EAU2025OncologyLast updated 29 May 2026

EAU 2025 Guidelines: Prostate Cancer

Guideline Summary

A plain-language overview and the key recommendations. The complete recommendation tables are in the Full Guidelines section below.

What This Guideline Covers

The EAU 2025 Prostate Cancer guideline provides evidence-based recommendations across 22 topic areas. The key (Strong-rated) recommendations are summarised below; the complete recommendation tables — including Weak recommendations with their strength ratings — plus classification and evidence tables are in the Full Guidelines tab.

Key Recommendations at a Glance

Every Strong-rated EAU recommendation. Where the guideline labels its sections, they are used as sub-headings.

Classification and staging systems

Use the Tumour, Node, Metastasis (TNM) classification for staging of PCa.
Clinical stage should be based on digital rectal examination only; additional staging information based on imaging should be reported separately.
Use the International Society of Urological Pathology (ISUP) 2019 system for grading of PCa.
Do not subject men to prostate-specific antigen (PSA) testing without counselling them on the potential risks and benefits.
Offer early PSA testing to well-informed men at elevated risk of having PCa: • men from 50 years of age; • men from 45 years of age and a family history of PCa; • men of African descent from 45 years of age; • men carrying breast cancer gene 2 (BRCA2) mutations from 40 years of age.
Stop early diagnosis of PCa based on life expectancy and performance status; men who have a life-expectancy of less than fifteen years are unlikely to benefit.
Offer germline testing in men with a family history of high-risk germline mutations or multiple cancers on the same side of the family.
Offer germline testing to patients with BRCA mutations on somatic testing.
In asymptomatic men with a PSA level between 3 and 20 ng/mL and a normal DRE, use one of the following tools for biopsy indication: • magnetic resonance imaging of the prostate;

MRI imaging in biopsy indication and strategy

Do not use magnetic resonance imaging (MRI) as an initial screening tool.
Adhere to PI-RADS guidelines for MRI acquisition and interpretation and evaluate MRI results in multidisciplinary meetings with pathological feedback.
Perform MRI before prostate biopsy in men with suspected organ confined disease.
If MRI is not available, use a risk calculator and systematic biopsies if indicated.
When performing systematic biopsy only, at least twelve cores are recommended.

Performing prostate biopsy

Perform prostate biopsy using the transperineal approach due to the lower risk of infectious complications and better antibiotic stewardship.
Use routine surgical disinfection of the perineal skin for transperineal biopsy.
Use rectal cleansing with povidone-iodine prior to transrectal prostate biopsy.
Ensure that prostate core biopsies from different sites are submitted separately for processing and pathology reporting.

Staging of prostate cancer

Do not use additional imaging for staging purposes.
Perform metastatic screening using PSMA- PET/CT if available and at least cross- sectional abdominopelvic imaging and a bone-scan.

Evaluating health status and life expectancy

Use individual life expectancy, health status, and co-morbidity in PCa management.
Use the Geriatric-8, mini-COG and Clinical Frailty Scale tools for health status screening.
Perform a full specialist geriatric evaluation in patients with a G8 score ≤ 14.
Offer palliative symptom-directed therapy alone to frail patients.

Active surveillance strategy

Offer active surveillance (AS) as standard of care for low-risk disease.
Exclude patients with cribriform or intraductal histology on biopsy from AS.
Perform magnetic resonance imaging (MRI) before a confirmatory biopsy if no MRI has been performed before the initial biopsy.
Take targeted and perilesional biopsy cores (of any PI-RADS ≥ 3 lesion) if a confirmatory or repeat biopsy is performed.
Base the strategy of AS on a strict follow- up protocol including PSA (at least once every six months), digital rectal examination (DRE) (at least once yearly), and repeated biopsy (every 2-3 years for 10 years).
Perform MRI and repeat biopsy if PSA is rising (PSA-doubling time < 3 years).

Management of low-risk disease

Manage patients with a life expectancy < 10 years by watchful waiting.
Manage patients with a life expectancy > 10 years and low-risk disease by active surveillance .

Management of intermediate-risk disease*

Offer watchful waiting in asymptomatic patients with life expectancy < 10 years (based on co-morbidities and age).
Patients with ISUP grade group 3 disease should be excluded from AS protocols.
Offer RP to patients with a life expectancy of > 10 years.
Offer nerve-sparing surgery to patients with a low risk of extra-capsular disease on that side.
Offer low-dose rate (LDR) brachytherapy to patients with good urinary function and NCCN favourable intermediate-risk disease.
Offer intensity-modulated radiotherapy (IMRT)/volumetric modulated arc therapy (VMAT) plus image-guided radiotherapy (IGRT), with a total dose of 76–78 Gy or moderate hypofractionation (60 Gy/20 fx in 4 weeks or 70 Gy/28 fx in 6 weeks), in combination with short-term androgen deprivation therapy (ADT) (four to six months).
Only offer whole-gland ablative therapy (such as cryotherapy, high-intensity focused ultrasound, etc.) or focal ablative therapy within clinical trials or registries.

Management of high-risk localised disease*

Offer watchful waiting to asymptomatic patients with life expectancy < 10 years.
Offer RP to selected patients as part of potential multi-modal therapy.
In patients undergoing a lymph node dissection you should perform an extended PLND.
Do not perform a frozen section of nodes during RP to decide whether to proceed with, or abandon, the procedure.
Offer intensity-modulated radiotherapy (IMRT)/volumetric modulated arc therapy (VMAT) plus image-guided radiotherapy (IGRT), with a total dose of 76–78 Gy or moderate hypofractionation (60 Gy/20 fx in 4 weeks or 70 Gy/28 fx in 6 weeks), in combination with long-term androgen deprivation therapy (ADT) (two to three years).
Do not offer either whole gland or focal therapy.
Only offer ADT monotherapy to patients unwilling or unable to receive any form of local treatment if they have a prostate- specific antigen (PSA)-doubling time < 12 months, and either a PSA > 50 ng/mL or a poorly-differentiated tumour.

