In this largest-to-date PSMA-PET–staged retrospective series (n=213, median follow-up ~58 months) and majority only 1-2 oligometastasis, SABR produced a median ADT-free survival of ~42 months, with 37.5% of patients remaining ADT-free at 5 years. Biochemical failure-free survival at 12, 24, and 36 months was modest (46%, 26%, 19%), while clinical failure-free survival remained higher (71%, 50%, 39%), suggesting that many biochemical relapses did not necessitate immediate systemic escalation. Most lesions treated were nodal or osseous, and only 13% of patients received concurrent ADT.
Clinical Implications:
- SABR following PSMA-PET staging can provide a clinically meaningful ADT-free interval of over three years, delaying systemic therapy and its associated quality-of-life impacts.
- While biochemical recurrence is common, not all PSA rises warrant systemic therapy — reinforcing the need for individualised surveillance and selective re-intervention.
- Optimal patient selection remains key: those with limited nodal or bone-only disease and favourable biology are most likely to benefit.
As a retrospective series, the study lacks a randomized comparator and did not control for initiation of ADT. Future trials will assess improved staging (whole-body PET, new PSMA tracers) and integration with systemic therapy, including lutetium-PSMA, will refine the role of SABR in omPC.
Take-Home:
In well-selected, PSMA-PET–staged omPC, SABR is an effective strategy to postpone systemic therapy for years, with outcomes supporting its growing role in metastasis-directed management.
Disclosure: The authors declare no competing interests related to this commentary.
Written by:
- Isabelle Schupak, GenesisCare, St. Vincent's Hospital, Fitzroy, Victoria, Australia; Olivia Newton-John Cancer Wellness & Research Centre (Austin Health), Heidelberg, Victoria, Australia
- Michael Ng, GenesisCare, St. Vincent's Hospital, Fitzroy, Victoria, Australia; Faculty of Medicine, The University of Melbourne, Carlton, Victoria, Australia