 (11%)</td></tr><tr><td>CHR/CH</td><td>39 (27%)</td><td>20 (26%)</td><td>7 (22%)</td><td>12 (34%)</td></tr><tr><td>Other<sup>a</sup></td><td>3 (2%)</td><td>2 (3%)</td><td>1 (3%)</td><td>0 (0%)</td></tr><tr><td>Experience</td><td></td><td></td><td></td><td></td></tr><tr><td>Median (years)</td><td>17 [1–45]</td><td>18 [3–45]</td><td>16 [6–40]</td><td>15 [1–32]</td></tr><tr><td>Number of mHSPC patients/year</td><td></td><td></td><td></td><td></td></tr><tr><td>Median (years)</td><td>30 [1–500]</td><td>23 [5–300]</td><td>30 [7–250]</td><td>40 [1–500]</td></tr><tr><td>Management protocol for the treatment of mHSPC</td><td></td><td></td><td></td><td></td></tr><tr><td>3C network protocol (French regional adaptation of national guidelines)</td><td>61 (43%)</td><td>33 (43%)</td><td>16 (50%)</td><td>12 (34%)</td></tr><tr><td>Center-specific protocol</td><td>29 (20%)</td><td>13 (17%)</td><td>5 (16%)</td><td>11 (16%)</td></tr><tr><td>No mHSPC protocol</td><td>48 (34%)</td><td>26 (34%)</td><td>10 (31%)</td><td>12 (34%)</td></tr><tr><td>Other<sup>b</sup></td><td>10 (7%)</td><td>4 (5%)</td><td>2 (6%)</td><td>4 (6%)</td></tr><tr><td>Guidelines used for mHSPC treatment</td><td></td><td></td><td></td><td></td></tr><tr><td>ccAFU</td><td>122 (85%)</td><td>73 (96%)</td><td>26 (81%)</td><td>23 (66%)</td></tr><tr><td>European Guidelines (ESMO, EAU-EANM-ESTRO-ESUR-ISUP-SIOG)</td><td>94 (66%)</td><td>22 (29%)</td><td>30 (94%)</td><td>21 (60%)</td></tr><tr><td>International Guidelines (ASCO, NCCN)</td><td>40 (28%)</td><td>7 (9%)</td><td>13 (41%)</td><td>20 (57%)</td></tr><tr><td>Localization</td><td></td><td></td><td></td><td></td></tr><tr><td>Auvergne-Rhône-Alpes</td><td>13</td><td>10</td><td>3</td><td>0</td></tr><tr><td>Burgundy-Franche-Comté</td><td>6</td><td>3</td><td>2</td><td>1</td></tr><tr><td>Brittany</td><td>18</td><td>10</td><td>3</td><td>5</td></tr><tr><td>Centre-Val de Loire</td><td>7</td><td>2</td><td>0</td><td>5</td></tr><tr><td>Corsica</td><td>2</td><td>2</td><td>0</td><td>0</td></tr><tr><td>Grand Est</td><td>10</td><td>4</td><td>3</td><td>3</td></tr><tr><td>Guadeloupe</td><td>2</td><td>0</td><td>2</td><td>0</td></tr><tr><td>Hauts-de-France</td><td>12</td><td>9</td><td>0</td><td>3</td></tr><tr><td>Île-de-France</td><td>22</td><td>11</td><td>8</td><td>3</td></tr><tr><td>Normandy</td><td>4</td><td>3</td><td>1</td><td>0</td></tr><tr><td>New Aquitaine</td><td>10</td><td>3</td><td>4</td><td>3</td></tr><tr><td>Occitania</td><td>15</td><td>6</td><td>2</td><td>7</td></tr><tr><td>Pays de la Loire</td><td>8</td><td>7</td><td>1</td><td>0</td></tr><tr><td>Provence-Alpes-Côte d'Azur</td><td>14</td><td>6</td><td>6</td><td>2</td></tr></tbody></table>

CLCC: French Cancer Treatment Center – CH: Hospital Center – CHU: University Hospital Center – CHR: French Regional Hospital Center.

