A Genomic Score That Flags Lethal Prostate Cancer — and Who Gains From Extra Hormone Therapy

A Genomic Score That Flags Lethal Prostate Cancer — and Who Gains From Extra Hormone Therapy

A biopsy-based score sorts calm tumours from killers

A genetic test that analyses cancer-cell genes in a small piece of an existing tissue biopsy can flag which men with prostate cancer face the highest risk of spread and death. The tool, called Decipher and made by US diagnostics firm Veracyte, converts the tumour's biology into a score ranging from calm and unlikely to spread to aggressive and highly likely to spread. In the new analysis, each 0.1-point rise in the score was linked to a 49 per cent higher risk of distant metastasis and a 38 per cent higher risk of dying from prostate cancer.

Retrospective read-out on 6,000 men earns Level 1B rating

The evidence comes from a retrospective analysis of the randomised Phase III STAMPEDE trial covering more than 6,000 men, led by Dr Sarah Howlett of University College London. The work provides Level 1B predictive evidence in clinically very high-risk, nonmetastatic disease, with a statistically significant treatment-by-Decipher interaction (p=0.01) for distant metastasis in node-negative patients. The findings are scheduled as a proffered-paper oral presentation at the ESMO Congress 2026 in Madrid on Oct 24.

Abiraterone halves mortality — but only some men need it

The treatment at stake is abiraterone, a hormone therapy that blocks testosterone from fuelling prostate cancer. STAMPEDE has shown that adding it to standard androgen deprivation therapy in high-risk localised disease can halve the risk of death and slow overall progression. The catch is toxicity and overtreatment: until now doctors lacked a reliable way to tell which high-risk men gain enough to justify the extra drug.

Five-year benefit is 11% at the top, 2% at the bottom

The new stratification is stark. At five years, the absolute reduction in distant metastasis from adding abiraterone was 10 per cent in high-Decipher patients and 11 per cent in very-high patients, versus just 2 per cent in lower-score patients. Howlett said men with high-risk disease but a low Decipher score have low spread rates and could potentially be spared more intensive treatment, while high scorers should be prioritised for it.

NHS rollout in England makes timing matter

The UK context sharpens the relevance. Androgen deprivation therapy remains the backbone of care, and NHS England announced in January it would roll out abiraterone for high-risk locally advanced disease within weeks, with similar patients in Wales and Scotland already covered. Veracyte's medical director for urology, Elai Davicioni, said the growing evidence gives physicians a stronger reason to use Decipher before decisions affecting both cancer outcomes and quality of life, extending its predictive evidence to the abiraterone question.

Validation still required before routine use

The researchers caution that further validation is needed before routine clinical use. Still, the direction is clear: prostate cancer is not one disease, and therapy is moving from one-size-fits-all toward genomic risk stratification. The next questions are practical — when the test enters care pathways, who pays, and how safely the low-score, de-escalation boundary can be drawn.