2025 AFU guideline updates: Prostate cancer

What are the key updates in prostate cancer management?

The 2025 recommendations from the French Urology Association’s Cancer Committee (CCAFU) outline updates across prostate cancer diagnostic pathways, localized disease management, recurrence strategies, and the treatment of metastatic hormone–sensitive prostate cancer (mHSPC) and metastatic castration–resistant prostate cancer (mCRPC).¹ These recommendations integrate evidence published between July 2024 and September 2025 and translate recent trial data into graded guidance.

How has the prostate cancer diagnostic strategy changed?

Biparametric MRI as an alternative standard

AFU recognizes biparametric magnetic resonance imaging (bpMRI) as an alternative to multiparametric MRI (mpMRI) for detecting clinically significant prostate cancer when imaging quality and radiological expertise are sufficient. This strong recommendation is supported by noninferiority evidence from the PRIME trial.

Transperineal biopsy preferred

When technically feasible, AFU recommends transperineal biopsy over transrectal biopsy. This strong recommendation reflects randomized evidence, including the TRANSLATE trial, showing comparable cancer detection with fewer infectious complications.

Emerging alternative biopsy methods

AFU acknowledges microultrasound‑guided biopsy as a potential alternative to MRI‑guided fusion biopsy where MRI access is limited, provided adequate operator expertise. This is informed by non‑inferiority results from the OPTIMUM trial.

What are the key AFU guideline updates for low- and intermediate-risk prostate cancer?

Active surveillance

Active surveillance remains the preferred management strategy for patients with low‑risk prostate cancer, supported by long‑term prospective cohort data.

Lymph node dissection

Post hoc data suggest extended lymph node dissection may improve metastasis-free survival compared with standard ilio‑obturator dissection. However, the AFU does not change current recommendations and supports further evaluation in selected patients at risk of biochemical recurrence.

Radiotherapy regimens

The AFU recommends stereotactic body radiotherapy (SBRT) for patients with low‑risk to favorable intermediate‑risk localized prostate cancer when appropriate technical expertise and quality assurance are available. This strong recommendation is supported by PACE-B non‑inferiority outcomes.

High‑intensity–focused ultrasound

Whole‑gland high‑intensity–focused ultrasound (HIFU) may be considered for selected low‑ to intermediate‑risk patients who meet HIFI trial criteria. This remains a limited‑evidence recommendation based on short‑term oncologic and functional outcome data.

What are the updates in prostate cancer recurrence management?

Metastasis‑directed therapy

Radiotherapy to metastases outside a symptomatic context has not shown a survival benefit and should be restricted to clinical trials. For oligometastatic hormone‑sensitive disease, the AFU recommends combining metastasis‑directed therapy with at least 6 months of androgen deprivation therapy (ADT), based on phase 2 data from STORM and RADIOSA.

High‑risk biochemical recurrence

ADT plus enzalutamide is strongly recommended for patients meeting EMBARK high‑risk biochemical recurrence criteria who have no metastases on conventional imaging and no feasible local salvage options. Enzalutamide monotherapy may be considered as a conditional alternative.

What are the AFU guideline updates for mHSPC?

Radiotherapy to the primary tumor

Radiotherapy to the primary tumor is recommended for patients with low‑volume mHSPC identified on conventional imaging. In combination with ADT, abiraterone, apalutamide, and enzalutamide are strongly recommended androgen‑receptor pathway inhibitor (ARPI) options, while darolutamide is conditionally recommended. Evidence from PEACE‑1, STAMPEDE, and HORRAD supports this approach in low‑volume disease.

Systemic intensification

The AFU recommends systemic treatment intensification with an ARPI plus ADT for all patients with mHSPC. This strong recommendation is supported by multiple phase 3 trials, including ARANOTE (darolutamide plus ADT).

PARP inhibition in HRR‑altered disease

Niraparib plus abiraterone may be proposed as first-line treatment for patients with BRCA1/2 or other homologous recombination repair (HRR) alterations, based on AMPLITUDE outcomes.

What are the AFU guideline updates for mCRPC?

Radioligand therapy

AFU recommends ¹⁷⁷Lu‑PSMA‑617 for patients progressing after at least one ARPI and a taxane, and may be considered for selected patients delaying chemotherapy in PSMA PET–positive disease. This is supported by phase 3 data from PSMAfore and VISION.

PARPi–ARPI combinations

In patients without known HRR alterations, abiraterone plus olaparib may be offered as a conditional first-line option for mCRPC depending on prior therapy. Enzalutamide plus talazoparib is strongly recommended based on TALAPRO‑2.

Radium‑223 combinations

Enzalutamide plus six cycles of radium‑223 may be proposed for patients with no or mildly symptomatic bone‑predominant mCRPC without visceral metastases, and where bone‑resorptive therapy is indicated. This conditional recommendation is supported by PEACE-3.

What are the clinical implications of the 2025 AFU prostate cancer updates?

Overall, the 2025 AFU recommendations support broader use of bpMRI and transperineal biopsy; expand guideline‑supported options for selected patients with localized prostate cancer, including SBRT and whole-gland HIFU; reinforce systemic intensification in mHSPC; and clarify the roles of molecular stratification, radioligand therapy, and treatment combinations in mCRPC.

For additional perspective on resistance mechanisms and evolving treatment strategies, read our article on targeting resistance pathways in mCRPC.

Reference

1. Ploussard, 2025. French recommendations from the AFU Cancer Committee for prostate cancer: 2025 summary of changes. https://doi.org/10.1016/j.fjurol.2025.103010

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