Prostate Cancer Working Group offers New Recommendations

by | Oct 20, 2026 | Prostate Cancer

PCWG is the Prostate Cancer Working Group, an association of experts who meet to discuss and advise on Prostate Cancer research. 

PCGW4, their recommendations for 2026, are not merely new terms for old concepts.  There are fundamental changes in how to describe prostate cancer. These are meant mostly for research communication – at least until they percolate into the clinical world, which has started to happen.

PCGW4 emphasizes describing prostate cancer according to its measurable characteristics rather than relying only on broad disease labels, by calling for reports to clarify metastatic status, specify imaging methods used, provide the testosterone levels, describe symptoms and prior treatments, provide genetic features when relevant, and be very specific when describing the manifestation of progression.

Here are some of the PCGW4 recommendations:

  • Nonmetastatic cancer should be qualified according to the imaging used to establish the absence of metastases. A patient may have no metastases on conventional CT and bone scanning but have lesions detected by PSMA PET. Reports should therefore identify the imaging modality and, for PET, the tracer used. (Ed: addressing an old gripe heard often at AnCan).
  •  Bone scan progression should use prostate cancer-specific confirmatory criteria designed to account for flare
  • PSMA PET findings and other next-generation imaging should identify the modality, tracer, and interpretation criteria and should not automatically be combined with conventional imaging endpoints.
  • PSA decline on treatment response of at least 50 percent (PSA50) is a commonly reported outcome and ordinarily requires confirmation, but it should not be equated with objective radiographic response or assumed to be a surrogate for survival
  • Treatment history should be clear and complete: identify the drugs received, disease setting, duration, response, and reason for discontinuation. Simple therapy labels may be inadequate when patients receive combinations or continue one component while changing another.

Let’s touch on some other PCGW4 recommendations and clarifications before getting to terminology below:

  • Patient-reported outcomes, such as symptoms, pain, physical functioning, quality of life, treatment burden, and toxicity, should be incorporated alongside survival and imaging outcomes. That’s our voices they are talking about.
  • Oligometastatic and oligoprogressive disease should be similarly pre-defined. PCWG4 recognizes this state, but stresses the need for standard definitions (e.g., number and location of metastases, imaging modality), the number and location of lesions, timing of disease, and imaging modality.
  • Composite endpoints, which we often see in research, should be prespecified, clinically justified, and reported together with their individual components. It encourages combining PSA,  radiographic, and symptomatic progression.
  • Polyprogression: Term introduced for situations where progression occurs in multiple metastatic sites simultaneously.
Imaging Terminology has been clarified:
  • Conventional Imaging (CI): Refers specifically to bone scan and CT/MRI.
  • Next-Generation Imaging (NGI): Refers to PET-based and other novel modalities.
  • Imaging-Detected Progression: Requires specification of modality (CI or NGI) to avoid confusion.
So YES, there’s a huge amount in PCGW4, and you can actually read it for yourself. There is open access on JCO at https://ascopubs.org/doi/10.1200/JCO-25-02834.

Now let’s address the terminology….

PCWG4 uses “APM” to mean androgen pathway modulator, an umbrella term for treatments that inhibit androgen production or androgen receptor signaling.  This means the “ides” and abiraterone, which we might have called ARPI or ARSI.

  • APM naïve (APMn) means the patient has never received an APM.
  • APM exposed means the patient previously received an APM. This term does not by itself indicate whether the cancer responded or progressed.
  • APM sensitive (APMs) means the cancer demonstrates clinical benefit or disease control during APM treatment. The specific response criteria and treatment setting should be stated.
  • APM resistant (APMr) means the cancer progresses during APM treatment despite continued castrate testosterone levels. Resistance should be linked to the particular drug and disease setting rather than assumed to apply equally to every APM.

