PCWG4 vs PCWG3: Advanced Prostate Cancer Terminology Overhaul
The Prostate Cancer Working Group 4 (PCWG4), published in February 2026, introduces patient-centric updates to advanced prostate cancer trial design, shifting from PCWG3’s clinical state model to a therapeutic indication framework. PCWG4 replaces outdated terms like “castration-resistant prostate cancer” (CRPC), “non-metastatic castration-resistant prostate cancer” (nmCRPC), “metastatic castration-resistant prostate cancer” (mCRPC), “hormone-sensitive prostate cancer” (HSPC), and “castration-sensitive prostate cancer” (CSPC), which PCWG3 used to describe disease based on testosterone levels, with “androgen pathway modulation” (APM) terminology: APM-naïve/sensitive (APMN/S, formerly HSPC/CSPC) for treatment-untreated or early-response states, and APM-resistant (APMR, formerly CRPC) for progression after diverse therapies beyond just castration.
This change, driven by patient feedback on insensitive language and the rise of non-castration APM agents like androgen receptor pathway inhibitors (ARPIs), better reflects modern biology and serial profiling via biopsies. PCWG4 also integrates prostate-specific membrane antigen positron emission tomography (PSMA-PET) for staging and progression (new lesions, not SUV changes), contrasting PCWG3’s reliance on conventional CT/bone scans, while updating bone scan rules: ≥6 new lesions confirm progression without re-scan (vs. PCWG3’s 2-scan confirmation for any new lesions). Overall, these evolve trials toward biomarkers, patient-reported outcomes (PROs, direct patient reports on symptoms, quality of life, and functioning via validated questionnaires), and diversity, optimizing endpoints like radiographic progression-free survival (rPFS) in heterogeneous populations.
Hormone sensitive and hormone resistant made sense to the average Prostate Cancer Patient. Now it is clear as mud for the average person. Castration was the offending term…now we have jumped to the obscure. Where were the patient advocates in this process? As a patient advocate and survivor….I VOTE NO!
Hello JPnSD,
You are absolutely right that terms like hormone-sensitive and hormone-resistant were easier for many patients to understand. One of the biggest challenges with updates like those introduced by the Prostate Cancer Working Group 4 (PCWG4) is balancing scientific accuracy with clear communication.
The shift toward terms like androgen pathway modulation (APM) was not meant to make things obscure, but to reflect the reality that today’s treatments go beyond traditional castration-based approaches and include many newer therapies that target the androgen pathway in different ways.
In my personal view, one of the most interesting aspects of the article is the second section, where greater importance is given to radiographic progression. This shift reflects a growing recognition that imaging-based progression provides a more reliable measure of disease evolution than PSA changes alone.
That said, your point about clarity is extremely valid. In practice, many clinicians and educators, including those of us who communicate research updates, will likely continue to translate these newer technical terms into patient-friendly language so that no one is left behind.
It will be extra work for us, at least for a long while! Thank you for your comment.
Max