Beyond Suppression: Rethinking Prostate Cancer Through Biology, Balance, and Precision

 Chapter 7 of ProstateScan 2026:

REFRAMING PROSTATE CANCER THROUGH EVIDENCE, QUALITY OF LIFE, AND PRECISION-GUIDED CARE

Insights from Dr. Alex Van Hoof

For decades, prostate cancer has been defined—and treated—through the lens of hormonal suppression. Yet as research advances and clinical experience deepens, a more nuanced picture is emerging—one that balances tumor biology, patient quality of life, and precision-guided innovation. According to Dr. Alex Van Hoof, a clinician deeply engaged in prostate cancer research and education, the field is undergoing a quiet but meaningful transformation

Dr. Van Hoof points to the historical foundations of prostate cancer care, dating back to the landmark discoveries of Huggins and Hodges in the 1940s, which established androgen deprivation as a powerful means of controlling disease progression. That principle remains valid today—but its application has grown more sophisticated. Modern care now recognizes that while androgen signaling drives progression in established cancer, prostate cancer itself is initiated by genetic and molecular changes long before hormones become dominant players.

One of the most significant recent shifts, Dr. Van Hoof notes, is the growing use of intensified combination therapy in men diagnosed with high-risk disease. Large trials such as STAMPEDE have demonstrated that adding advanced androgen receptor pathway inhibitors (ARPIs) to traditional androgen deprivation therapy and radiation can substantially improve overall survival and metastasis-free survival. What was once applied to a minority of patients is rapidly becoming standard practice for a majority, reflecting a recalibration of how aggressively clinicians intervene earlier in the disease course.

Yet progress is not limited to escalation. Dr. Van Hoof emphasizes that innovation in prostate cancer also involves re-examining long-held assumptions, particularly around hormones themselves. One of the most provocative areas of ongoing research involves testosterone replacement therapy (TRT) in select men who have undergone definitive treatment for localized prostate cancer. Historically viewed as contraindicated, TRT is now being studied as a potential quality-of-life intervention in carefully selected patients.

This evolving conversation has been championed by Dr. Abraham (Abe) Morgentaler, a urologist and researcher whose work has challenged the dogma that any testosterone exposure is inherently dangerous in men with a history of prostate cancer. Dr. Morgentaler’s research has helped clarify the concept of a saturation model, suggesting that once androgen receptors are maximally stimulated, additional testosterone may not further fuel cancer growth. While not applicable to men with active or advanced disease, this research has opened doors for survivors struggling with fatigue, cognitive decline, and sexual dysfunction after curative therapy.

Dr. Van Hoof also highlights emerging PSMA-targeted theranostics as another frontier reshaping prostate cancer care. Initially developed as imaging tracers for PET scans, PSMA-based ligands are now being paired with therapeutic agents, allowing clinicians to both visualize and treat metastatic disease with unprecedented specificity. These approaches represent a convergence of diagnostics and therapeutics that aligns with precision oncology’s broader goals.

What unites these advances, Dr. Van Hoof suggests, is a growing respect for individualized decision-making. Prostate cancer is no longer treated as a monolithic disease but as a spectrum of biologically distinct conditions requiring tailored strategies. The challenge for clinicians is not simply choosing the most powerful therapy, but selecting the right therapy for the right patient at the right time.

In this evolving landscape, education plays a critical role. As Dr. Van Hoof’s insights reveal, today’s “standard of care” is increasingly defined not by rigid protocols, but by adaptive frameworks that integrate biology, imaging, genetics, and patient priorities. Prostate cancer care, once dominated by suppression alone, is now entering an era defined by balance, precision, and informed restraint.