Management of locally-advanced disease*

In patients undergoing a lymph node dissection you should perform an extended PLND.
Offer patients with cN0 disease intensity- modulated radiation therapy (IMRT)/ volumetric modulated arc therapy (VMAT) plus image-guide radiation therapy in combination with long-term androgen deprivation therapy (ADT).
Offer long-term ADT for at least two years.
Offer IMRT/VMAT plus IGRT to the prostate in combination with long-term ADT and two years of abiraterone to cN0M0 patients with ≥ 2 high-risk factors (cT3-4, Gleason ≥ 8 or PSA ≥ 40 ng/mL).
Offer IMRT/VMAT plus IGRT to the prostate plus pelvis in combination with long-term ADT and two years of abiraterone to cN1M0 patients.
Do not offer whole gland treatment or focal treatment.

Adjuvant treatment for pN0 and pN1 disease after radical prostatectomy*

Do not prescribe adjuvant androgen deprivation therapy (ADT) to pN0 patients.
In pN0 patients with ISUP grade group 4–5 and pT3 ± positive margins, offer adjuvant intensity-modulated radiation therapy (IMRT)/volumetric modulated arc therapy (VMAT) plus image-guided radiation therapy (IGRT).

Local salvage treatment

Offer early salvage intensity-modulated radiotherapy/volumetric arc radiation therapy plus image-guided radiotherapy to men with two consecutive prostate- specific antigen (PSA) rises.
A negative positron emission tomography/ computed tomography (PET/CT) scan should not delay salvage radiotherapy (SRT), if otherwise indicated.
Do not wait for a PSA threshold before starting treatment. Once the decision for SRT has been made, SRT (at least 64 Gy) should be given as soon as possible.
Only offer salvage radical prostatectomy (RP), brachytherapy, stereotactic body radiotherapy, high-intensity focused ultrasound, or cryosurgical ablation to highly selected patients with biopsy-proven local recurrence within a clinical trial setting or well-designed prospective cohort study undertaken in experienced centres.
Do not offer androgen deprivation therapy (ADT) to M0 patients with a PSA-doubling time > 12 months.
Offer enzalutamide with or without ADT to M0 patients with a high-risk BCR, defined as a PSA doubling time of ≤ 9 months and a PSA level of ≥ 2ng/mL above nadir after radiation therapy or ≥ 1 ng/mL after radical prostatectomy with or without post- operative radiation therapy
Routinely follow-up asymptomatic patients by obtaining at least a disease-specific history and serum PSA measurement.
At recurrence, only perform imaging if the result will affect treatment planning.

First-line treatment of hormone-sensitive metastatic disease*

Discuss all patients with hormone-sensitive metastatic disease in a multidisciplinary team.
Offer immediate systemic treatment with androgen deprivation therapy (ADT) to palliate symptoms and reduce the risk for potentially serious sequelae of advanced disease (spinal cord compression, pathological fractures, ureteral obstruction) to M1 symptomatic patients.
Offer LHRH antagonists or orchiectomy to patients with impending clinical complications such as spinal cord compression or bladder outlet obstruction at the start of ADT.
Do not offer AR antagonist monotherapy to patients with M1 disease.
Do not offer ADT monotherapy to patients whose first presentation is M1 disease if they have no contra-indications for combination therapy and have a sufficient life expectancy to benefit from combination therapy (≥ 1 year) and are willing to accept the increased risk of side effects.
Offer ADT combined with abiraterone acetate plus prednisone or apalutamide or enzalutamide to patients with M1 disease who are fit for the regimen.
Offer docetaxel only in combination with ADT plus abiraterone or darolutamide to patients with M1 disease who are fit for docetaxel.
Offer ADT combined with prostate radiotherapy (using doses up to the equivalent of 72 Gy in 2 Gy fractions) to patients whose first presentation is M1 disease and who have low volume of disease by CHAARTED criteria.
Do not offer ADT combined with surgery to M1 patients outside of clinical trials.
Only offer metastasis-directed therapy to M1 patients within a clinical trial setting or a well-designed prospective cohort study.
Assess osteoporosis risk factors and perform a dexa scan when commencing long-term ADT, to mitigate osseous complications.
Offer bone protection to avoid fractures in patients receiving combination treatment.
Offer calcium and vitamin D supplementation when prescribing either denosumab or bisphosphonates and monitor serum calcium.
Treat painful bone metastases early on with palliative measures such as intensity- modulated radiation therapy/volumetric arc radiation therapy plus image-guided radiation therapy and adequate use of analgesics.
In patients with spinal cord compression start immediate high-dose corticosteroids and assess for spinal surgery potentially followed by radiation. Offer radiation therapy alone if surgery is not appropriate.

Life-prolonging treatments of castrate-resistant disease

Ensure that testosterone levels are confirmed to be < 50 ng/dL before diagnosing castrate-resistant PCa (CRPC).
Counsel, manage and treat patients with metastatic CRPC (mCRPC) in a multidisciplinary team.
Treat patients with mCRPC with life- prolonging agents.
Offer mCRPC patients somatic and/ or germline molecular testing as well as testing for mismatch repair deficiencies or microsatellite instability.