<footnote>a Hospital and private × 1, ESPIC (private non-profit healthcare facility) × 1, 100% private and 50% public × 1.</footnote>

<footnote>b Clinical trials × 2, ESMO, AFU, ASCO guidelines × 8.</footnote>
<figure><img src="image_4.png" /></figure>

**Abbreviations:** ISUP: International Society of Urological Pathology; PSA: Prostate-Specific Antigen.

<figure><img src="image_5.png" /></figure>

**Fig. 1.** Criteria used to assess poor prognostic features of metastatic hormone-sensitive prostate cancer (mHSPC) based on the disease status. (A.) Criteria for synchronous patients; (B.) Criteria for metachronous patients. "Could you rank the poor prognostic criteria you use for synchronous (A)/metachronous cases (B) cases, from the most to the least frequently used in your practice (excluding those you do not use at all)?" [Multiple-choice question]. ISUP: International Society of Urological Pathology; PSA: prostate-specific antigen.

When respondents were asked which systemic and/or local treatments they would initiate for the following patient scenarios, they showed varying preferences based on disease characteristics:

* patient case 1 (60 years old, ISUP grade 4, moderate hypertension, dysuria, ECOG score 0; conventional imaging: 5 axial bone metastases; PET scan: extensive axial and appendicular bone metastases): more than half of respondents (57%) favored a doublet regimen combining ADT with ARPI, while 39% opted for triplet therapy with ADT, ARPI, and docetaxel. Additionally, 43% would include a local treatment such as radiotherapy or prostate surgery, with or without pelvic therapy (Fig. 2A);

* patient case 2 (52 years old, ISUP grade 4, ECOG score 0; computed tomography scan of the chest–abdomen–pelvis: distant nodal and

bone lesions, no visceral metastases; bone scintigraphy: dissemi-
nated bone involvement throughout the entire axial skeleton and
proximal appendicular skeleton): the majority of respondents (77%)
preferred triplet therapy (ADT + ARPI + docetaxel), with most not
including local treatments in the management plan (Fig. 2B);

* patient case 3 (54 years old, ISUP grade 4, pT3b pN0/12 stage, R1 margin post-prostatectomy, ECOG score 0; recurrence [rising PSA] within 12 months; PET scan: 3 intense foci in nodal, bone, and visceral sites): just over half (52%) favored ADT + ARPI, while 36% would prescribe triplet therapy. One-third (27%) would propose radiotherapy or prostate surgery, with or without pelvic therapy, and 24% would target metastases with radiotherapy (Fig. 2C);

* patient case 4 (75 years old, ISUP grade 4, T3b, ECOG score 0; conventional imaging: N0M0; PET scan: T3bN1M1b with bilateral
<figure><img src="image_6.png" /><figcaption>**B. Patient case 2:** 52-years old, ISUP grade 4, ECOG score 0; computed tomography scan of the chest-abdomen-pelvis: numerous lymph node and bone lesions, no visceral metastases; Bone scintigraphy: disseminated bone involvement throughout the entire axial skeleton and proximal appendicular skeleton</figcaption></figure>

<figure><img src="image_7.png" /><figcaption>**C. Patient case 3:** 54 years old, ISUP grade 4, pT3b pN0/12 stage, Prostatectomy: R1 margin post-prostatectomy, ECOG score 0, recurrence (rising PSA) within 12 months; PET scan: 3 intense foci in nodal, bone, and visceral sites</figcaption></figure>

<figure><img src="image_8.png" /><figcaption>**Fig. 2.** Treatment strategies for the 5 patient cases proposed in the questionnaire. (A) Patient case 1; (B) Patient case 2; (C) Patient case 3; (D) Patient case 4; (E) Patient case 5. "What systemic and/or local treatments would you initiate for the following patients?".</figcaption></figure>

pelvic and lombo-aortic lymph nodes, and a single axial bone metastasis): most respondents (73%) chose a doublet strategy with ADT and ARPI (Fig. 2D);

* patient case 5 (86 years old, ISUP grade 5, ECOG 2 with disease-related symptoms, PSA 1300 ng/mL; conventional imaging: multiple widespread bone metastases and one pulmonary lesion): the vast majority (83%) would initiate ADT + ARPI. Additionally, 60% would include local treatments such as radiotherapy or prostate surgery, and 46% would consider radiotherapy directed at metastases (Fig. 2E).

### 3.3. Theoretical patient cases discussed in MCM

The theoretical patient cases discussed during the MCM are summarized in Table 2, with full case details available in Appendix A2 and A3.

