Salvage therapy for radiorecurrent prostate cancer: beyond equipoise - a call for biomarker-driven stratification

The increasing incidence of localized radiorecurrent prostate cancer demands a shift from modality-centric comparisons toward biomarker-driven patient selection. Light et al. provide a matched comparison of salvage focal therapy (sFT) versus salvage radical prostatectomy (sRP), reporting comparable 10-year cancer-specific survival but fewer complications with sFT. However, the study lacks integration of modern PSMA PET/CT restaging and genomic risk stratification (e.g., Decipher classifier), both of which could profoundly influence therapeutic outcomes. Moreover, salvage reirradiation-a promising third option-is omitted. We argue that equipoise is no longer sufficient; the field needs prospective registries or trials that stratify by imaging and genomic biomarkers, with coprimary endpoints of metastasis-free survival and patient-reported functional outcomes. We also discuss the limitations of PSMA PET/CT for small-volume lesions and the importance of validating genomic thresholds specifically in the salvage setting. Only such an approach will enable truly personalized salvage therapy.