Six societies - the EAU with the European associations for nuclear medicine, radiotherapy, urogenital radiology, urological pathology and geriatric oncology - have updated Part II of the prostate cancer guidelines, covering relapsing disease, metastatic hormone-sensitive disease and castration-resistant disease. The panel reviewed evidence published between 2023 and 2025 and attached a strength rating to each recommendation based on systematic review.
Two themes run through the summary. The first is that risk stratification after primary therapy now guides salvage decisions, rather than relapse being treated as a single category. The second is that the options have multiplied: androgen receptor pathway inhibitors, metastasis-directed therapy, PARP inhibitors and combinations of them, and PSMA-directed radioligand therapy. That is a rapidly moving field in which a guideline's main service is telling you what the evidence currently supports and how strongly.
The panel includes a sentence that deserves reading twice by anyone practising outside western Europe: the recommendations are based on clinical evidence and do not account for variations in cost, reimbursement structures or resource availability. In India, PSMA-based radioligand therapy is available at a handful of centres and largely self-funded, PARP inhibitors require germline or somatic testing that is not routinely reimbursed, and androgen receptor pathway inhibitors vary enormously in price between originator and generic. The guideline describes what should happen; the conversation in clinic is about what can.
- Download the full guideline rather than working from the summary - the strength ratings are the operative content
- Check whether the recommendations you intend to follow depend on molecular testing that is available and affordable for your patient
- Where PSMA-based therapy is recommended, establish access and cost before raising it with the patient
- Use the risk stratification for relapse after primary therapy to decide salvage timing rather than treating all biochemical recurrence alike
- Document where you have deviated from guideline recommendations for resource reasons, and why
Why it matters
It resets the reference standard for relapsed and metastatic disease, in a field where the standard has moved several times since the last version.
Don't overread it
A guideline summary - the recommendations and their strength ratings live in the full document, not in this abstract.
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