Systemic treatments of castrate-resistant disease

Base the choice of treatment on the performance status (PS), symptoms, co-morbidities, location and extent of disease, genomic profile, patient preference, and on previous treatment for hormone-sensitive metastatic PCa (mHSPC) (alphabetical order: abiraterone, cabazitaxel, docetaxel, enzalutamide, 177lutetium-PSMA-617-radioligand therapy, radium-223, sipuleucel-T, and for patients with DNA homologous recombination repair [HRR] alterations olaparib, olaparib/ abiraterone, niraparib/abiraterone, rucaparib, talazoparib/enzalutamide).
Offer chemotherapy to patients previously treated with abiraterone or enzalutamide.
Offer patients with mCRPC who are candidates for cytotoxic therapy and are chemotherapy naïve docetaxel with 75 mg/m2 every three weeks.
Offer patients previously untreated for mCRPC and harbouring an HRR or BRCA mutation abiraterone in combination with olaparib if the patient is fit for both agents and did not previously receive an ARPI.
Offer patients previously untreated for mCRPC and harbouring a BRCA mutation abiraterone in combination with niraparib if the patient is fit for both agents and did not previously receive an ARPI.
Offer patients previously untreated for mCRPC and harbouring an HRR-mutation enzalutamide in combination with talazoparib if the patient is fit for both agents and did not previously receive an ARPI.
Offer poly(ADP-ribose) polymerase (PARP) inhibitors to pre-treated mCRPC patients with relevant DNA repair gene mutations.
Offer patients with mCRPC and progression following docetaxel chemotherapy further life-prolonging treatment options, which include abiraterone, cabazitaxel, enzalutamide, radium-223 and olaparib in case of DNA HRR alterations.
Base further treatment decisions of mCRPC on PS, previous treatments, symptoms, co-morbidities, genomic profile, extent of disease and patient preference.
Offer abiraterone or enzalutamide to patients previously treated with one or two lines of chemotherapy.
Offer cabazitaxel to patients previously treated with docetaxel.
Offer cabazitaxel to patients previously treated with docetaxel and who have progressed within twelve months of treatment with abiraterone or enzalutamide for mCRPC.
Offer 177Lu-PSMA-617 to pre-treated mCRPC patients with one or more metastatic lesions, highly expressing PSMA (exceeding the uptake in the liver) on the diagnostic radiolabelled PSMA PET/CT scan.

Non-metastatic castrate-resistant disease

Offer apalutamide, darolutamide or enzalutamide to patients with M0 CRPC and a high risk of developing metastasis (PSA-DT < 10 months) to prolong time to metastases and overall survival.

Follow-up after treatment with curative intent

Routinely follow-up asymptomatic patients by obtaining at least a disease-specific history and a prostate-specific antigen measurement.
At recurrence, only perform imaging if the result will affect treatment planning.

Follow-up during hormonal treatment

The follow-up strategy must be individualised based on stage of disease, prior symptoms, prognostic factors and the treatment given.
In patients on long-term androgen deprivation therapy (ADT), measure initial bone mineral density to assess fracture risk.
In patients receiving combination treatment offer bone protection to avoid fractures.
In patients with stage M0 disease, schedule follow-up at least every six months. As a minimum requirement, include a disease- specific history, serum prostate-specific antigen (PSA) determination, as well as liver and renal function in the diagnostic work-up.
In M1 patients, schedule follow-up at least every three to six months including imaging at regular intervals.
During follow-up of patients receiving ADT, check PSA and testosterone levels and monitor patients for symptoms associated with metabolic syndrome as a side effect of ADT.
In patients on long-term ADT, as a minimum requirement, include a medical history including assessment of ADT- induced complications, haemoglobin, serum creatinine, alkaline phosphatase, lipid profiles and HbA1c level measurements.
Counsel patients (especially with M1b status) about the clinical signs suggestive of spinal cord compression.
When disease progression is suspected, restaging is needed and the subsequent follow-up should be adapted/individualised.
In patients with suspected progression, assess the testosterone level. By definition, castration-resistant PCa requires a testosterone level < 50 ng/dL (< 1.7 nmol/L).

Quality of life in men undergoing local treatments

Advise patients eligible for active surveillance that global quality of life is equivalent for up to five years compared to radical prostatectomy or external beam radiotherapy (RT).
Discuss the negative impact of surgery on urinary and sexual function, as well as the negative impact of RT on bowel function with patients.

Quality of life in men undergoing systemic treatments

Offer men on androgen deprivation therapy (ADT), twelve weeks of supervised (by trained exercise specialists) combined aerobic and resistance exercise.
Advise men on ADT to maintain a healthy weight and diet, to stop smoking, reduce alcohol to ≤ 2 units daily and have yearly screening for diabetes and hypercholesterolemia. Ensure that calcium and vitamin D meet recommended levels.
Offer men after any radical treatment specialist nurse-led, multi-disciplinary rehabilitation based on the patients’ personal goals addressing incontinence, sexuality, depression and fear of recurrence, social support and positive lifestyle changes.
Offer men starting on long-term ADT dual emission X-ray absorptiometry (DEXA) scanning to assess bone mineral density.
Offer anti-resorptive therapy to men on long term ADT with either a BMD T-score of < -2.5 or with an additional clinical risk factor for fracture or when annual bone loss on ADT is confirmed to exceed 5%.

Read Full Guidelines

Full Guidelines

Reproduced from the official EAU 2025 publication.

