PSA Alone Can Miss Prostate Cancer Growth; Regular Imaging Urged

In two major trials of enzalutamide for advanced prostate cancer, up to about 25% of patients showed radiographic progression on imaging despite stable or undetectable PSA levels, correlating with worse survival. The findings suggest PSA monitoring alone may miss disease growth, underscoring the value of periodic imaging—especially in the first two years—and may prompt updates to clinical guidelines. Possible mechanisms include tumors evolving to grow independent of androgen receptor signaling through lineage plasticity or neuroendocrine transformation.