Here are some closely related terms you’ll see

  • Primary APM resistance means progression from the beginning of APM treatment.
  • Acquired APM resistance means the cancer initially benefits from an APM but later progresses.
  • APM rechallenge means using an APM again after previously discontinued, ordinarily after intervening treatment or a meaningful treatment free interval.

The APM category generally does not refer to the foundational medical Androgen Deprivation Therapy including Estradiol/E2 (ADT), nor surgical castration used to maintain low testosterone.
Because PCWG terminology is intended for precise research reporting, authors should name the individual drug, disease state, prior exposure, response, and reason for discontinuation rather than relying on an APM label alone. Terms such as APM resistant should not be interpreted as proving resistance to every drug in the class.

Old vs New

  • mHSPC is now mAPMs or mAPMn.
  • nmHSPC is now nmAPMs or nmAPMn – per stated imaging technique
  • mCRPC is now mAPMr
  • nmCRPC is nmAPMr. –  per stated imaging technique

‘n’ or ‘nm’ should be clarified by which imaging made the call, so while AnCan doesn’t much care for ‘nm’ we now know what produced that designation.

APMr should explain the testosterone level.

Progression explains the criteria used:

  • Clinical Progression: Now separated from biochemical (PSA) and radiographic progression. Clinical progression emphasizes symptom development or worsening.
  • PSA Progression: Now standardized for use with next-generation imaging and early relapse scenarios.
  • Radiographic Progression: Criteria refined for both bone and soft tissue lesions, especially with the adoption of next-generation imaging (NGI).

PSA, radiographic, symptomatic, and other forms of progression should be documented specifically. PSA progression should follow prespecified criteria and does not by itself necessarily require discontinuation of an otherwise beneficial treatment.

Remember, this is all designed to standardize language used ONLY to describe prostate cancer clinical trials. So what does that have to do with the patient, and why should our Gents be concerned about wrapping your head around these terms? Rick tells us why…

Thanks, Dr. John – what a new mouthful, but in the long run the new language will make us all more comfortable. Ironically, part of the unacknowledged rationale for the new terminology is very patient-centric. Doctors and patients alike wince over the use of one word – ‘castrate’. Whether physically, literally, or metaphorically, most everyone in the prostate cancer world resents its use – and understandably. Think about it – we don’t even employ that word when it comes to our animals, never mind adult men. Personally, I always try to substitute ‘hormone’ for ‘castrate’ – it makes me feel better.

When the language was first suggested at GU ASCO t this past February, Dr. John wrote up an explanation at my request. However, other Moderators and our Brains Trust vetoed us. They felt that the language was intended for clinical trials and that it would only confuse our AnCan’rs. Now that the FDA’s PSMAddition has incorporated the new terminology into its approval, we’ve made an executive decision to place this new medical speak on your radar.

The PSMAddition trial led to a new and potentially game-changing FDA Approval at the end of July for the use of radioligand therapy, Lutetium-177 vipivotide tetraxetan. That’s an even bigger mouthful, so we’ll call it Pluvicto. You recall the big news when Pluvicto was made available pre-chemo in March of 2025. BUT you still had to have metastatic castration-resistant prostate cancer (mCRPC). There’s that nasty word again.
This July’s approval was for (ready…) metastatic Androgen Pathway Modulation Sensitive/Naive (mAPMS/N) men. It’s taken a while, especially for those of you with a touch of ADHD, but now you see where we’ve been going.

As we said, the new language is forcing its way into our everyday prostate cancer lexicon. And what’s the bottom line? If you are early in disease progression, just found out you are metastatic, and are on an ARPI, you are eligible for Pluvicto, a systemic, non-chemo alternative. As far as we can tell from the FDA approval, it appears to cover monotherapy ARPI, but that remains to be seen in practice.

To refer to our chat with Novartis, you can understand now why it asked us about the new terminology and the PSMAddition approval. The video referenced is fairly short and worth a watch. It’s designed for HCPs, but we’re betting you’ll be able to follow along quite easily. Watch it HERE.