Recommendations

Recommendations for classification and staging systems

Recommendation	Strength rating
Use the Tumour, Node, Metastasis (TNM) classification for staging of PCa.	Strong
Clinical stage should be based on digital rectal examination only; additional staging information based on imaging should be reported separately.	Strong
Use the International Society of Urological Pathology (ISUP) 2019 system for grading of PCa.	Strong

Recommendations

Recommendation	Strength rating
Individual early detection
Do not subject men to prostate-specific antigen (PSA) testing without counselling them on the potential risks and benefits.	Strong
Offer an individualised risk-adapted strategy for early detection to a well- informed man with a life-expectancy of at least fifteen years.	Weak
Offer early PSA testing to well-informed men at elevated risk of having PCa: • men from 50 years of age; • men from 45 years of age and a family history of PCa; • men of African descent from 45 years of age; • men carrying breast cancer gene 2 (BRCA2) mutations from 40 years of age.	Strong
Offer a risk-adapted strategy (based on initial PSA level), with follow-up intervals of two years for those initially at risk: • men with a PSA level of > 1 ng/mL at 40 years of age; • men with a PSA level of > 2 ng/mL at 60 years of age Postpone follow-up to eight years in those not at risk.	Weak
Stop early diagnosis of PCa based on life expectancy and performance status; men who have a life-expectancy of less than fifteen years are unlikely to benefit.	Strong
Germline testing*
Consider germline testing in men with multiple family members diagnosed with PCa at age < 60 years or a family member who died from PCa.	Weak
Offer germline testing in men with a family history of high-risk germline mutations or multiple cancers on the same side of the family.	Strong
Offer germline testing to patients with BRCA mutations on somatic testing.	Strong
Screening and individual early detection
In asymptomatic men with a PSA level between 3 and 10 ng/mL and a normal digital rectal examination (DRE), repeat the PSA test prior to further investigations.	Weak
In asymptomatic men with a PSA level between 3 and 20 ng/mL and a normal DRE, use one of the following tools for biopsy indication: • magnetic resonance imaging of the prostate;	Strong
• risk-calculator, provided it is correctly calibrated to the population prevalence; • an additional serum, urine biomarker test.	Weak

Recommendations for MRI imaging in biopsy indication and strategy

Recommendation	Strength rating
Do not use magnetic resonance imaging (MRI) as an initial screening tool.	Strong
Adhere to PI-RADS guidelines for MRI acquisition and interpretation and evaluate MRI results in multidisciplinary meetings with pathological feedback.	Strong
Where MRI has shown a suspicious lesion, MR-targeted biopsy can be obtained through cognitive guidance, US/MR fusion software or direct in-bore guidance.	Weak
Perform MRI before prostate biopsy in men with suspected organ confined disease.	Strong
In men with suspicion of locally advanced disease on digital rectal examination (DRE) and/or PSA > 50 ng/mL, or those not for curative treatments, consider limited biopsy without MRI.	Weak
When MRI is positive (i.e., PI-RADS ≥ 4), combine targeted biopsy with perilesional sampling.	Weak
When MRI is negative (i.e., PI-RADS ≤ 2), and clinical suspicion of PCa is low (PSA density < 0.20 ng/mL/cc, negative DRE findings, no family history), omit biopsy and offer PSA monitoring; otherwise consider systematic biopsy.	Weak
When MRI is indeterminate (PI-RADS = 3), and clinical suspicion of PCa is very low (PSA density < 0.10 ng/mL/cc, negative DRE findings, no family history), omit biopsy and offer PSA monitoring; otherwise consider targeted biopsy with perilesional sampling.	Weak
If MRI is not available, use a risk calculator and systematic biopsies if indicated.	Strong
When performing systematic biopsy only, at least twelve cores are recommended.	Strong

Recommendations for performing prostate biopsy

Recommendation	Strength rating
Perform prostate biopsy using the transperineal approach due to the lower risk of infectious complications and better antibiotic stewardship.	Strong
Use routine surgical disinfection of the perineal skin for transperineal biopsy.	Strong
Use rectal cleansing with povidone-iodine prior to transrectal prostate biopsy.	Strong
Use either target prophylaxis based on rectal swab or stool culture; or augmented prophylaxis (two or more different classes of antibiotics); for transrectal biopsy.	Weak
Ensure that prostate core biopsies from different sites are submitted separately for processing and pathology reporting.	Strong

Recommendations for staging of prostate cancer

Recommendation	Strength rating
Any risk group staging
Use pre-biopsy magnetic resonance imaging (MRI) for local staging information.	Weak
Low-risk localised disease
Do not use additional imaging for staging purposes.	Strong
Intermediate-risk disease
For patients with International Society of Urological Pathology (ISUP) grade group 3 disease perform prostate-specific antigen- positron emission tomography/computed tomography (PSMA-PET/CT) if available to increase accuracy or at least cross- sectional abdominopelvic imaging and a bone-scan.	Weak
High-risk localised disease/locally advanced disease
Perform metastatic screening using PSMA- PET/CT if available and at least cross- sectional abdominopelvic imaging and a bone-scan.	Strong

Recommendations for evaluating health status and life expectancy

Recommendation	Strength rating
Use individual life expectancy, health status, and co-morbidity in PCa management.	Strong
Use the Geriatric-8, mini-COG and Clinical Frailty Scale tools for health status screening.	Strong
Perform a full specialist geriatric evaluation in patients with a G8 score ≤ 14.	Strong
Consider standard treatment in vulnerable patients with reversible impairments (after resolution of geriatric problems) similar to fit patients, if life expectancy is > 10 years.	Weak
Offer adapted treatment or watchful waiting to patients with irreversible impairment.	Weak
Offer palliative symptom-directed therapy alone to frail patients.	Strong

