In contrast to a previous trial (RTOG 9601) that told us that ADT can be safely avoided if PSA<0.7, this trial suggests at least 4 months of ADT and whole pelvic treatment. The reason for the difference in recommendations is due to the choice of endpoint. SPPORT is telling us that if we are willing to put up with 4 months of ADT and some extra short-term toxicity from the wider field of radiation. a cure is likely. RTOG 9601 tells us that if your PSA<0.7, you aren't likely to die if you don't get the extra hormone therapy, but you may have to have lifelong ADT eventually.
Results may possibly be improved further with:
•Better patient selection using PET scans (PSMA, Axumin, or NaF)
•Extra radiation to the prostate bed
•Boost doses to cancer detected with a PSMA PET scan (if PSA> 0.5 - but do not wait!)
•Selection of patients who would benefit from treatment intensification using a Decipher test
•Hormone therapy intensification in select patients