The 2026 Advanced Prostate Cancer Consensus Conference (APCCC 2026) has published its voting results on the management of high-risk localised, locally advanced, and biochemically recurrent prostate cancer (PCa), drawing on the expertise of 133 international panellists across medical oncology, urology, radiation oncology, and nuclear medicine. The report, published in European Urology, covers five clinical domains: treatment of high-risk and locally advanced disease, prostate-specific antigen (PSA) persistence and recurrence after radical-intent therapy, genetic evaluation, management of treatment-related side effects, and bone protection.
Of 134 consensus questions addressed in this report, formal consensus (≥75% agreement) was reached for only 44 (32.8%), with seven achieving strong consensus (≥90% agreement). The authors emphasise that the voting results are intended to complement, not replace, evidence-based guidelines, and that the high proportion of questions without consensus underscores the breadth of unresolved clinical uncertainty in this disease space.
Key finding
Across 134 consensus questions on high-risk localised, locally advanced, and biochemically recurrent PCa, APCCC 2026 reached agreement on fewer than one-third of questions, highlighting that expert opinion remains broadly divided on many management decisions — a finding the authors attribute to the scarcity of high-quality prospective evidence rather than to differences in clinical philosophy.
Study Design
| Conference | Advanced Prostate Cancer Consensus Conference (APCCC) 2026 |
|---|---|
| Panel composition | 133 voting panellists: medical oncologists (46%), urologists (29%), radiation/clinical oncologists (21%), nuclear medicine physicians (4%); 11 non-voting experts in radiology, pathology, statistics, and patient advocacy |
| Question development | 313 multiple-choice questions developed by 144 international experts using a modified Delphi process; 134 questions addressed in this report cover high-risk localised/locally advanced disease, PSA persistence and recurrence, genetic evaluation, treatment side effects, and bone protection |
| Survey method | Web-based survey administered to panellists prior to the conference |
| Consensus thresholds | Consensus: ≥75% agreement on a single answer option; strong consensus: ≥90% agreement |
The APCCC process is designed to surface expert opinion in areas where prospective evidence is limited or conflicting. Panellists were instructed to assume universal availability of all diagnostics and treatments and to vote as though the patient had no option to enroll in a clinical trial and had no treatment-limiting comorbidities. The conference did not conduct a formal literature review or meta-analysis, and its voting results do not constitute guideline recommendations.
Results and Safety
For patients with high-risk localised PCa, a majority of panellists (62–68%, depending on imaging modality used for staging) favoured radiotherapy (RT) plus long-term androgen deprivation therapy (ADT) with or without an androgen receptor pathway inhibitor (ARPI), while 32–38% preferred surgery as part of a multimodal approach. For very high-risk disease as defined by NCCN/STAMPEDE criteria, 65–71% voted for RT plus long-term ADT combined with abiraterone for two years, reflecting the influence of the STAMPEDE trial data; very few panellists selected enzalutamide in this setting, consistent with the neutral overall result of the ENZARAD trial. Consensus was reached against routine perioperative ADT plus an ARPI in patients planned for radical prostatectomy (RP), though the authors note that the PROTEUS trial, which reported a statistically significant improvement in metastasis-free survival (MFS) with perioperative apalutamide, was published after APCCC 2026 and was therefore not incorporated into the voting. A strong consensus (92%) supported delivering a focal RT boost to radiographically positive lymph nodes in patients with cN1 disease undergoing prostate and pelvic RT, and consensus was also reached in favour of dose escalation with a focal boost to a visible dominant intraprostatic lesion when technically feasible.
In the PSA recurrence setting, no single treatment approach achieved consensus across most clinical scenarios, reflecting the heterogeneity of this population. For patients with high-risk PSA recurrence meeting EMBARK trial criteria and negative PSMA-PET imaging, consensus was reached in favour of immediate systemic therapy (76%) and for ADT plus an ARPI as the preferred regimen (87%). Among patients with PSMA-PET-detected oligometastatic disease in an EMBARK-like scenario, consensus favoured combining metastasis-directed therapy with systemic treatment (86%), though panellists were evenly split between short-term and long-term ADT plus ARPI regimens. For PSA persistence after RP, no consensus was reached on whether all patients require immediate salvage RT, the optimal type and duration of systemic therapy, or the use of genomic biomarkers to guide decisions. Regarding adjuvant therapy after RP in patients with undetectable postoperative PSA and node-negative disease, consensus (including strong consensus for R0 margins) favoured monitoring with early salvage RT over routine adjuvant RT, consistent with findings from RADICALS-RT, RAVES, GETUG-AFU 17, and the ARTISTIC meta-analysis.
On treatment-related toxicities, strong consensus was reached for recommending phosphodiesterase type 5 inhibitors as first-line therapy for erectile dysfunction after local treatment (96%), and consensus was reached for alpha-blockers as first-line management of bothersome obstructive voiding symptoms (79%) and for pelvic floor physiotherapy for stress urinary incontinence (76%). No consensus was reached on prophylaxis or treatment of gynaecomastia and mastodynia in patients receiving androgen receptor (AR) antagonist monotherapy or transdermal oestrogen. For bone protection, consensus supported osteoclast-targeted therapy in selected patients receiving prolonged ADT with or without an ARPI (76% in both scenarios), though no consensus was reached on treatment duration.
Clinical Context
The APCCC 2026 results arrive at a moment of considerable flux in the management of high-risk and biochemically recurrent PCa. Intensification of systemic therapy, including the addition of ARPIs to ADT and RT, has reshaped treatment paradigms in recent years, driven largely by STAMPEDE. Yet the neutral overall result of ENZARAD, the contrasting outcomes of EMBARK and PRESTO, and the late publication of PROTEUS all illustrate how rapidly the evidentiary landscape can shift and how difficult it is to translate individual trial results into universal practice recommendations. The voting data reveal that clinicians are increasingly incorporating PSMA-PET findings, genomic classifiers, and individualised risk assessments into treatment decisions, but that the prospective evidence needed to validate these approaches in localised and biochemically recurrent disease largely remains to be generated.
The authors identify several specific areas warranting prospective investigation, including the optimal integration of modern imaging into treatment field and systemic therapy decisions, the role of perioperative ARPI therapy before RP in light of PROTEUS, the optimal duration of bone-protective therapy in patients receiving prolonged hormonal treatment, the utility of genomic classifiers such as Decipher and ArteraAI MMAI for treatment escalation or de-escalation decisions, and the management of testosterone recovery and symptomatic hypogonadism following ADT plus RT. The findings also reinforce that biochemical recurrence is not a single clinical entity and that a uniform salvage strategy is unlikely to be appropriate across the spectrum of patients who experience PSA relapse after radical-intent treatment.
Sources
- European Urology / ScienceDirect. “Management of Patients with High-risk Localised, Locally Advanced, and Biochemically Recurrent Prostate Cancer: Report from the 2026 Advanced Prostate Cancer Consensus Conference.” Journal article. 2026. View source
