The European Association of Urology and its partner societies in nuclear medicine, radiotherapy, urogenital radiology, urological pathology and geriatric oncology have updated Part II of their prostate cancer guidelines, covering relapsing disease, metastatic hormone-sensitive disease and castration-resistant disease. The panel reviewed new data from 2023 to 2025 and added a strength rating to each recommendation based on systematic review.
Two substantive shifts are named. Risk stratification of biochemical relapse after primary therapy may now guide salvage decisions, rather than every recurrence prompting the same response. And the treatment range for metastatic disease has widened considerably: androgen receptor pathway inhibitors, metastasis-directed therapy, PARP inhibitors and their combinations, and prostate-specific membrane antigen-based therapy.
The sentence to note is the one about resources. The guidelines state that recommendations rest on clinical evidence and do not account for cost, reimbursement structures or resource availability. That is honest and it is also a warning label for readers outside western European health systems. A recommendation for a PARP inhibitor combination or lutetium-based prostate-specific membrane antigen therapy is a recommendation for a treatment that a majority of Indian patients cannot fund and many centres cannot deliver.
So the usable part is the sequencing logic rather than the drug list. Knowing which line a therapy belongs in, and what has to be established first — homologous recombination repair testing before a PARP inhibitor, prostate-specific membrane antigen imaging before that therapy — is what transfers. The risk stratification of relapse transfers completely and costs nothing.
- Use risk stratification of biochemical relapse to decide on salvage rather than treating all recurrences alike
- Establish homologous recombination repair status before considering a PARP inhibitor, not after
- Read the recommendations against local availability and cost; the panel says explicitly that it did not
- Record the strength rating alongside the recommendation when quoting it in a multidisciplinary meeting
- Keep androgen deprivation intensification as the decision that affects most patients most
Why it matters
The guideline explicitly excludes cost and availability, which is exactly the variable that decides treatment for most patients reading it.
Don't overread it
A guideline summary is a framework with strength ratings, not new trial evidence, and the panel states it did not weigh cost or access.
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