PSMAfore: Taxane-naive PSMA-positive mCRPC after one prior ARPI progression
Authored by Neal Shore, published on 2026-05-08 20:56:52.0
Start: progressive mCRPC on exactly one prior ARPI
Continue ADT/castrate testosterone management. Confirm adenocarcinoma, adult patient, ECOG 0–1, and disease progression after abiraterone, enzalutamide, apalutamide, or darolutamide.
Is patient taxane-naive in the metastatic setting and appropriate to delay taxane chemotherapy?
No
This is outside the core PSMAfore population. Use standard mCRPC sequencing: taxane chemotherapy, post-taxane radioligand therapy when indicated, clinical trial, or other guideline-directed care.
Yes
Proceed to PSMA-PET selection and rule out trial-defined exclusions before choosing radioligand therapy versus ARPI change.
68Ga-PSMA-11 PET/CT: ≥1 PSMA+ lesion and no exclusionary PSMA-negative lesion?
No / equivocal
Do not use the PSMAfore-preferred pathway. Consider ARPI change only if clinically appropriate, chemotherapy, targeted therapy if eligible, trial enrollment, or other non-PSMA-directed care.
Yes
Confirm no better standard alternative was identified by genomics or prior therapy history. PSMAfore excluded known candidates for alternative standard therapies based on genomic alterations.
Prior disallowed therapy or better biomarker-driven option?
Yes
Not a PSMAfore-like decision. Examples: Prior taxane in metastatic setting Recent systemic/hemibody radiotherapy Prior immunotherapy except sipuleucel-T PARP-inhibitor candidacy Other trial-excluded standard option
No
PSMAfore-like patient: favor 177Lu-PSMA-617 over switching to another ARPI when the practical goal is to delay taxane chemotherapy.
Preferred PSMAfore-based treatment choice
177Lu-PSMA-617 7.4 GBq (200 mCi) ±10% every 6 weeks for 6 cycles + best supportive care/ADT. Do not administer ARPI concurrently with 177Lu-PSMA-617 in the study-treatment period.