The European Society for Medical Oncology has updated its clinical practice guidelines for the management of localised prostate cancer and biochemical recurrence, refining diagnostic pathways and redefining treatment thresholds after primary therapy.

The updated document developed by experts from four continents serves as a practical road map for clinicians. This clarifies when to suspect aggressive disease and how to manage patients who experience rising prostate-specific antigen (PSA) levels after an initially successful treatment.

These recommendations reflect a shift towards greater diagnostic precision and earlier intervention for high-risk relapse, with direct implications for both primary and specialist care.

Imaging First

One of the strongest recommendations in the new guidelines is the systematic use of multiparametric MRI (mpMRI) before any prostate biopsy. This approach helps avoid unnecessary procedures in indolent tumours and allows targeted sampling of suspicious lesions, including a Prostate Imaging Reporting and Data System score 4 or 5. A score of 1 means that it is very unlikely to be a cancer, while a score of 5 means that it looks concerning.

When mpMRI findings are negative but clinical suspicion remains, PSA density becomes a key biomarker. If the value exceeds 0.15 ng/mL/cc, calculated as PSA level divided by prostate volume, biopsy is still recommended.

Regarding the technique, the guidelines mark a turning point by recommending the transperineal approach over the transrectal route. The rationale for this is patient safety. Access through the perineal skin markedly reduces the risk for sepsis and urinary tract infections and may allow the procedure to be performed without prophylactic antibiotics.

Current data show infection rates of up to 4.1% with transrectal biopsy compared with approximately 1.2% using the transperineal approach.

Targeted Screening

The guidelines do not support population-based screening but advocate early detection stratified by risk. General practitioners are advised to initiate PSA testing and mpMRI surveillance in four defined groups:

• Men aged ≥ 50 years with a life expectancy exceeding 10 years.
• Men aged ≥ 45 years with a family history of prostate cancer.
• Men aged ≥ 45 years of African descent. Epidemiologic data indicate that 1 in 4 Black men will develop prostate cancer, roughly double the risk observed in other ethnic groups, with earlier disease onset.
• Carriers of BRCA gene mutations, particularly BRCA2, start at the age of 40 years.

Managing Biochemical Recurrence

When a patient previously treated with surgery or radiotherapy develops rising PSA levels, clinicians must distinguish between a slow increase and high-risk biochemical recurrence.

For patients with high-risk relapse, defined by a PSA doubling time shorter than 9 months, the guidelines introduce combined androgen deprivation therapy with enzalutamide for the first time. This recommendation applies even when conventional imaging does not reveal a metastatic disease.

This combined approach has been shown to significantly delay the onset of metastases. Clinicians are advised to monitor for adverse effects, including fatigue, falls, and gynaecomastia.

For patients who decline chemical castration, enzalutamide monotherapy is positioned as an alternative with demonstrated clinical benefits.

The overall message is clear. Therefore, post-treatment surveillance must be rigorous. Biochemical recurrence does not always mean immediate initiation of medication, but a rapid PSA doubling time represents an oncologic emergency that requires intensified treatment.

The shift towards transperineal biopsy and PSA density improves safety and diagnostic accuracy early in care, including in primary practice.

Disclosures and conflicts of interest for the authors are available in the original document.

This story was translated from Univadis Spain, part of the Medscape Professional Network.