Lunan-Taylor M, Raval AD, Phan NTN, Korn MJ, Quintero V, McKay RR. Radium-223 in men with metastatic castration-resistant prostate cancer: a systematic literature review of real-world outcomes in observational studies. Eur Urol Oncol. 2025 Aug;8(4):1150-64. doi: 10.1016/j.euo.2025.06.002

BACKGROUND AND OBJECTIVE: Radium-223 (Ra-223) has been approved since 2013 for men with metastatic castration-resistant prostate cancer (mCRPC) with bone metastases. Since then, the treatment landscape has changed dramatically, and a comprehensive understanding of the real-world outcomes of Ra-223 use is needed. This systematic literature review summarizes the real-world effectiveness and safety of Ra-223 in men with mCRPC.

METHODS: Electronic databases were searched systematically for real-world observational studies from the past 10 yr examining the outcomes in men with mCRPC treated with Ra-223.

KEY FINDINGS AND LIMITATIONS: Forty-eight studies including 15 368 men with mCRPC met the inclusion criteria. Most studies were from Europe (n = 22) and North America (n = 18; sample size range, 104-1628). Studies in Europe and North America reported ≥60% and 55% completing five or more cycles of Ra-223, respectively. First-line therapy, no prior chemotherapy or immunotherapy, and high hemoglobin and neutrophil levels were the key factors associated with completing five or more cycles. The median real-world overall survival varied (11-24 mo), with one exception. Completion of five or more cycles was associated with a two- to five-fold increase in the median real-world overall survival. Of 14 studies reporting fractures, incidence was <10% in most studies (n = 12), with trends toward lower rates using bone health agents (BHAs).

CONCLUSIONS AND CLINICAL IMPLICATIONS: This is the most comprehensive review of the effectiveness and safety of the use of Ra-223 in a population after the adoption of androgen-receptor pathway inhibitors. The findings highlight the survival benefits of the early use of Ra-223 with completion of five or more cycles, a favorable safety profile, and low rates of fracture when guideline-recommended BHAs are used.