Recommendations for active surveillance strategy

Recommendation	Strength rating
Offer active surveillance (AS) as standard of care for low-risk disease.	Strong
Exclude patients with cribriform or intraductal histology on biopsy from AS.	Strong
Perform magnetic resonance imaging (MRI) before a confirmatory biopsy if no MRI has been performed before the initial biopsy.	Strong
Take targeted and perilesional biopsy cores (of any PI-RADS ≥ 3 lesion) if a confirmatory or repeat biopsy is performed.	Strong
Perform per-protocol confirmatory prostate biopsies if MRI is not available.	Weak
Do not perform confirmatory biopsies if a patient has had upfront MRI and targeted biopsies.	Weak
Base the strategy of AS on a strict follow- up protocol including PSA (at least once every six months), digital rectal examination (DRE) (at least once yearly), and repeated biopsy (every 2-3 years for 10 years).	Strong
Exclude patients with a low-risk PCa, a stable MRI (PRECISE 3) and a stable low PSA density (< 0.15) from repeat biopsy when MRI is repeated before repeat biopsy. In addition, serial DRE may be omitted if MRI is stable.	Weak
Perform MRI and repeat biopsy if PSA is rising (PSA-doubling time < 3 years).	Strong
Base change in treatment on biopsy progression, not on progression on MRI, PSA, and/or DRE.	Weak

Recommendations for the management of low-risk disease

Recommendation	Strength rating
Manage patients with a life expectancy < 10 years by watchful waiting.	Strong
Manage patients with a life expectancy > 10 years and low-risk disease by active surveillance .	Strong

Recommendations for the management of intermediate-risk disease*

Recommendation	Strength rating
Expectant management
Offer watchful waiting in asymptomatic patients with life expectancy < 10 years (based on co-morbidities and age).	Strong
Offer active surveillance (AS) to selected patients with ISUP grade group 2 disease (e.g., < 10% pattern 4, PSA < 10 ng/mL, ≤ cT2a, low disease extent on imaging and low extent of tumour in biopsies (≤ 3 positive cores with Gleason score 3+4 and ≤ 50% cancer involvement/core), or another single element of intermediate- risk disease with low disease extent on imaging and low biopsy extent, accepting the potential increased risk of metastatic progression.	Weak
Patients with ISUP grade group 3 disease should be excluded from AS protocols.	Strong
Re-classify patients with low-volume ISUP grade group 2 disease included in AS protocols, if repeat non-MRI-based systematic biopsies performed during monitoring reveal > 3 positive cores or maximum CI > 50%/core of ISUP grade group 2 disease.	Weak
Radical prostatectomy (RP)
Offer RP to patients with a life expectancy of > 10 years.	Strong
Radical prostatectomy can be safely delayed for at least three months.	Weak
Offer nerve-sparing surgery to patients with a low risk of extra-capsular disease on that side.	Strong
Radiotherapeutic treatment
Offer low-dose rate (LDR) brachytherapy to patients with good urinary function and NCCN favourable intermediate-risk disease.	Strong
Offer intensity-modulated radiotherapy (IMRT)/volumetric modulated arc therapy (VMAT) plus image-guided radiotherapy (IGRT), with a total dose of 76–78 Gy or moderate hypofractionation (60 Gy/20 fx in 4 weeks or 70 Gy/28 fx in 6 weeks), in combination with short-term androgen deprivation therapy (ADT) (four to six months).	Strong
Offer focal boosting to MRI-defined dominant intra-prostatic tumour when using conventionally fractionated IMRT/ IGRT (1.8-2.0 Gy per fraction) ensuring that Organ at Risk constraints are not exceeded.	Weak
Offer ultra-hypofractionated IMRT/IGRT or SBRT, using either 36.25 Gy (40 Gy to prostate) in 5 fx or 42.7 Gy in 7 fx delivered alternate days.	Weak
Offer LDR brachytherapy boost combined with IMRT/VMAT plus IGRT to patients with good urinary function and NCCN unfavourable intermediate-risk disease, in combination with short-term ADT (four to six months).	Weak
Offer high-dose rate (HDR) brachytherapy boost combined with IMRT/VMAT plus IGRT to patients with good urinary function and NCCN unfavourable intermediate-risk disease, in combination with short-term ADT (four to six months).	Weak
Other therapeutic options
Only offer whole-gland ablative therapy (such as cryotherapy, high-intensity focused ultrasound, etc.) or focal ablative therapy within clinical trials or registries.	Strong
Do not offer ADT monotherapy to asymptomatic men not able to receive any local treatment.	Weak

Recommendations for the management of high-risk localised disease*

Recommendation	Strength rating
Expectant management
Offer watchful waiting to asymptomatic patients with life expectancy < 10 years.	Strong
Radical prostatectomy (RP)
Offer RP to selected patients as part of potential multi-modal therapy.	Strong
Extended pelvic lymph node dissection (PLND)
In patients undergoing a lymph node dissection you should perform an extended PLND.	Strong
Do not perform a frozen section of nodes during RP to decide whether to proceed with, or abandon, the procedure.	Strong
Radiotherapeutic treatment
Offer intensity-modulated radiotherapy (IMRT)/volumetric modulated arc therapy (VMAT) plus image-guided radiotherapy (IGRT), with a total dose of 76–78 Gy or moderate hypofractionation (60 Gy/20 fx in 4 weeks or 70 Gy/28 fx in 6 weeks), in combination with long-term androgen deprivation therapy (ADT) (two to three years).	Strong
Offer focal boosting to MRI-defined dominant intra-prostatic tumour when using normo-fractionated IMRT/IGRT (1.8- 2.0 Gy per fraction) ensuring that Organ at Risk constraints are not exceeded.	Weak
Offer patients with good urinary function IMRT/VMAT plus IGRT with brachytherapy boost (either high-dose rate or low-dose rate), in combination with long-term ADT (two to three years).	Weak
Therapeutic options outside surgery or radiotherapy
Do not offer either whole gland or focal therapy.	Strong
Only offer ADT monotherapy to patients unwilling or unable to receive any form of local treatment if they have a prostate- specific antigen (PSA)-doubling time < 12 months, and either a PSA > 50 ng/mL or a poorly-differentiated tumour.	Strong

