The AUA/SUO 2026 amendment places PSMA-PET at the centre of biochemical recurrence and metastatic hormone-sensitive disease; risk-based classification and the ADT plus ARPI combination are becoming standard.
PSMA-PET is now central in biochemical recurrence and metastatic hormone-sensitive disease; risk-based classification and combination treatments are becoming standard
6 August 2026 | Source: The Journal of Urology, American Urological Association, Urology Times, OncLive | Topic: Advanced Prostate Cancer / Guideline Update
KEY FINDINGS
- PSMA-PET is now the preferred imaging method: Because of its high sensitivity, PSMA-PET is recommended as the first choice in patients with PSA recurrence in whom local treatment options have been exhausted.
- A risk-based approach in biochemical recurrence: Patients with a PSA doubling time (PSADT) ≤9 months are considered high risk and ADT plus enzalutamide is recommended for this group; in low-risk patients with PSADT >9 months, ADT should not be started routinely.
- Combination therapy has become the rule in mHSPC: An ARPI should be given in addition to ADT to the great majority of patients (Strong Recommendation, Evidence Level A).
- Genetic testing for every patient: Germline testing should be recommended to all patients with advanced prostate cancer, and somatic tumour testing additionally to those with metastatic disease.
- A new option in BRCA2-positive patients: ADT plus abiraterone plus niraparib may be offered as an option in mHSPC patients carrying an HRR gene alteration - particularly BRCA2.
- Farewell to first-generation antiandrogens: Bicalutamide, flutamide and nilutamide should not be used in mHSPC other than to block testosterone flare (Strong Recommendation, Evidence Level A).
Background: Why an Amendment?
The American Urological Association (AUA) and the Society of Urologic Oncology (SUO) incorporated evidence published since the 2023 version of the Advanced Prostate Cancer Guideline through the AUA amendment process. The systematic literature review covered 38 studies published between 16 March 2022 and 26 August 2025 and taken forward to full-text assessment; 40 recommendations were updated as a result.
The amendment was published in two parts. Part I covers the assessment and treatment of biochemical recurrence (BCR) developing after local treatment options have been exhausted, and metastatic hormone-sensitive prostate cancer (mHSPC). Part II addresses metastatic castration-resistant prostate cancer (mCRPC) and was published on 16 July 2026.
Two main themes define the amendment: combination therapy becoming standard care at almost every stage of the disease and the increasing weight of molecular and genomic testing in guiding treatment.
1. Early Assessment and Counselling
The guideline defines as a clinical principle that germline testing should be offered to all patients with advanced prostate cancer, with somatic tumour testing additionally in those with metastatic disease. It emphasises that treatment decisions should be made on the basis of life expectancy, comorbidities, patient preferences and tumour characteristics, and with a multidisciplinary approach wherever possible. Optimising pain control and symptom support, and directing patients to professional and community-based support resources, are also among the explicit recommendations.
2. Biochemical Recurrence: Imaging and Risk Classification
PSMA-PET imaging has been rapidly adopted over the past five years and has been integrated throughout the guideline in the 2026 amendment, across both localized and advanced disease. In patients with PSA recurrence in whom local treatment options have been exhausted, PSMA-PET is recommended preferentially because of its higher sensitivity, or to be deployed where conventional imaging is negative.
| Risk Group | Definition | Recommended Approach |
|---|---|---|
| Low risk | PSADT >9 months | Surveillance should be offered; ADT should not be started routinely (Expert Opinion) |
| High risk | PSADT ≤9 months | ADT plus enzalutamide should be offered (Expert Opinion) |
| High risk - after response | Favourable response to ADT ± ARPI | Intermittent therapy may be offered instead of continuous therapy |
3. Metastatic Hormone-Sensitive Prostate Cancer (mHSPC)
In newly diagnosed mHSPC patients, the extent of metastatic spread (lymph node, bone, visceral) should be assessed and the disease classified as low volume or high volume. High-volume disease is defined as the presence of four or more bone metastases on conventional imaging with at least one outside the spine/pelvis, and/or visceral metastasis.