FROM THE SOURCE

Alexander Van Hoof, MD, is a clinical researcher in urology with a focused expertise in prostate cancer, bladder cancer, and renal cancer. With more than a decade of experience in medical and clinical trial research, his work spans urologic oncology, evidence generation, and translational science. Through extensive academic involvement—including scientific writing, abstracts, and publications—Dr. Van Hoof has developed strong proficiency in interpreting complex medical data and effectively disseminating it to diverse clinical audiences. He has presented research findings to physicians and key opinion leaders at national medical conferences, earning recognition for clarity and impact. His clinical training as a medical doctor, combined with hands-on experience in clinical trials, has provided firsthand insight into how cutting-edge research and emerging technologies meaningfully affect patients and their families. Dr. Van Hoof is particularly passionate about leveraging his expertise in medical affairs and alues interdisciplinary collaboration, mentorship, and lifelong learning as essential drivers of progress in modern cancer care.

 

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Part 2:

Imaging as the Unifying Force across Standard Therapies

By Robert L. Bard, MD, DABR, FAIUM, FASLMS
Cancer Radiologist | Diagnostic Imaging Specialist

Prostate cancer care has evolved into a highly structured, evidence-based continuum—one that balances disease biology, patient risk stratification, and quality-of-life considerations. Across decades of clinical observation and imaging-based assessment, it is clear that no single therapy stands alone. Instead, modern prostate cancer management is defined by appropriate treatment selection, timely intervention, and objective monitoring, all anchored by diagnostic imaging.

As a cancer radiologist specializing in advanced diagnostic imaging, my role is not to replace standard therapies, but to corroborate, validate, and refine them. Imaging serves as the common language that links surveillance, intervention, and follow-up—ensuring that treatment decisions align with tumor behavior rather than assumptions alone.

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Risk Stratification and the Foundation of Care

Current standards of prostate cancer treatment appropriately rely on risk group classification, clinical staging, PSA kinetics, Gleason grading, and overall patient health. These variables determine whether a patient is best served by conservative monitoring or active intervention.

Imaging has become indispensable in this process. High-resolution ultrasound, multiparametric MRI, PET-based tracers, and Doppler vascular assessment now provide real-time insights into tumor location, aggressiveness, vascularity, and response to therapy—allowing clinicians to act with precision rather than excess.

---

Primary Treatments (Localized / Curative Intent)

Active Surveillance and Watchful Waiting: For patients with low-risk, slow-growing prostate cancer, active surveillance remains a clinically sound and patient-centered strategy. Imaging plays a critical role in this pathway by confirming disease stability, detecting subtle progression, and reducing unnecessary biopsies or premature treatment. Surveillance is not passive—it is data-driven vigilance.

Surgery: Radical Prostatectomy- Radical prostatectomy remains a cornerstone curative option, particularly for localized disease in otherwise healthy patients. Preoperative imaging assists in surgical planning, margin assessment, and lymph node evaluation, while postoperative imaging helps identify recurrence early, should PSA levels rise.

 

Radiation Therapy- has advanced significantly, offering multiple precise modalities:

• External Beam Radiation Therapy (EBRT)
• Intensity-Modulated Radiation Therapy (IMRT)
• Brachytherapy (radioactive seed implantation)

In addition, proton therapy and CyberKnife® stereotactic radiosurgery represent highly refined radiation approaches. Proton therapy allows for targeted dose delivery with reduced collateral tissue exposure, while CyberKnife uses robotic X-ray guidance for sub-millimeter accuracy. Imaging is essential in treatment planning, targeting, and post-therapy assessment for all radiation modalities.

---

Advanced or Recurrent Disease Treatments

Hormone Therapy (Androgen Deprivation Therapy – ADT)

Hormone therapy remains foundational in advanced, recurrent, or metastatic prostate cancer. Agents such as Lupron®, Firmagon®, and Orgovyx® suppress testosterone signaling to slow disease progression. Imaging helps determine treatment response, detect castration-resistant changes, and guide escalation or combination strategies.

Chemotherapy: Systemic agents such as docetaxel and cabazitaxel are used when prostate cancer spreads or becomes resistant to hormone therapy. Imaging evaluates disease burden, tracks metastatic spread, and informs timing and effectiveness of chemotherapy interventions.

Targeted Therapy: The emergence of genetically targeted therapies, including PARP inhibitors like olaparib, has introduced a new level of personalization. Imaging complements genomic testing by demonstrating phenotypic response and guiding treatment continuation or adjustment.

