Matthias Saar, MD, on inductive hormonal therapy for T4 prostate cancer

In the following interview, conducted at the 2026 ASCO Genitourinary Cancers Symposium in San Francisco, California, Matthias Saar, MD, discusses findings from the prospective, phase 2 INDUCTA trial evaluating an inductive hormonal therapy approach to render patients with T4 prostate cancer operable.¹ Saar is director and chair of the department of urology at the University Hospital RWTH Aachen in Aachen, Germany.

T4 prostate cancer remains a particularly challenging clinical scenario, as these tumors are typically considered inoperable and are managed with systemic therapy and/or radiotherapy. Prior retrospective analyses suggested that some patients could undergo radical prostatectomy following androgen deprivation therapy (ADT), but the proportion of patients who could reliably achieve operability was unclear. To address this gap, the INDUCTA trial was designed as the first prospective study to evaluate whether combined inductive therapy with ADT plus apalutamide (Erleada) could consistently downstage disease and enable surgery in this population.

The single-arm, prospective trial enrolled 21 patients with nonmetastatic cT4 prostate cancer deemed inoperable based on clinical and imaging criteria. All patients received 6 months of ADT in combination with apalutamide, followed by reassessment of local tumor stage and operability. Advanced imaging with PSMA-PET was also incorporated as an exploratory component. Patients who were deemed operable after induction proceeded to robot-assisted radical prostatectomy, with the primary end point being the proportion of patients achieving operability.

Results demonstrated that inductive therapy was highly effective at downstaging disease. Operability was confirmed in 100% of patients who completed treatment, with 95% becoming operable after the initial 6-month treatment period and only 1 patient requiring additional therapy. Ultimately, nearly all patients underwent prostatectomy, with 1 operable patient foregoing surgery due to cardiac deterioration.

No residual T4 disease was observed at surgery, with the highest pathological stage being pT3. According to Saar, surgical outcomes were comparable to those seen in patients with initially operable, locally advanced disease. The positive survival margin rate was 35%.

The safety profile of this approach was also favorable. Perioperative complications were consistent with those expected for radical prostatectomy, with some grade 2 and 3 events but no grade 4 or 5 complications reported. Additionally, no rectal injuries were observed, and quality-of-life measures did not show deterioration from baseline.

According to the authors, these findings suggest that inductive therapy with ADT plus apalutamide may offer a viable strategy to convert inoperable T4 prostate cancer into a surgically manageable condition, potentially setting the stage for a new standard of care for this high-risk population.

REFERENCE

1. Saar M, Linxweiler J, Kranz J, et al. A feasibility trial investigating inductive apalutamide therapy combined with radical prostatectomy in patients with locally advanced T4 high risk prostate cancer: First results of the prospective phase II INDUCTA study. J Clin Oncol. 2026;44(7). doi:10.1200/JCO.2026.44.7_suppl.370