| Recommendation | Strength of Recommendation | Note |
|---|---|---|
| ADT (LHRH agonist/antagonist or surgical castration) | Strong Recommendation - Evidence Level B | The backbone in all mHSPC patients |
| ADT plus ARPI (abiraterone+prednisone, apalutamide, enzalutamide or darolutamide) | Strong Recommendation - Evidence Level A | Should be offered to the majority of patients |
| ADT plus docetaxel plus (abiraterone+prednisone or darolutamide) - "triplet" | Strong Recommendation - A / B | In selected patients |
| Primary radiotherapy to the prostate plus ADT ± ARPI | Conditional Recommendation - Evidence Level C | In selected patients (low-volume disease) |
| ADT plus abiraterone plus niraparib | Expert Opinion | In those carrying an HRR gene alteration, particularly BRCA2 |
| First-generation antiandrogens plus an LHRH agonist | Strong Recommendation - SHOULD NOT BE USED (Evidence Level A) | The exception is solely to block testosterone flare |
For follow-up, serial PSA measurement at three to six-month intervals after starting ADT and periodic imaging are recommended.
Implications for Clinical Practice
1. Imaging decisions are being reshaped
PSMA-PET becoming the first-choice imaging method in biochemical recurrence produces two concrete consequences: low-volume disease missed by conventional imaging can be detected earlier, and the treatment decision - systemic therapy or metastasis-directed therapy - can be made more accurately. That said, it should not be forgotten that increased sensitivity leads to stage migration and that its effect on long-term outcomes is not yet fully clear.
2. Not treatment for every patient, but the right treatment for the right patient
That the guideline explicitly states that ADT should not be started routinely in low-risk biochemical recurrence is a sign of the maturation of uro-oncological practice. In a patient with PSADT >9 months, the cardiometabolic burden, bone loss, hot flushes and loss of quality of life brought by early hormone therapy may be disproportionate to the oncological gain obtained. Conversely, delaying treatment intensification in a patient with PSADT ≤9 months means a missed opportunity.
3. Genetic testing is no longer a privilege but a standard
Recommending germline testing to every patient with advanced disease directly affects not only the patient's treatment options but also the screening strategy for family members. That BRCA2 carriage opens the door to a niraparib-containing combination at the mHSPC stage shows that molecular profiling is an inseparable part of the treatment plan.
4. What it means for the surgical team
Our follow-up protocols after radical prostatectomy need to be restructured on the basis of PSA kinetics. Calculating PSADT rather than reflexively moving to hormone therapy in a patient with PSA recurrence after surgery, and restaging with PSMA-PET where necessary, will prevent both an unnecessary treatment burden and delayed intervention.
Conclusion
The AUA/SUO 2026 amendment shows that the treatment philosophy in advanced prostate cancer is crystallising along two axes: more accurate patient selection through more sensitive imaging and more intensive, combination-based treatment in the correctly selected patient. The question is no longer "should we treat?" but "which patient, with which combination, at what time?"
For our patients the meaning of this is encouraging: even in metastatic hormone-sensitive disease we today have multiple treatment options supported by evidence level A. Equally important is that the guideline also explicitly recommends avoiding unnecessary treatment - that is, a commitment to preserving not only the patient's disease control but also their quality of life.
References
- Scarpato KR, Cookson MS, Dreicer R, et al. Advanced Prostate Cancer: AUA/SUO Guideline Amendment (2026). Part I. The Journal of Urology. doi:10.1097/JU.0000000000005220
- Scarpato KR, Cookson MS, Dreicer R, et al. Advanced Prostate Cancer: AUA/SUO Guideline Amendment (2026). Part II - mCRPC. 16 July 2026. doi:10.1097/JU.0000000000005219
- American Urological Association. Advanced Prostate Cancer: AUA/SUO Guideline (2026) - guideline text and list of recommendations.
- Clarke H. 2026 AUA/SUO Advanced Prostate Cancer Guideline: Key updates and clinical FAQs. Urology Times.
- Scarpato KR. Updated AUA/SUO Advanced Prostate Cancer guideline emphasizes role of PSMA-PET. Urology Times.
- OncLive. AUA and SUO Amend Advanced Prostate Cancer Guideline. (PMID: 42462144)
Important Note: This article has been prepared for information purposes and does not constitute individual medical advice. The diagnosis and treatment of prostate cancer are planned by assessing the stage of disease, PSA kinetics, imaging findings, genetic profile and the patient's general health together. Always consult your physician regarding treatment decisions.
Dr. Murat Binbay - Urology, Uro-Oncology and Robotic Surgery