Immunotherapy: Immunotherapeutic approaches such as Sipuleucel-T represent an important option for select patients. While immune response may not always be immediately reflected in PSA changes, imaging provides objective insight into disease stabilization or progression.

Radiopharmaceutical Therapy: Radium-223 is a targeted radiopharmaceutical used specifically for prostate cancer metastases to bone. Imaging is critical in identifying appropriate candidates, monitoring skeletal response, and distinguishing therapeutic benefit from disease-related bone changes.

 

---

Ablative and Supportive Treatment Modalities

Cryotherapy and HIFU: Minimally invasive ablative techniques such as cryotherapy and high-intensity focused ultrasound (HIFU) are increasingly utilized in focal therapy or salvage settings. Imaging ensures accurate targeting, confirms tissue ablation, and monitors adjacent structures.

Bone-Targeted Therapy: For patients with bone metastases, bisphosphonates and denosumab are essential for skeletal protection and pain management. Imaging tracks bone integrity, fracture risk, and therapeutic response.

 

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Imaging as the Integrator of Prostate Cancer Care

Across all treatment categories—whether curative, systemic, or palliative—diagnostic imaging serves as the objective validator. It informs when to treat, how aggressively to intervene, and when to adjust course. Imaging transforms prostate cancer care from protocol-driven to precision-guided, reducing overtreatment while safeguarding against missed progression.

The future of prostate cancer management lies not in choosing one therapy over another, but in intelligent integration—where surgery, radiation, hormone therapy, systemic agents, and emerging technologies are applied in harmony, guided by accurate, real-time diagnostic insight.

---

Closing Perspective

Modern prostate cancer care is robust, multidisciplinary, and continually advancing. Current standards—from active surveillance to proton therapy, CyberKnife, systemic treatments, and supportive care—are well-founded and effective when applied appropriately. Diagnostic imaging stands at the center of this ecosystem, ensuring that every decision is informed, justified, and aligned with the patient’s unique disease profile.

In prostate cancer, seeing clearly is not optional—it is essential.

Prostate Cancer Treatments Using Hormone Therapy

Written by: Lennard M. Goetze, Ed.D |  Clinical Field Review by: Dr. Robert L. Bard 1-25-2026

Prostate cancer is fundamentally a hormone-driven disease. From its earliest stages through advanced progression, the growth and survival of most prostate cancer cells are fueled by androgens—primarily testosterone and its more potent derivative, dihydrotestosterone (DHT). This biological dependence makes hormone therapy, also known as androgen deprivation therapy (ADT), one of the most effective and widely used treatments in prostate cancer care. While hormone therapy is not considered curative on its own, it plays a critical role in controlling disease progression, alleviating symptoms, enhancing the effectiveness of other treatments, and extending survival across multiple stages of prostate cancer.

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Understanding Hormone Therapy (Androgen Deprivation Therapy)

Hormone therapy works by disrupting the androgen signaling pathways that many prostate cancers depend on for growth and progression. Prostate cancer is generally initiated by genetic and epigenetic alterations in genes that regulate cell proliferation, DNA repair, and survival. Once malignant transformation has occurred, androgen receptor (AR) signaling often becomes a dominant driver of tumor behavior. In many cases, perturbations of the AR axis—including AR gene amplification, activating DNA mutations, altered co-regulator activity, and post-translational modifications of the AR protein—can make tumor cells more sensitive to the growth-promoting effects of androgens, thereby fueling disease progression and therapeutic resistance, rather than causing de novo tumor development.

ADT aims to either reduce the body’s production of testosterone or block its ability to activate androgen receptors. This systemic approach differs from localized treatments such as surgery or radiation, as hormone therapy affects cancer cells throughout the body. By depriving tumors of hormonal stimulation, ADT can slow or halt disease progression, often resulting in a significant decline in prostate-specific antigen (PSA) levels.