A total of 10 centers studied the theoretical patient cases in MCM, with 7 single centers (4 public and 3 private hospitals) and 3 grouped centers (public and private hospitals). Urologists and medical oncologists were the most represented specialties and 3 MCM involved 6 different specialties (92% of urologists, 92% of medical oncologists, 77% of radiation oncologists, 46% of nuclear medicine physicians, 31% of pathologists, and 31% of radiologists). One center conducted 4 separate MCM with different specialties. Overall, the 6 patients cases led to 45 responses.

Seven teams discussed the management of patient case MCM#1. Common strategies included double hormonal therapy (ADT + ARPI; 100%) and prostate radiotherapy (100%). Divergences involved the duration of ARPI (2 years versus indefinite; 29% versus 71%), the use of choline-PET (14%), and variations in radiotherapy fields (including lumbar, 14%; pelvic, 14%; or lombo-aortic, 29%). Some approaches mentioned prostate resection for dysuria, clinical trial inclusion, and medication reconciliation for ARPI choice.
**D. Patient case 4 (optional case):** 75 years old, ISUP grade 4, T3b, ECOG score 0; Conventional imaging: N0M0; PET scan: T3BN1M1b (bilateral pelvic lymph node involvement (2 nodes) and 2 retroperitoneal lymph nodes at the L2-L3 level + 1 solitary axial bone metastasis)

<figure><img src="image_9.png" /></figure>

**E. Patient case 5 (optional case):** 86 years old, ISUP grade 5, ECOG score 2 (with disease-related symptoms), PSA 1300 ng/mL; Conventional imaging: multiple widespread bone metastases and one pulmonary lesion

<figure><img src="image_10.png" /><figcaption>Fig. 2. (Continued)</figcaption></figure>

The treatment strategies proposed for patient case MCM#2, discussed by 8 teams, included the use of first- and second-generation hormonal therapy (ADT + ARPI; 100%), chemotherapy with docetaxel (88%), and BRCA mutation screening (88%). Some teams disagreed on performing an oncogenetic consultation (38%) and the timing of chemotherapy (early vs. later; 13%).

Six teams discussed the management of patient case MCM#3. Four teams (67%) proposed to practice biopsy to confirm hepatic lesion, guide therapy, or explore neuroendocrine tumor. Some teams were aligned on the use of ADT + ARPI (50%), BRCA mutation screening (33%), and oncogenetic consultation (33%). Two teams (33%) would combine treatment with docetaxel.

A total of 8 teams discussed patient case MCM#4. Among them, 6 teams (75%) agreed on the use of ADT + ARPI. Three teams would also recommend an oncogeriatric consultation (38%). Radiotherapy was suggested as a potential option at a later stage (25%). Some responses emphasized cardiac assessment (13%) and PSMA-PET scans (25%) for more comprehensive investigations.

Regarding patient case MCM#5, 9 teams discussed its management. Four teams (44%) recommended first- and second-generation hormonal therapies. Prostatic and pelvic radiotherapy were also proposed in association with ADT and ARPI for others (56%). Cardiological evaluation was advised by 3 teams (33%) due to cardiovascular risks. Radiotherapy was recommended by one team (11%) for localized metastases, with re-evaluation in 4-6 months. PET-PSMA imaging was also suggested by 5 teams (56%).

The management of patient case MCM#6 was discussed by 7 teams. Most teams recommended doublet therapy (ADT + ARPI; 71%) with spine MRI for epiduritis (29%) and oncogeriatric consultation for chemotherapy suitability (29%). Some teams (43%) considered triplet therapy (ADT + ARPI + docetaxel) with some palliative care to manage its intensity. Other distinct recommendations included BRCA screening (14%) and a formal supportive care referral (14%).

# 4. Discussion

## 4.1. Findings and interpretation

The objective of this survey and patient cases was to examine how mHSPC is currently managed in France. In particular, the practice survey examined how clinical decisions vary based on patient characteristics and the roles of healthcare providers. Theoretical cases were used to demonstrate these decision-making processes in real-life settings.

The study surveyed 143 clinicians (53% urologists, 25% medical oncologists, 22% radiation oncologists) with an average of 18 years of experience, evenly split between private and public practice. Participants from all regions of France managed about 50 mHSPC patients annually, offering diverse perspectives. Experienced providers could deliver long-term insights, while high-volume oncologists shared recent, intensive practice trends. This broad representation across specialties, settings, and regions strengthens the survey's robustness and generalizability.

