A structured overview searched six major society guidelines to October 2025 — EAU 2025, AUA/SUO 2023, NCCN 2025, CUA 2024, ASCO 2025 and ESMO 2020 — plus the joint EANM/SNMMI procedural guideline and the 2024 Advanced Prostate Cancer Consensus Conference.
The convergence is near-complete for the established indication. Every society except ESMO, which has not updated, endorses 177Lu-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 is consistent: 7.4 GBq every six weeks for up to six cycles, with continued androgen deprivation 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-naïve men progressing after an androgen receptor pathway inhibitor. For Indian practice the constraint is not the guidance but access: radioligand therapy requires a licensed nuclear medicine facility and the cost is almost entirely out of pocket, so the practical question at the multidisciplinary meeting is whether this patient can reach a centre that provides it, and when to raise that before the taxane decision rather than after.
- For PSMA-positive mCRPC after an ARPI and a taxane, treat radioligand therapy as standard where accessible
- Confirm PSMA positivity on PET before committing — the indication is imaging-defined
- Raise referral feasibility early, not after chemotherapy has been given
- Treat the taxane-naïve indication as emerging: NCCN endorses it, EAU is more cautious, ESMO has not updated
- Plan the 7.4 GBq six-weekly schedule around the patient's ability to travel to the centre
Why it matters
The guidelines have converged while access has not, which makes referral timing the actual clinical variable.
Don't overread it
A synthesis of existing guidance, not new trial evidence — the earlier-line recommendation rests on PSMAfore and is not yet uniform across societies.
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