Six society guidelines were compared — EAU 2025, AUA/SUO 2023, NCCN 2025, CUA 2024, ASCO 2025 and ESMO 2020 — alongside the joint EANM/SNMMI procedural guideline and the 2024 Advanced Prostate Cancer Consensus Conference. All except ESMO, which has not updated its guidance, endorse lutetium-177 PSMA-617 for PSMA-positive metastatic castration-resistant prostate cancer after both an androgen receptor pathway inhibitor and taxane chemotherapy, on level 1 evidence from VISION and TheraP. The regimen they converge on is 7.4 GBq every six weeks for up to six cycles, with androgen deprivation continued and multidisciplinary oversight.
The movement is at the earlier line. Following PSMAfore, NCCN version 1.2025 and, more cautiously, EAU 2025 acknowledge use in taxane-naive patients progressing after an androgen receptor pathway inhibitor. Those two documents differ in how firmly they say it, and that difference is the live question rather than a discrepancy to resolve.
What to do with this depends on where you practise. Where the therapy is available, the actionable step is upstream of the treatment decision: a man reaching castration resistance needs PSMA imaging early enough for eligibility to be assessed while his performance status still permits six cycles, and referral pathways to a nuclear medicine service need to exist before he needs them. Where it is not available — which is most of India outside a handful of centres — the honest version is that this is a treatment with level 1 evidence that most patients cannot access, and the conversation should be about clinical trials and about what the sequence looks like without it. Do not describe the taxane-naive indication as established; two guidelines acknowledge it and the trials defining it are still reporting.
- Arrange PSMA imaging early in castration-resistant disease so eligibility is known before performance status falls.
- Establish the referral route to a nuclear medicine service ahead of the first eligible patient.
- The agreed regimen is 7.4 GBq every six weeks for up to six cycles, with androgen deprivation continued.
- Describe the taxane-naive setting as emerging, not established — NCCN and EAU differ in firmness.
- Where the therapy is inaccessible, discuss trials and the alternative sequence rather than the guideline.
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