The survey showed that 43% of respondents reported following the French regional adaptation of national guidelines (3C network protocol), while 34% indicated the absence of a specific institutional protocol for mHSPC management. In parallel, 85% reported adhering to the CCAFU recommendations for treatment selection, 66% referred to European guidelines (ESMO, EAU-EANM-ESTRO-ESUR-ISUP-SIOG), and 28% followed international guidelines (ASCO, NCCN). These findings highlight the emphasis on multidisciplinary coordination among urologists, oncologists, and radiologists in treatment decision-making. It also reflects the majority of physicians managing mHSPC follow national guidelines, and among them, some do so without adhering to a specific local protocol.

However, this could lead to variability in care, potentially resulting in gaps in treatment quality compared to the more structured approaches of the ccAFU recommendations and 3C network [6]. Regarding the use of PET scans, practices were largely homogeneous
<table><caption>**Table 2**
Theoretical patient cases presented in multidisciplinary consultation meeting (MCM).</caption><thead><tr><th></th><th>Diagnosis</th><th>Age</th><th>History</th><th>Previous evaluations</th></tr></thead><tbody><tr><td>Patient case MCM#1</td><td>ISUP 4 T3bN0M0 on conventional assessment, T3bN1M1a on PET scan evaluation</td><td>75</td><td>Hypertension and diabetes<br>Clopidogrel and Irbesartan treatment<br>Moderate to severe dysuria (IPSS 19)<br>PSA of 23 ng/mL, without prior PSA measurements in the last 5 years</td><td>Prostate biopsy (03/04/2023): classic acinar prostate adenocarcinoma, Gleason 8 (4 + 4), ISUP 4, bilateral involvement, 4 out of 6 positive biopsies, no perineural invasion, extra-prostatic extension in the right median lobe, with biopsy stage pT3a<br>Conventional assessment: T3b N0 M0. Prostate MRI shows a PI-RADS 5 lesion in the right lobe and left base with suspected extracapsular extension and right seminal vesicle involvement. Bone scintigraphy normal; Fluoro-Choline PET scan: T3b N1 M1a, indicating bilateral prostate involvement with extracapsular extension and right seminal vesicle involvement, along with bilateral pelvic (2 nodes) and 2 para-aortic lymph nodes at L2-L3 (all &lt; 10 mm). No distant visceral or bone metastasis</td></tr><tr><td>Patient case MCM#2</td><td>High volume de novo mHSPC</td><td>52</td><td>Personal history: healed hepatitis B, stroke<br>Lifestyle: Senegalese origin, living in France for 10 years, married with 5 children, truck driver<br>Tobacco: 10 pack-years<br>Suspicious bone lesions on standard radiographs<br>PSA = 1035 ng/mL<br>Rectal exam: hardened prostate<br>Allergy: chlorhexidine</td><td>Prostate evaluation: prostate adenocarcinoma; differentiation: moderately differentiated; Gleason score: 4 + 4 = 8; ISUP: 4; presence of cribriform architecture foci; location: bilateral; number of positive biopsies: 12/12 performed; percentage of biopsy involvement: ranges from 40% to 90%, corresponding to tumor invasion extents between 5 mm and 15 mm; no perineural tumour invasion; no signs of extracapsular tumor extension<br>Imaging: bone scintigraphy suggests bone involvement (lytic and sclerotic) scattered throughout the entire axial skeleton and proximal appendicular skeleton; CT scan (TAP): lymph node metastases (lateral aortic and inter-aortocaval), numerous mixed bone metastases (lytic and sclerotic), with the largest lesion in the sacral region causing bilateral involvement of the 2nd, 3rd, and 4th sacral foramina, no pulmonary or hepatic lesions, large prostate tumor (75 mm × 75 mm)<br>Choline PET scan: slight hyperfixation in a right common iliac lymph node formation, suspected of recurrence of the known prostate neoplasia; non-specific bilateral inguinal fixation<br>PSMA PET scan: suspected right inguinal lymph node formation, doubtful retro-umbilical tissue focus to be correlated with surgical history, suspicious subtle morphological focus in the left ilium, focus in the hepatic dome<br>Abdominal and hepatic MRI: lesion in segment VII of the liver (42 × 27 × 19 mm), likely extra-hepatic with scalloping; second 8 mm lesion in segment VII with similar characteristics; peritoneal nodules and small high diffusion signals, suggesting peritoneal carcinomatosis; celiac adenomegaly (28 × 15 mm) and multiple small retroperitoneal lymph