Record scratch. The prostate cancer treatment movie has gotten a much better script lately, but too many of the people who actually need the ending are still stuck outside the theater, wondering why the cast looks nothing like them.
A new review in JNCCN by McManus, George, and Shevach asks a deceptively simple question: when prostate cancer clinical trials prove a treatment works, do doctors believe those results apply to the patient sitting in front of them? For older adults, people with several health conditions, rural patients, and men of non-European ancestry, the answer can be: "Maybe? Please hold while we squint at the trial enrollment table."
That is not exactly how modern oncology should run.
The Trial Version Versus the Real-World Cut
Clinical trials are the prestige TV of medicine. Carefully scripted. Well monitored. Everyone has a defined role. The lighting is excellent.
Real life is more like a chaotic streaming-service crossover episode. A patient may be 78, taking six medications, living two hours from the cancer center, managing diabetes, and still trying to get the lawn mowed before the rain. That person is not a statistical nuisance. That person is the audience.
The review argues that prostate cancer trials often miss key groups who make up everyday oncology practice. That gap matters because prostate cancer care has changed fast. For metastatic hormone-sensitive prostate cancer, doctors no longer rely on androgen deprivation therapy, or ADT, alone as the default old-school move. ADT lowers or blocks androgens, hormones that prostate cancer cells often use like a motivational Spotify playlist. Newer strategies add androgen receptor pathway inhibitors, chemotherapy, or combinations that can extend survival for appropriate patients.
But if the trials mostly enrolled fitter, less complicated patients, doctors may hesitate. Not because they hate progress. Because nobody wants to hand a Marvel-level treatment combo to someone whose real-world health looks more like a tender indie drama with kidney disease, frailty, and transportation problems.
Why "Representation" Is Not Just a Nice Poster
Underrepresentation is not only unfair. It makes the science less useful.
A meta-analysis in JAMA Oncology found that Black and Hispanic men were underrepresented in prostate cancer clinical trials compared with their share of prostate cancer incidence, and Black representation stayed low over two decades. That is especially awkward because prostate cancer outcomes already differ by race and ancestry. If the research bench keeps saying, "We tested this in the usual suspects," clinicians and patients have every right to ask, "Cool, but what about us?"
Ancestry can also matter biologically. It may affect tumor genetics, drug metabolism, side effects, and biomarkers. Leaving ancestry-diverse populations out of trials is like trying to review every Star Wars movie after watching only the trailers for three of them. You might have opinions. They will not be complete.
Older adults face a different version of the same problem. Many prostate cancer patients are older, and many have other medical conditions. Yet trial eligibility criteria can quietly filter out people with heart disease, kidney problems, limited mobility, or messy medication lists. The result: a beautifully clean dataset that may not answer the messier question clinicians actually face on Monday morning.
The Treatment Gap Is Already Showing
This is not theoretical hand-wringing with a lab coat on.
A 2024 systematic review in BJU International found that ADT intensification for metastatic hormone-sensitive prostate cancer has increased, but many real-world patients still receive ADT alone. Factors linked with intensified treatment included younger age, better performance status, fewer comorbidities, lower cost barriers, and care from an oncologist. Translation: the people who look most like trial participants are often the people most likely to receive the trial-proven upgrades.
Another systematic review in European Urology Oncology reached a similar point: big trials changed the standard of care, but access in routine practice has lagged. The blockbuster science arrived. The distribution plan, apparently, got stuck buffering.
How to Fix the Casting Problem
McManus and colleagues push for practical changes, especially in later-phase trials. Broaden eligibility. Recruit from community and rural sites, not only major academic centers. Build trials that include patients with common comorbidities. Make participation less punishing with telehealth, local labs, travel support, and simpler visit schedules. Collect better data on race, ethnicity, ancestry, frailty, geography, and social barriers.
None of this means lowering scientific standards. It means asking better questions. A trial can still be rigorous while admitting that patients do not arrive as perfectly laminated medical charts.
Real-world evidence can help too, but it should not become the understudy for inclusive trials. Observational data can show what happens after treatments leave the controlled environment, but it cannot fully replace randomized evidence in the people most likely to receive the drugs.
The Better Sequel
The future of prostate cancer care should not be "great treatments, selectively trusted." It should be more like a well-cast ensemble show: older adults, rural patients, people with comorbidities, and ancestry-diverse populations all represented before the final credits roll.
Because when trials reflect real patients, doctors can prescribe with more confidence, patients can make decisions with less guesswork, and cancer care stops treating everyday complexity like a deleted scene.
References
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McManus HD, George DJ, Shevach JW. Real-World Representation in Prostate Cancer Clinical Trials: Needs and Opportunities. Journal of the National Comprehensive Cancer Network. 2026. DOI: 10.6004/jnccn.2026.7002
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Riaz IB, et al. Disparities in the Inclusion of Racial and Ethnic Minority Groups and Older Adults in Prostate Cancer Clinical Trials: A Meta-analysis. JAMA Oncology. 2023;9(2):180-188. PMCID: PMC9685549. DOI: 10.1001/jamaoncol.2022.5511
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Raval AD, Chen S, Littleton N, Constantinovici N. Real-world use of androgen-deprivation therapy intensification for metastatic hormone-sensitive prostate cancer: a systematic review. BJU International. 2025;135(3):408-421. PMCID: PMC11842892. DOI: 10.1111/bju.16577
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Dodkins J, Nossiter J, Cook A, Payne H, Clarke N, van der Meulen J, Aggarwal A. Does Research from Clinical Trials in Metastatic Hormone-sensitive Prostate Cancer Treatment Translate into Access to Treatments for Patients in the "Real World"? A Systematic Review. European Urology Oncology. 2024;7(1):14-24. DOI: 10.1016/j.euo.2023.05.002
Disclaimer: The image accompanying this article is for illustrative purposes only and does not depict actual experimental results, data, or biological mechanisms.