13 Optimal prostate-specific antigen cutoff linked to improved prostate cancer survival A drop in prostate-specic antigen (PSA) levels is an indicator that is used to monitor treatment success for men with metastatic prostate cancer. A recent real-world study published by Freedland, S. J., et al. showed that reaching a PSA level below 0.2 ng/mL is an indicator of improved patient survival. Two commonly used measures are used to determine treatment success: • Absolute PSA level: Achieving a PSA nadir below 0.2 ng/mL. • Percentage PSA reduction: Achieving a reduction of at least 90% from the pretreatment PSA level. The researchers wanted to determine which measure was more strongly associated with overall survival and disease progression. Investigators analysed Veterans Health Administration data on 4,890 patients who received testosterone deprivation therapy with or without other treatments in 2018–2023 for metastatic hormone-sensitive prostate cancer. The primary outcomes were: • Overall survival (OS): The time until death. • Disease progression: A composite outcome that included PSA progression, initiation of a new anticancer treatment, development of castration resistance or death. Reference: Freedland SJ, Gao W, Touya M, et al. (2026). How low do you need to go? Association between various prostate-specic antigen response measures and clinical outcomes in metastatic castration-sensitive prostate cancer in the Veterans Health Administration data. Cancer. Cancer. 2026 Aug 15;132(16):e70494. Conclusion “These data show that we need to target a PSA below 0.2 ng/ml as our metric of success to optimize outcomes for our patients with metastatic prostate cancer." Stephen J. Freedland, MD, corresponding author, professor of Urology at Cedars-Sinai and Staff Physician at the Durham VA Medical Center Key ndings: • Over a median follow-up of approximately 2 years, 896 patients died. • Patients whose PSA levels dropped below 0.2 ng/mL within 9 months of starting treatment were 54% less likely to die than patients whose levels did not drop this low, whether their PSA levels also decreased by at least 90% or not. • Patients who had at least a 90% PSA decline but did not achieve a PSA of less than 0.2 ng/ml had no improvement in survival. The ndings suggest that patients who do not experience a PSA drop below 0.2 ng/mL could be candidates for more aggressive treatments. In addition, patients who received androgen deprivation therapy (ADT) plus an androgen deprivation therapy pathway inhibitor (ARPI) were more likely to reach a PSA below 0.2 ng/mL, demonstrating once again that ADT monotherapy is no longer standard of care.
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