nodes</td></tr><tr><td>Patient case MCM#3</td><td>High risk metachronous mHSPC</td><td>52</td><td>Hypertension<br>Robot-assisted prostatectomy: ISUP 4, pT3b, pN0/12, R1 (apex), 6 weeks post-op, PSA: 0.04 ng/mL<br>Radiotherapy, hormone therapy, PSA monitoring: 6 months after hormone therapy, PSA: 1.05 ng/mL; PSA doubling time: 1.8 months</td><td>Prostate biopsy: adenocarcinoma; Gleason score: 4 + 4 = 8; ISUP: 4; percentage of grade 4: 95% and 100%; presence of cribriform architecture foci; location: bilateral, with a slight dominance on the right side; number of positive biopsies: 7/12 performed; percentage of biopsy involvement: ranges from &lt; 5% to 80%, corresponding to tumor invasion extents between 0.1 mm and 13 mm; no perineural tumor invasion; no signs of extracapsular tumor extension; presence of extensive simple glandular atrophy foci<br>Bone scintigraphy: disseminated secondary bone involvement of the axial and appendicular skeleton<br>TAP CT scan: right hilar lymphadenopathy, pre-aortic and peri-aortic tissue infiltrates, inguinal and pelvic lymphadenopathies, and bilateral adrenal masses</td></tr><tr><td>Patient case MCM#4</td><td>High volume and high risk de novo mHSPC – T2 N1 M1</td><td>76</td><td>Hypertension, hypercholesterolemia, rheumatoid arthritis, ex-smoker (quit 30 years ago)<br>Current treatment: vitamin D, Irbesartan, Rosuvastatin, Fluticasone<br>PSA = 808 ng/mL, mild nocturnal polyuria, firm prostate on rectal exam, no palpable nodules</td><td>Prostate biopsy: prostate adenocarcinoma; Gleason score: 4 + 4 = 8; ISUP: 4; bilateral, predominantly on the left side, 9 positive biopsies out of 16, No perineural invasion, emboli, or visible extracapsular extension, PSA significantly elevated to 75 ng/mL<br>TAP CT scan: multiple juxta-centimetric lymph nodes in the mesorectum, pre-sacral space, up to the level of the promontory<br>Bone scintigraphy: suspicion of metastatic involvement in the left intertrochanteric region<br>Prostate MRI: extensive bilateral prostate tumor with extracapsular extension to the mesorectum and anterior rectal wall, seminal vesicle involvement, iliac lymphadenopathies, diffuse pelvic bone invasion, and predominant lesion at the left femoral neck</td></tr><tr><td>Patient case MCM#5</td><td>Low volume de novo mHSPC</td><td>71</td><td>Hypertension, abdominal aortic aneurysm treated with bilateral iliac stent<br>Current treatment: Candesartan<br>PSA: 8.82 ng/mL<br>Prostate massively invaded by adenocarcinoma, stony and multinodular, bulging against the rectal wall<br>Bruising on the lower limbs, oedema and bruising on the left hand secondary to a diffuse infusion</td><td>WHO 2; bilateral lower limb oedema extending to the lower back; diffuse pain; rectal exam: T3 prostate; G8: 8/10; PSA: 3354 ng/mL<br>PAL: 1300 UI/L; albumin 25 g/L Hb 9.0 g/dL<br>Prostate adenocarcinoma; Gleason 9 (4 + 5), ISUP grade group 5, no neuroendocrine component; presence of perineural invasion and extracapsular extension<br>Bone scintigraphy: multiple secondary axial and extra-axial locations, bilateral external iliac lymph node involvement, para-aortic lymph node involvement</td></tr><tr><td>Patient case MCM#6</td><td>High volume mHSPC<br>WHO 2</td><td>85</td><td>Hypertension, dyslipidemia<br>Current treatment: Irbesartan, Atorvastatin<br>Progressive deterioration of general condition with the onset of bilateral lower limb edema<br>Difficulty maintaining independence at home</td><td></td></tr></tbody></table>
across respondents, with 94% using PET for biochemical recurrences, 78% for initial assessments of high-risk patients, and 73% for castration-resistant recurrences, which was in line with current guidelines [1,6,8]. However, it is important to note that the use of PET scans was not recommended specifically at the time of the survey for initial diagnosis or for castration-resistant status. Survey respondents reported managing both synchronous (40%) and metachronous (60%) mHSPC patients and using different indicators to identify poor prognostic features depending on the presentation. For synchronous cases, the most commonly cited factors were the presence of visceral metastases (cited by 97% of respondents) and the ISUP grade (78%). In metachronous cases, poor prognostic features were mainly assessed using the presence of visceral metastases as well (88%) and PSA doubling time (73%).

