Testosterone-Sparing Treatment Strategies for Biochemically Recurrent Prostate Cancer After Radical Prostatectomy

Advances in multifactorial risk stratification-including genomic classifiers and artificial intelligence (AI)-driven models-are reshaping treatment decision-making and may help identify patients unlikely to benefit from ADT. PSMA-PET has redefined disease staging and is increasingly used to guide salvage radiation therapy and metastasis-directed therapy. Several emerging TST strategies-including enzalutamide monotherapy, salvage radiation without ADT, metastasis-directed therapy, salvage lymph node dissection, radioligand therapy, and structured lifestyle interventions-demonstrate potential to delay or avoid hormonal therapy. Early evidence suggests select patients can maintain cancer control while avoiding testosterone suppression and its associated toxicities. BCR represents a heterogeneous clinical state, requiring individualized management strategies that balance oncologic efficacy with long-term survivorship concerns. Testosterone-sparing approaches may provide safe alternatives to ADT in appropriately selected patients. Ongoing work to validate predictive biomarkers and integrate AI-derived decision tools is expected to refine patient selection as emerging clinical trials mature.