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Types of Hormone Therapy Used in Prostate Cancer

LHRH Agonists and Antagonists
Luteinizing hormone–releasing hormone (LHRH) agonists and antagonists are among the most commonly used forms of hormone therapy in prostate cancer. These injectable or oral agents suppress testosterone production by acting on the hypothalamic–pituitary–gonadal axis. LHRH agonists may cause a transient testosterone “flare” at treatment initiation, whereas antagonists achieve more rapid suppression without this effect. While testosterone suppression is generally reversible with short-term use of LHRH agents, long-term therapy may result in prolonged or permanent testosterone suppression, particularly in older men or those treated for extended durations. These therapies are typically administered on monthly, quarterly, or annual schedules and require individualized monitoring based on patient age, treatment duration, and overall health status.

Anti-Androgens
Anti-androgen medications block testosterone from binding to androgen receptors on prostate cancer cells. Older agents were often used alongside LHRH drugs, while newer, second-generation anti-androgens such as enzalutamide and apalutamide provide more potent receptor inhibition. These drugs are increasingly used in both advanced and earlier stages of disease due to their improved efficacy.

Androgen Synthesis Inhibitors
Some prostate cancers continue to thrive despite low circulating testosterone by producing androgens locally or utilizing adrenal sources. Androgen synthesis inhibitors, such as abiraterone acetate, block testosterone production throughout the body. These medications are commonly used in metastatic or castration-resistant prostate cancer and are typically combined with low-dose steroids to manage side effects.

Surgical Hormone Therapy (Orchiectomy)
Orchiectomy, the surgical removal of the testes, provides permanent testosterone suppression. While effective and cost-efficient, it is less commonly chosen today due to its irreversible nature and psychological impact. However, it remains a valid option in select cases.

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When Hormone Therapy Is Used

Hormone therapy is utilized across a wide range of clinical scenarios. In localized or high-risk prostate cancer, it is often combined with radiation therapy to improve treatment outcomes. For patients who experience biochemical recurrence—rising PSA levels after surgery or radiation—ADT can delay disease progression. In advanced and metastatic prostate cancer, hormone therapy is a primary treatment, often used alongside chemotherapy or newer targeted agents. Treatment strategies may involve continuous therapy or intermittent schedules designed to reduce side effects while maintaining disease control.

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Benefits and Clinical Outcomes

Hormone therapy consistently lowers PSA levels and can significantly shrink tumors or slow their growth. In metastatic disease, it often provides rapid symptom relief, particularly for bone pain and urinary obstruction. Numerous studies have demonstrated improved survival when ADT is appropriately combined with radiation or systemic therapies, underscoring its central role in prostate cancer management.

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Side Effects and Quality-of-Life Considerations

Despite its benefits, hormone therapy is associated with a range of side effects. Common issues include hot flashes, fatigue, reduced libido, erectile dysfunction, weight gain, and muscle loss. Long-term therapy may increase the risk of osteoporosis, metabolic syndrome, diabetes, and cardiovascular disease. Cognitive changes and mood disturbances have also been reported. These effects highlight the importance of proactive monitoring, lifestyle interventions, bone health management, and patient education to preserve quality of life during treatment.

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The Role of Personalization and Monitoring

Modern prostate cancer care increasingly emphasizes individualized treatment strategies informed by tumor biology, disease extent, and patient-specific risk factors. In men with high-grade, high-risk, recurrent, or metastatic prostate cancer, germline genetic testing is now recommended by NCCN guidelines to identify inherited mutations in DNA repair genes such as BRCA1, BRCA2, and related pathways. Identification of these alterations has direct therapeutic implications, including eligibility for PARP inhibitor therapy, often in combination with androgen deprivation therapy.

In parallel, PSA kinetics, advanced imaging findings, and longitudinal biomarker trends guide decisions regarding treatment intensity, sequencing, and duration. Diagnostic imaging remains central to this personalized approach, enabling objective assessment of tumor response, early detection of progression, and timely modification of therapy. Shared decision-making between patients and multidisciplinary care teams ensures that treatment strategies balance oncologic control with long-term quality of life.

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Conclusion: Hormone Therapy as Part of an Integrated Strategy

Hormone therapy remains one of the most powerful tools in prostate cancer treatment. When thoughtfully applied and carefully monitored, it offers meaningful disease control and survival benefit. The most successful outcomes arise from an integrated approach—combining hormone therapy with imaging, supportive care, and personalized treatment planning—ensuring patients receive not only longer life, but better quality of life as well.