Respondents to the survey managed both synchronous (40%) and metachronous (60%) mHSPC patients. While national incidence data typically indicate a significantly higher prevalence of metachronous metastases compared to synchronous ones (90% versus 10%) [9], this result may reflect the strong representation of urologists among the respondents. To assess poor prognostic features, respondents used different markers for each type.

The majority of respondents emphasized the importance of multidisciplinary input in treatment decisions (including ARPI initiation), reflecting the alignment with current guidelines such as the 3C network protocol. This collaborative approach is particularly important when determining the appropriate therapy for mHSPC. In terms of treatment strategies, the age and general health of the patient emerged as key factors in guiding therapy selection. Indeed, for younger, asymptomatic patients with widespread metastases, such as in patient cases 1 and 2, systemic therapy with ADT and ARPI (doublet therapy) was favored by most respondents, with 39% opting to consider docetaxel (triplet therapy) for patient case 1 for a more intensive approach. The results suggest that despite differences between proposed strategies, the management choices seemed aligned with clinical reasoning and patient-specific considerations. This highlights flexibility in clinical decision-making, where both doublet and triplet therapies were considered appropriate depending on the patient's health status, disease burden, and treatment goals, demonstrating that varied strategies can coexist within the framework of optimal care. The triplet therapy was also recommended for patient case 2, which presented a more aggressive case. In contrast, for patients with limited metastases (patient cases 3 and 5), doublet therapy was preferred, with additional local treatments including radiotherapy or surgery. Patient case 3 was young but the visceral location of metastases renders this case as atypical, explaining the management proposed by respondents. Radiotherapy proposed by respondents for patient case 5, where a single bone lesion and pelvic lymph node involvement were present, was deemed relevant because of the low metastatic load. For elderly patients with advanced, symptomatic and high-volume disease, as in patient case 4, respondents preferred doublet therapy to minimize side effects. Ultimately, these results highlighted the need for treatment decisions to balance disease burden, symptoms, and overall health, using systemic therapies (doublet or triplet) for widespread disease and local treatments for more limited cases. In general, triplet therapy was favored for younger, healthier patients with high-volume metastatic disease, reflecting a more aggressive treatment approach, while radiotherapy was less favored for those with more advanced disease. Our data are consistent with current guidelines, which recommend combining systemic therapies, such as ADT, with radiotherapy for managing low-volume mHSPC [8]. However, for patients with low-volume disease who are eligible for chemotherapy, the use of docetaxel in combination with ADT is generally not advised [10].

The proposition of theoretical cases in MCM allowed for a more detailed examination of the complex management of mHSPC in real-world settings. Overall, the strategies proposed by each team were largely endorsed by the scientific committee, with the exception of

