Bottom lineA duration-stratified approach is supported, with ADT length scaling to biochemical and genomic risk. Recommendations span 4 to 6 months for favorable disease through 24 months or longer for high-risk recurrence.
Intermediate-risk recurrenceFor unfavorable intermediate-risk biochemical recurrence after prostatectomy, 6-month ADT alongside salvage radiation improved metastasis-free survival without major toxicity escalation Spratt 2018Pollack 2022. NRG/RTOG 0534 demonstrated a clear MFS benefit at 5 years.
High-risk recurrenceFor Gleason ≥8 or pre-radiation PSA ≥0.7 ng/mL, 24-month ADT demonstrated superior overall survival vs 6-month courses in randomized trials Carrie 2019. Benefit was largest in patients without comorbid cardiovascular disease.
Genomic stratificationDecipher genomic classifier-positive cohorts may benefit from extended ADT regardless of clinical risk strata Feng 2020. NRG-GU006 is prospectively validating biomarker-driven duration selection.
Most trials excluded patients with PSA doubling time <10 months. Optimal duration in this high-progression-risk subgroup remains undefined.
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