Exploring Radiation Therapy’s Reach in Prostate Cancer

Radiotherapy remains a cornerstone of prostate cancer management across disease stages, with advanced imaging now fundamentally reshaping treatment planning and delivery. The modern paradigm emphasizes personalization—tailoring the treatment modality, dose, and fractionation precisely to the patient’s risk stratification and unique clinical scenario.

In a recent interview, J. Benjamin Wilkinson, MD, a radiation oncologist at Coastal Radiation Oncology Medical Group in Santa Maria, California, discussed this evolving landscape, highlighting key technological advances, persistent challenges, and the critical importance of a personalized approach.

Targeted Oncology: What is one of the most exciting advancements in prostate cancer right now?

J. Benjamin Wilkinson, MD: The ability to visualize microscopic disease we previously could not see, particularly in higher-risk patients. The most transformative tool is the PSMA PET scan. Historically, we lacked a sensitive whole-body imaging method for prostate cancer at diagnosis to see if disease has spread. Now, even if lymph nodes or bones look normal on a CT or MRI, a PSMA PET scan can reveal small sites of disease. This allows us to address these areas upfront rather than waiting until later in the diagnosis. It provides clarity and can significantly alter our initial treatment plan.

What is one of the biggest challenges in the field right now?

We still encounter biologically aggressive prostate cancers that we don't fully understand. Some men present with seemingly limited disease yet progress rapidly. To move beyond our current arsenal, we need a deeper biological understanding of these tumor types to develop more effective, targeted therapies.

What advice would you give to other community oncologists regarding GU cancers?

Every person is an individual. While we assign a stage or risk category, it’s crucial to take time to see what is unique about each case—including the social or family dynamics—to help that patient and family most effectively. In our clinic, we try to think through every detail of the diagnosis and identify potential barriers to care. Our goal is to help each individual, not just treat the cancer in a general sense.

How is artificial intelligence (AI) being used in your field, and what are your thoughts on it?

In radiation oncology, AI is automating tasks we traditionally did manually. The main use I’ve seen is in “contouring”—outlining normal anatomy on scans for treatment planning. The software isn’t 100% correct and requires checking, but it improves efficiency and consistency, as each person might contour structures slightly differently. It also improves quality of life for our dosimetrists.

For physicians, evidence-synthesis AI tools are emerging. One example, "Open Evidence," is very helpful. I can input a clinical question to quickly check if new data might alter my interpretation of historical evidence. It's a promising tool for staying current.

Can you discuss how radiation therapy options have evolved for prostate cancer?

Radiation therapy has evolved significantly. We used to treat the entire prostate gland with 1 dose over a long period, such as 8 weeks. Now, shorter treatment lengths are effective with reasonable adverse events.

One exciting development is the simultaneous integrated boost.¹ We give a higher dose to areas visible on MRI or PSMA PET while decreasing the dose to critical structures such as the urethra. Patients are treated in the same timeframe, but we see significantly better outcomes than with conventional plans.

Brachytherapy remains a viable option, either as a boost with external beam radiation or used as monotherapy. It’s a great option under the radiation therapy umbrella that patients don’t always hear about.

There are also emerging technologies. MRI-guided linear accelerators allow us to watch soft tissue in real-time during treatment, enabling smaller treatment margins and real-time adjustments. Proton therapy is another unique technology, though access can be limited by geography.

Is there anything else you’d like to add about PSMA-targeting?

Pairing PSMA PET’s diagnostic capabilities with a therapeutic counterpart is important. We can attach a radioisotope to the PSMA-targeting molecule. This radioligand, Lu 177 vipivotide tetraxetan (Pluvicto; formerly 177Lu-PSMA-617),² finds and treats distant microscopic disease. Currently, it’s used after chemotherapy for castrate-resistant metastatic prostate cancer, but trials are looking at moving it earlier in the treatment sequence. I see a lot of promise here—specifically finding and treating microscopic disease. I expect we’ll see several new agents based on this concept developed over the next few years.

REFERENCES

1. Onal C, Erbay G, Guler OC, Yavas C, Oymak E. Treatment outcomes of simultaneous integrated boost to intraprostatic lesions with external beam radiotherapy in localized prostate cancer patients. Prostate. 2023;83(12):1158-1166. doi:10.1002/pros.24558

2. Novartis Pluvicto approved by FDA as first targeted radioligand therapy for treatment of progressive, PSMA positive metastatic castration-resistant prostate cancer. News release. May 23, 2022. Accessed January 19, 2026. https://tinyurl.com/3u8n5pkm