Recommendations for management of locally-advanced disease*

Recommendation	Strength rating
Radical prostatectomy (RP)
Offer RP to patients with cN0 disease as part of multi-modal therapy.	Weak
Extended pelvic lymph node dissection (PLND)
In patients undergoing a lymph node dissection you should perform an extended PLND.	Strong
Radiotherapeutic treatments
Offer patients with cN0 disease intensity- modulated radiation therapy (IMRT)/ volumetric modulated arc therapy (VMAT) plus image-guide radiation therapy in combination with long-term androgen deprivation therapy (ADT).	Strong
Offer patients with cN0 disease and good urinary function, IMRT/VMAT plus IGRT with brachytherapy boost (either high-dose or low-dose rate), in combination with long- term ADT.	Weak
Offer long-term ADT for at least two years.	Strong
Offer IMRT/VMAT plus IGRT to the prostate in combination with long-term ADT and two years of abiraterone to cN0M0 patients with ≥ 2 high-risk factors (cT3-4, Gleason ≥ 8 or PSA ≥ 40 ng/mL).	Strong
Offer IMRT/VMAT plus IGRT to the prostate plus pelvis in combination with long-term ADT and two years of abiraterone to cN1M0 patients.	Strong
Other therapeutic options
Do not offer whole gland treatment or focal treatment.	Strong

Recommendations for adjuvant treatment for pN0 and pN1 disease after radical prostatectomy*

Recommendation	Strength rating
Do not prescribe adjuvant androgen deprivation therapy (ADT) to pN0 patients.	Strong
In pN0 patients with ISUP grade group 4–5 and pT3 ± positive margins, offer adjuvant intensity-modulated radiation therapy (IMRT)/volumetric modulated arc therapy (VMAT) plus image-guided radiation therapy (IGRT).	Strong
In pN1 patients, after an extended lymph node dissection, discuss three management options, based on nodal involvement characteristics: 1. Offer adjuvant ADT. 2. Offer adjuvant ADT with additional IMRT/VMAT plus IGRT. 3. Offer observation (expectant management) to a patient after ePLND and ≤ 2 nodes and a undetectable PSA.	Weak

Recommendations for the management of persistent PSA after radical prostatectomy

Recommendation	Strength rating
Offer a prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/ CT) scan to men with a persistent and rising prostate-specific antigen (PSA) if the results will influence subsequent treatment decisions.	Weak
Treat men with persistent PSA and no evidence of distant metastatic disease with salvage radiotherapy and additional hormonal therapy.	Weak

Local salvage treatment

Recommendation	Strength rating
Recommendations for biochemical recurrence (BCR) after radical prostatectomy
Offer early salvage intensity-modulated radiotherapy/volumetric arc radiation therapy plus image-guided radiotherapy to men with two consecutive prostate- specific antigen (PSA) rises.	Strong
A negative positron emission tomography/ computed tomography (PET/CT) scan should not delay salvage radiotherapy (SRT), if otherwise indicated.	Strong
Offer monitoring, including PSA to EAU low- risk BCR patients.	Weak
Do not wait for a PSA threshold before starting treatment. Once the decision for SRT has been made, SRT (at least 64 Gy) should be given as soon as possible.	Strong
Offer hormonal therapy in addition to SRT to men with BCR.	Weak
Recommendations for BCR after radiotherapy
Offer monitoring, including PSA to EAU low-risk BCR patients.	Weak
Only offer salvage radical prostatectomy (RP), brachytherapy, stereotactic body radiotherapy, high-intensity focused ultrasound, or cryosurgical ablation to highly selected patients with biopsy-proven local recurrence within a clinical trial setting or well-designed prospective cohort study undertaken in experienced centres.	Strong
Recommendations for systemic salvage treatment
Do not offer androgen deprivation therapy (ADT) to M0 patients with a PSA-doubling time > 12 months.	Strong
Offer enzalutamide with or without ADT to M0 patients with a high-risk BCR, defined as a PSA doubling time of ≤ 9 months and a PSA level of ≥ 2ng/mL above nadir after radiation therapy or ≥ 1 ng/mL after radical prostatectomy with or without post- operative radiation therapy	Strong
Recommendations for follow-up after radical prostatectomy or radiotherapy
Routinely follow-up asymptomatic patients by obtaining at least a disease-specific history and serum PSA measurement.	Strong
At recurrence, only perform imaging if the result will affect treatment planning.	Strong

Recommendations for the first-line treatment of hormone-sensitive metastatic disease*