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References

American Cancer Society. (2024). Hormone therapy for prostate cancer. https://www.cancer.org

Attard, G., Parker, C., Eeles, R. A., Schröder, F., Tomlins, S. A., Tannock, I., & de Bono, J. S. (2016). Prostate cancer. The Lancet, 387(10013), 70–82. https://doi.org/10.1016/S0140-6736(14)61947-4

National Cancer Institute. (2024). Prostate cancer treatment (PDQ®)–patient version. https://www.cancer.gov

Nguyen, P. L., Alibhai, S. M. H., Basaria, S., D’Amico, A. V., Kantoff, P. W., Keating, N. L., & Penson, D. F. (2015). Adverse effects of androgen deprivation therapy and strategies to mitigate them. European Urology, 67(5), 825–836. https://doi.org/10.1016/j.eururo.2014.07.010

Sharifi, N., Gulley, J. L., & Dahut, W. L. (2010). Androgen deprivation therapy for prostate cancer. JAMA, 294(2), 238–244. https://doi.org/10.1001/jama.294.2.238

 

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Part 2:

Imaging as the Unifying Force across Standard Therapies

By Robert L. Bard, MD, DABR, FAIUM, FASLMS
Cancer Radiologist | Diagnostic Imaging Specialist

Prostate cancer care has evolved into a highly structured, evidence-based continuum—one that balances disease biology, patient risk stratification, and quality-of-life considerations. Across decades of clinical observation and imaging-based assessment, it is clear that no single therapy stands alone. Instead, modern prostate cancer management is defined by appropriate treatment selection, timely intervention, and objective monitoring, all anchored by diagnostic imaging.

As a cancer radiologist specializing in advanced diagnostic imaging, my role is not to replace standard therapies, but to corroborate, validate, and refine them. Imaging serves as the common language that links surveillance, intervention, and follow-up—ensuring that treatment decisions align with tumor behavior rather than assumptions alone.

---

Risk Stratification and the Foundation of Care

Current standards of prostate cancer treatment appropriately rely on risk group classification, clinical staging, PSA kinetics, Gleason grading, and overall patient health. These variables determine whether a patient is best served by conservative monitoring or active intervention.

Imaging has become indispensable in this process. High-resolution ultrasound, multiparametric MRI, PET-based tracers, and Doppler vascular assessment now provide real-time insights into tumor location, aggressiveness, vascularity, and response to therapy—allowing clinicians to act with precision rather than excess.

---

Primary Treatments (Localized / Curative Intent)

Active Surveillance and Watchful Waiting: For patients with low-risk, slow-growing prostate cancer, active surveillance remains a clinically sound and patient-centered strategy. Imaging plays a critical role in this pathway by confirming disease stability, detecting subtle progression, and reducing unnecessary biopsies or premature treatment. Surveillance is not passive—it is data-driven vigilance.

Surgery: Radical Prostatectomy- Radical prostatectomy remains a cornerstone curative option, particularly for localized disease in otherwise healthy patients. Preoperative imaging assists in surgical planning, margin assessment, and lymph node evaluation, while postoperative imaging helps identify recurrence early, should PSA levels rise.

 

Radiation Therapy- has advanced significantly, offering multiple precise modalities:

• External Beam Radiation Therapy (EBRT)
• Intensity-Modulated Radiation Therapy (IMRT)
• Brachytherapy (radioactive seed implantation)

In addition, proton therapy and CyberKnife® stereotactic radiosurgery represent highly refined radiation approaches. Proton therapy allows for targeted dose delivery with reduced collateral tissue exposure, while CyberKnife uses robotic X-ray guidance for sub-millimeter accuracy. Imaging is essential in treatment planning, targeting, and post-therapy assessment for all radiation modalities.

---

Advanced or Recurrent Disease Treatments

Hormone Therapy (Androgen Deprivation Therapy – ADT)

Hormone therapy remains foundational in advanced, recurrent, or metastatic prostate cancer. Agents such as Lupron®, Firmagon®, and Orgovyx® suppress testosterone signaling to slow disease progression. Imaging helps determine treatment response, detect castration-resistant changes, and guide escalation or combination strategies.