case MCM#4. In this case, the use of PSMA-PET imaging was questioned because of its high cost and limited added value for an elderly patient. Current guidelines advise against the overuse of expensive imaging techniques like PSMA-PET in older or frail patients, where clinical benefit may be limited [11]. Additionally, it is important to note that PSMA-PET is not recommended at the de novo mHSPC stage, as existing studies are primarily based on conventional imaging, and the impact of PSMA-PET on disease outcomes remains unknown. Instead, management should include a comprehensive oncogeriatric assessment to evaluate functional status, comorbidities, and overall suitability for intensive cancer therapies [1,11]. Regarding patient case MCM#1, the inclusion of radiotherapy was deemed appropriate according to current recommendations [1]. However, the lack of specific details on the radiotherapy target area limits the ability to fully assess the adequacy of the proposed treatment plan. The NCCN guidelines recommend prostate radiotherapy for oligometastatic disease or for symptom control [11], which could be relevant in this case, but additional clinical details would be needed for a more accurate assessment. For patient case MCM#2, who was relatively young, nearly all teams agreed on the need for BRCA mutation screening at diagnosis. This aligns with current recommendations advocating genetic testing in patients with early-onset prostate cancer or a family history of cancer [1,11]. Additionally, knowing the BRCA status is crucial for considering the use of ARPI in the subsequent castration-resistant stage, as it can significantly influence treatment decisions and potential outcomes. The importance of hepatic biopsy was emphasized in patient case MCM#3. However, current guidelines lack specific recommendations for hepatic biopsy to guide treatment decisions [1,11]. In patient case MCM#5, the management strategies proposed by the teams, particularly regarding treatment intensification, were strongly supported by the scientific committee. This approach aligns with current guidelines, which recommend considering intensification in cases of high-risk or disease with poor prognosis [1,11]. Interestingly, the treatment strategies proposed during the multidisciplinary discussions were more consistent than those reported in the survey, suggesting that collective decision-making may lead to more efficient harmonized management in mHSPC.

Using clinical case scenarios offers a practical and insightful way to explore treatment preferences in mHSPC. However, the reliance on self-reported data introduces potential bias, and the results may not fully capture practices across all healthcare settings or geographic areas. Future research should aim to understand the sources of variability in treatment choices, particularly in older patients, and assess the impact of different therapeutic combinations on patient outcomes and quality of life. The variability in treatment choices observed in this study reflects the complexity of mHSPC management, influenced by multiple interconnected factors such as clinician specialties, practice settings, (e.g., urologists vs. oncologists, public vs. private institutions), and patient-specific factors (e.g., age, comorbidities, disease burden [e.g., visceral vs. bone metastases]). Finally, the evolving evidence base and multidisciplinary decision-making further contribute to variability, as clinicians integrate new data (e.g., PSMA-PET utility, BRCA testing) and collaborative input into their practice. This heterogeneity, while reflecting real-world adaptability, also underscores the need for further research to harmonize care where possible, particularly in older or high-risk populations where guideline recommendations may be less clear. Exploring the influence of patient preferences and shared decision-making would also enhance understanding of real-world management strategies for mHSPC.

## 4.2. Expert opinion

In light of the survey data and expert consensus, the following recommendations outline best practices for the clinical management of mHSPC.
### 4.2.1. Ensure individualized treatment while minimizing loss of opportunity

Treatment decisions should be adapted to each patient's profile—including age, functional status, balance of comorbidities, and disease burden—while avoiding the risk of undertreatment. Even in older or frail patients, intensification strategies should not be excluded without comprehensive geriatric assessment, as premature therapeutic de-escalation could deny eligible patients the potential benefits of modern therapies.

### 4.2.2. Balance local and systemic therapies based on disease profile

Doublet systemic therapy should be prioritized in mHSPC patients. Triplets should be discussed in patients with high-volume or disease with poor prognosis. However, in patients with low-volume or oligometastatic mHSPC, the addition of local treatments such as radiotherapy remains valuable and should be considered as part of a multimodal strategy.

### 4.2.3. Ensure appropriate use and harmonization of PET imaging

Although PET scan use was largely homogeneous and guideline-concordant, a clear framework for its appropriate use in older patients should be reinforced to balance clinical value with cost-effectiveness. PSMA-PET should be reserved for cases where it meaningfully impacts therapeutic decisions.

### 4.2.4. Integrate geriatric and genetic assessment into routine practice

For elderly patients, systematic geriatric evaluations are essential to guide safe and effective treatment choices. Similarly, BRCA germline mutation screening should be implemented at diagnosis for younger patients or those with a family history, in line with international recommendations, to guide treatment personalization and access to PARP inhibitors where indicated. BRCA somatic screening should also be discussed, especially in high volume disease. Additionally, it is essential to provide ongoing support to patients throughout their treatment journey.

### 4.2.5. Favor multidisciplinary case reviews (MCM) to harmonize practice

Multidisciplinary discussions led to greater alignment in treatment choices compared to individual survey responses. Promoting routine MCMs can help reconcile diverse clinical perspectives and ensure a more uniform and evidence-based approach across institutions.