Recommendation	Strength rating
First-line treatment
Discuss all patients with hormone-sensitive metastatic disease in a multidisciplinary team.	Strong
Offer immediate systemic treatment with androgen deprivation therapy (ADT) to palliate symptoms and reduce the risk for potentially serious sequelae of advanced disease (spinal cord compression, pathological fractures, ureteral obstruction) to M1 symptomatic patients.	Strong
Offer short-term administration of an older generation androgen receptor (AR) antagonist to M1 patients starting luteinising hormone-releasing hormone (LHRH) agonist to reduce the risk of the ‘flare-up’ phenomenon.	Weak
Offer LHRH antagonists or orchiectomy to patients with impending clinical complications such as spinal cord compression or bladder outlet obstruction at the start of ADT.	Strong
Do not offer AR antagonist monotherapy to patients with M1 disease.	Strong
Do not offer ADT monotherapy to patients whose first presentation is M1 disease if they have no contra-indications for combination therapy and have a sufficient life expectancy to benefit from combination therapy (≥ 1 year) and are willing to accept the increased risk of side effects.	Strong
Offer ADT combined with abiraterone acetate plus prednisone or apalutamide or enzalutamide to patients with M1 disease who are fit for the regimen.	Strong
Offer darolutamide to patients with M1 disease who are fit for the regimen.	Weak
Offer docetaxel only in combination with ADT plus abiraterone or darolutamide to patients with M1 disease who are fit for docetaxel.	Strong
Offer ADT combined with prostate radiotherapy (using doses up to the equivalent of 72 Gy in 2 Gy fractions) to patients whose first presentation is M1 disease and who have low volume of disease by CHAARTED criteria.	Strong
Do not offer ADT combined with surgery to M1 patients outside of clinical trials.	Strong
Only offer metastasis-directed therapy to M1 patients within a clinical trial setting or a well-designed prospective cohort study.	Strong
Supportive care
Assess osteoporosis risk factors and perform a dexa scan when commencing long-term ADT, to mitigate osseous complications.	Strong
Offer bone protection to avoid fractures in patients receiving combination treatment.	Strong
Offer calcium and vitamin D supplementation when prescribing either denosumab or bisphosphonates and monitor serum calcium.	Strong
Treat painful bone metastases early on with palliative measures such as intensity- modulated radiation therapy/volumetric arc radiation therapy plus image-guided radiation therapy and adequate use of analgesics.	Strong
In patients with spinal cord compression start immediate high-dose corticosteroids and assess for spinal surgery potentially followed by radiation. Offer radiation therapy alone if surgery is not appropriate.	Strong

Recommendations for life-prolonging treatments of castrate-resistant disease

Recommendation	Strength rating
Ensure that testosterone levels are confirmed to be < 50 ng/dL before diagnosing castrate-resistant PCa (CRPC).	Strong
Counsel, manage and treat patients with metastatic CRPC (mCRPC) in a multidisciplinary team.	Strong
Treat patients with mCRPC with life- prolonging agents.	Strong
Offer mCRPC patients somatic and/ or germline molecular testing as well as testing for mismatch repair deficiencies or microsatellite instability.	Strong

Recommendations for systemic treatments of castrate-resistant disease

Recommendation	Strength rating
Base the choice of treatment on the performance status (PS), symptoms, co-morbidities, location and extent of disease, genomic profile, patient preference, and on previous treatment for hormone-sensitive metastatic PCa (mHSPC) (alphabetical order: abiraterone, cabazitaxel, docetaxel, enzalutamide, 177lutetium-PSMA-617-radioligand therapy, radium-223, sipuleucel-T, and for patients with DNA homologous recombination repair [HRR] alterations olaparib, olaparib/ abiraterone, niraparib/abiraterone, rucaparib, talazoparib/enzalutamide).	Strong
Avoid sequencing of androgen receptor targeted agents.	Weak
Offer chemotherapy to patients previously treated with abiraterone or enzalutamide.	Strong
Offer patients with mCRPC who are candidates for cytotoxic therapy and are chemotherapy naïve docetaxel with 75 mg/m2 every three weeks.	Strong
Offer patients previously untreated for mCRPC and harbouring an HRR or BRCA mutation abiraterone in combination with olaparib if the patient is fit for both agents and did not previously receive an ARPI.	Strong
Offer patients previously untreated for mCRPC and harbouring a BRCA mutation abiraterone in combination with niraparib if the patient is fit for both agents and did not previously receive an ARPI.	Strong
Offer patients previously untreated for mCRPC and harbouring an HRR-mutation enzalutamide in combination with talazoparib if the patient is fit for both agents and did not previously receive an ARPI.	Strong
Offer poly(ADP-ribose) polymerase (PARP) inhibitors to pre-treated mCRPC patients with relevant DNA repair gene mutations.	Strong
Offer patients with mCRPC and progression following docetaxel chemotherapy further life-prolonging treatment options, which include abiraterone, cabazitaxel, enzalutamide, radium-223 and olaparib in case of DNA HRR alterations.	Strong
Base further treatment decisions of mCRPC on PS, previous treatments, symptoms, co-morbidities, genomic profile, extent of disease and patient preference.	Strong
Offer abiraterone or enzalutamide to patients previously treated with one or two lines of chemotherapy.	Strong
Offer cabazitaxel to patients previously treated with docetaxel.	Strong
Offer cabazitaxel to patients previously treated with docetaxel and who have progressed within twelve months of treatment with abiraterone or enzalutamide for mCRPC.	Strong
Offer 177Lu-PSMA-617 to pre-treated mCRPC patients with one or more metastatic lesions, highly expressing PSMA (exceeding the uptake in the liver) on the diagnostic radiolabelled PSMA PET/CT scan.	Strong