Chemotherapy: Systemic agents such as docetaxel and cabazitaxel are used when prostate cancer spreads or becomes resistant to hormone therapy. Imaging evaluates disease burden, tracks metastatic spread, and informs timing and effectiveness of chemotherapy interventions.

Targeted Therapy: The emergence of genetically targeted therapies, including PARP inhibitors like olaparib, has introduced a new level of personalization. Imaging complements genomic testing by demonstrating phenotypic response and guiding treatment continuation or adjustment.

Immunotherapy: Immunotherapeutic approaches such as Sipuleucel-T represent an important option for select patients. While immune response may not always be immediately reflected in PSA changes, imaging provides objective insight into disease stabilization or progression.

Radiopharmaceutical Therapy: Radium-223 is a targeted radiopharmaceutical used specifically for prostate cancer metastases to bone. Imaging is critical in identifying appropriate candidates, monitoring skeletal response, and distinguishing therapeutic benefit from disease-related bone changes.

 

---

Ablative and Supportive Treatment Modalities

Cryotherapy and HIFU: Minimally invasive ablative techniques such as cryotherapy and high-intensity focused ultrasound (HIFU) are increasingly utilized in focal therapy or salvage settings. Imaging ensures accurate targeting, confirms tissue ablation, and monitors adjacent structures.

Bone-Targeted Therapy: For patients with bone metastases, bisphosphonates and denosumab are essential for skeletal protection and pain management. Imaging tracks bone integrity, fracture risk, and therapeutic response.

 

---

Imaging as the Integrator of Prostate Cancer Care

Across all treatment categories—whether curative, systemic, or palliative—diagnostic imaging serves as the objective validator. It informs when to treat, how aggressively to intervene, and when to adjust course. Imaging transforms prostate cancer care from protocol-driven to precision-guided, reducing overtreatment while safeguarding against missed progression.

The future of prostate cancer management lies not in choosing one therapy over another, but in intelligent integration—where surgery, radiation, hormone therapy, systemic agents, and emerging technologies are applied in harmony, guided by accurate, real-time diagnostic insight.

---

Closing Perspective

Modern prostate cancer care is robust, multidisciplinary, and continually advancing. Current standards—from active surveillance to proton therapy, CyberKnife, systemic treatments, and supportive care—are well-founded and effective when applied appropriately. Diagnostic imaging stands at the center of this ecosystem, ensuring that every decision is informed, justified, and aligned with the patient’s unique disease profile.

In prostate cancer, seeing clearly is not optional—it is essential.

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Part 3:

Prostate Scan Now with Host: "Cousin Sal "Banchitta - Ret FDNY FF- presents BARRIE KOLSTEIN, PC Survivor 

 

My name is Sal Banchitta- aka- Cousin Sal. I've had an incredible 30+ year career in the NY Fire Department, what so many of considered to be the best job in the world. There is no other profession that even comes close to the rewards of being a city firefighter. We were the first and last line of defense to protect this great city from any catastrophe and aligned with a special family of the most unique and remarkable men and women is truly the ultimate blessing.  PROSTATE SCAN NOW: I welcome you to view our pilot episode in support of proactive checkups and Prostate Health!  I'm speaking to all my dude-friends in their 50's who need to start taking their health more seriously, while applauding those who have stayed on top of early detection and prevention. One such person is my latest hero in this- Mr. Barrie Kolstein. Check out our feature on this great motivator and role model!

STATS ABOUT PC:

"Prostate cancer is the second-leading cause of cancer death in American men, behind only lung cancer."  (Source- American Cancer Assoc)

"...leading cause of cancer death among men in the US, with 94 men dying from it every day." (Source: pcf.org)

"More than 3.3 million men in the United States who have been diagnosed with prostate cancer at some point are still alive today". (Source- American Cancer Assoc)

SEE COMPLETE FEATURE ON "THE COUSIN SAL MINUTE"