### 4.2.6. Encourage shared decision-making with patients

Incorporating patient preferences into treatment decisions is essential. Shared decision-making supports a more person-centered approach, improving adherence, satisfaction, and long-term outcomes.

## 5. Conclusion

The management of mHSPC remains complex, with multiple therapeutic strategies available that must be tailored to patient characteristics, tumor biology, and metastatic patterns. This study provides a snapshot of real-world mHSPC clinical practices in France, combining insights from clinician surveys and MCM discussions. While treatment strategies varied shaped by factors such as age, comorbidities, and disease extent, overall practices were generally aligned with national and international guidelines. The results highlight a clear trend toward treatment intensification in younger, fitter patients and more conservative approaches in frailer individuals. Notably, MCM discussions led to greater consistency in decision-making, emphasizing the value of multidisciplinary collaboration in optimizing patient care. To further improve outcomes and ensure that all eligible patients benefit from advances in mHSPC treatment, it is essential to reduce unwarranted variability and reinforce the use of structured, evidence-based approaches. Doing so will help avoid potential loss of opportunity, particularly for patients who might otherwise be undertreated due to subjective or inconsistent assessments. Promoting personalized, guideline-informed management supported by collective expertise—remains key to delivering equitable and effective care in mHSPC.

## Funding

This study received institutional support from Bayer.

## Author's contribution

X.A., P.B., G.C., A.G., A.I., L.J., B.L., S.L.C, R.M., P.M.A., G.P., J.R., F.R., C.S., S.S., and M.O.T. participated in the conception and design of the study, acquisition and interpretation of data. S.L.C. and M.C. drafted the article. X.A., P.B., G.C., A.G., A.I., L.J., B.L., R.M., P.M.A., G.P., J.R., F.R., C.S., S.S., and M.O.T. revised the article critically for important intellectual content. All authors gave their final approval of the submitted version of the manuscript.

## Disclosure of interest

Xavier Artignan has received honoraria for consultancy from Bayer.

Pierre Blanchard has received honoraria for speaking engagements and consultancy from Bayer, Astellas, Ipsen, Janssen, AstraZeneca, Boston Scientific, Merck Serono, Neolys, and MSD.

Gilles Crehange has received honoraria for consultancy from Bayer, Ferring, Ipsen, Astellas, AstraZeneca, Accord Healthcare, Bouchara Recordati, Ferring, and Johnson & Johnson.

Aurélien Gobert has received honoraria from Astellas, AstraZeneca, Bayer, BMS, Ipsen, Johnson & Johnson, Merck, MSD, Novartis, and Pfizer.

Alexandre Ingels has received honoraria from Astellas, Janssen, and Bayer.

Brigitte Laguerre has received honoraria for lectures and presentations from Bayer, Johnson & Johnson, Astellas, Ipsen, and Eisai, as well as support for attending meetings and/or travel from AstraZeneca, Adacap-Novartis, Pfizer, MSD, and BMS.

Romain Mathieu has received honoraria from AAA, Accord, Astellas, AstraZeneca, Bayer, Besins, Curium, Ferring, Ipsen, Intuitive, Janssen, MSD, Pfizer, and Viatris.

Pierre Mongiat-Artus has declared industry affiliations with Bayer, Ipsen, and Viatris.

Jérôme Rigaud has received honoraria from Ipsen, Johnson & Johnson (Janssen), Novartis, AAA, Astellas, Bayer, Telix, and BMS.

François Rozet has received honoraria from Astellas, Johnson & Johnson, Bayer, Pfizer, Accord, and Viatris.

Camille Serrate has received honoraria from Astellas, Ipsen, Pfizer, and Bayer.

Stéphane Supiot has received honoraria from Adacap-Novartis, Curium, Bayer, Astellas, Janssen, MSD, AstraZeneca, Ipsen, Recordati, and Accord Healthcare.

Marc-Olivier Timsit has received honoraria from Bayer, Orion, Johnson & Johnson, Ipsen, Recordati, and MSD.

Myriam Chebbah and Solenn Le Clanche declare that they have no competing interest.
## Acknowledgements

The authors thank Public Health Expertise for their medical writing and editorial support, as well as AFU and SFRO learned societies for their valuable contributions.

## Appendix A. Supplementary data

Supplementary data associated with this article can be found, in the online version, at https://doi.org/10.1016/j.fjurol.2025.103000.

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