Recommendation for non-metastatic castrate-resistant disease

Recommendation	Strength rating
Offer apalutamide, darolutamide or enzalutamide to patients with M0 CRPC and a high risk of developing metastasis (PSA-DT < 10 months) to prolong time to metastases and overall survival.	Strong

Recommendations for follow-up after treatment with curative intent

Recommendation	Strength rating
Routinely follow-up asymptomatic patients by obtaining at least a disease-specific history and a prostate-specific antigen measurement.	Strong
At recurrence, only perform imaging if the result will affect treatment planning.	Strong

Recommendations for follow-up during hormonal treatment

Recommendation	Strength rating
The follow-up strategy must be individualised based on stage of disease, prior symptoms, prognostic factors and the treatment given.	Strong
In patients on long-term androgen deprivation therapy (ADT), measure initial bone mineral density to assess fracture risk.	Strong
In patients receiving combination treatment offer bone protection to avoid fractures.	Strong
In patients with stage M0 disease, schedule follow-up at least every six months. As a minimum requirement, include a disease- specific history, serum prostate-specific antigen (PSA) determination, as well as liver and renal function in the diagnostic work-up.	Strong
In M1 patients, schedule follow-up at least every three to six months including imaging at regular intervals.	Strong
During follow-up of patients receiving ADT, check PSA and testosterone levels and monitor patients for symptoms associated with metabolic syndrome as a side effect of ADT.	Strong
In patients on long-term ADT, as a minimum requirement, include a medical history including assessment of ADT- induced complications, haemoglobin, serum creatinine, alkaline phosphatase, lipid profiles and HbA1c level measurements.	Strong
Counsel patients (especially with M1b status) about the clinical signs suggestive of spinal cord compression.	Strong
When disease progression is suspected, restaging is needed and the subsequent follow-up should be adapted/individualised.	Strong
In patients with suspected progression, assess the testosterone level. By definition, castration-resistant PCa requires a testosterone level < 50 ng/dL (< 1.7 nmol/L).	Strong

Recommendations for quality of life in men undergoing local treatments

Recommendation	Strength rating
Advise patients eligible for active surveillance that global quality of life is equivalent for up to five years compared to radical prostatectomy or external beam radiotherapy (RT).	Strong
Discuss the negative impact of surgery on urinary and sexual function, as well as the negative impact of RT on bowel function with patients.	Strong
Advise patients treated with brachytherapy of the negative impact on irritative urinary symptomatology at one year but not after five years.	Weak

Recommendations for quality of life in men undergoing systemic treatments

Recommendation	Strength rating
Offer men on androgen deprivation therapy (ADT), twelve weeks of supervised (by trained exercise specialists) combined aerobic and resistance exercise.	Strong
Advise men on ADT to maintain a healthy weight and diet, to stop smoking, reduce alcohol to ≤ 2 units daily and have yearly screening for diabetes and hypercholesterolemia. Ensure that calcium and vitamin D meet recommended levels.	Strong
Offer men after any radical treatment specialist nurse-led, multi-disciplinary rehabilitation based on the patients’ personal goals addressing incontinence, sexuality, depression and fear of recurrence, social support and positive lifestyle changes.	Strong
Offer men starting on long-term ADT dual emission X-ray absorptiometry (DEXA) scanning to assess bone mineral density.	Strong
Offer anti-resorptive therapy to men on long term ADT with either a BMD T-score of < -2.5 or with an additional clinical risk factor for fracture or when annual bone loss on ADT is confirmed to exceed 5%.	Strong

Classification & Evidence Tables

T - Primary Tumour (stage based on digital rectal examination [DRE] only)
TX Primary tumour cannot be assessed
T0 No evidence of primary tumour
T1 Clinically inapparent tumour that is not palpable
T1a Tumour incidental histological finding in 5% or less of tissue resected
T1b Tumour incidental histological finding in more than 5% of tissue resected
T1c Tumour identified by needle biopsy (e.g., because of elevated PSA)
T2 Tumour that is palpable and confined within prostate
T2a Tumour involves one half of one lobe or less
T2b Tumour involves more than half of one lobe, but not both lobes
T2c Tumour involves both lobes
T3 Tumour extends palpably through the prostatic capsule
T3a Extracapsular extension (unilateral or bilateral)
T3b Tumour invades seminal vesicle(s)
T4 Tumour is fixed or invades adjacent structures other than seminal vesicles: external sphincter, rectum, levator muscles, and/or pelvic wall

N - Regional (pelvic) Lymph Nodes1
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Regional lymph node metastasis
M - Distant Metastasis2
M0 No distant metastasis
M1 Distant metastasis
M1a Non-regional lymph node(s)
M1b Bone(s)
M1c Other site(s)

Gleason score	ISUP grade
2-6	1
7 (3+4)	2
7 (4+3)	3
8 (4+4 or 3+5 or 5+3)	4
9-10 (4+5 or 5+4 or 5+5)	5

Definition
Low-risk	Intermediate-risk		High-risk
	Favourable	Unfavourable
ISUP grade 1 and PSA < 10 ng/mL and cT1-2a*	ISUP grade 2 and PSA < 10 ng/mL and cT1-2b* Or ISUP grade 1 and PSA 10 – 20 ng/mL and cT1-2b* Or ISUP grade 1 and PSA < 10 ng/mL and cT2b*	ISUP grade 2 and PSA 10 – 20 ng/mL and cT1-2b* Or ISUP grade 3 and cT1-2b*	ISUP grade 4/5 Or PSA > 20 ng/mL Or cT2c*	cT3-4* and/ or cN+** any ISUP grade* any PSA
Localised				Locally advanced

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