When Radiation Changes the Outcome: New Strategies Against Prostate Cancer in Costa Rica

Prostate cancer is one of the most common malignancies in men and a major cause of morbidity and mortality worldwide. In Costa Rica, its impact goes beyond statistics, reflected in patients who, even after curative treatments, experience recurrence. In this context, Radiation Oncology has evolved significantly, becoming a discipline capable of offering more comprehensive and strategic solutions, particularly in complex scenarios such as nodal relapse.

For many years, the standard approach to recurrent prostate cancer in pelvic lymph nodes focused on treating only visible lesions using highly precise techniques such as stereotactic body radiotherapy (SBRT). This strategy allowed for targeted dose delivery with limited toxicity and greater patient convenience. However, growing clinical evidence has highlighted a critical limitation: even advanced imaging technologies like PSMA PET do not always detect microscopic disease.

A turning point in this field has been the PEACE V–STORM trial, published in The Lancet Oncology (2025), which compared two treatment strategies: targeting only the detected metastatic nodes versus irradiating the entire pelvic nodal region with an additional dose boost to visible lesions. The results demonstrated that the broader approach, known as elective nodal radiotherapy, achieved better disease control and reduced the risk of distant progression. This finding introduces an important conceptual shift: it is not enough to treat what is visible; clinicians must also anticipate what remains undetected.

For clinical practice in Costa Rica, these findings carry important implications. The integration of modern radiotherapy techniques, combining pelvic irradiation with advanced modalities such as IMRT and VMAT, enables more comprehensive treatments without a significant increase in toxicity. This is particularly relevant in centers with expertise in advanced treatment planning, where dose distribution can be optimized to spare healthy tissues while maintaining treatment efficacy.

Radiation Oncology in the country is currently in a phase of technological and conceptual consolidation. The incorporation of high-level evidence, such as that provided by the PEACE V–STORM trial, supports the refinement of treatment strategies and enhances patient selection. Today, cancer management is no longer limited to visible disease but instead incorporates a deeper understanding of tumor biology.

Nevertheless, this shift also requires careful clinical judgment. Not all patients will benefit equally from more extensive irradiation, and individualized treatment decisions remain essential. Factors such as tumor burden, PSA doubling time, and overall clinical context must be thoroughly evaluated. In addition, multidisciplinary collaboration continues to be crucial to ensure balanced, evidence-based decision-making.

The management of prostate cancer is entering a new era, where precision involves not only accuracy but also anticipation. In Costa Rica, the evolution of Radiation Oncology reflects this progress, positioning radiotherapy as a tool capable not only of treating disease but of altering its natural course. Emerging evidence supports a broader and more strategic approach, where treating beyond what is visible may ultimately make a meaningful difference in patient outcomes.