Transformative Impact of PSMA PET/CT Imaging in Prostate Cancer

Advancing Patient Care Through Precision PSMA PET/CT Imaging

The advent of prostate-specific membrane antigen (PSMA)-directed PET/CT is revolutionizing the staging and treatment decisions for prostate cancer patients. Substantial data now support its influence on patient outcomes and standard clinical care pathways, prompting updates to clinical guidelines recommending PSMA PET/CT imaging. This is particularly suggested for patients with suspected metastases, biochemical recurrence (BCR) based on elevated prostate-specific antigen (PSA) levels, and nonmetastatic castration-resistant prostate cancer with elevated PSA. It is also employed in monitoring advanced prostate cancer for progression and determining eligibility for PSMA-directed radioligand therapy.

Recent studies have scrutinized the impact of PSMA PET/CT imaging on prostate cancer staging and clinical management decisions. Below is a brief overview of studies assessing two FDA-approved PSMA tracers: gallium 68 (68Ga) PSMA-11 (also known as Ga 68 gozetotide) and fluorine 18 (18F)- DCFPyL (also known as piflufolastat F-18).

PSMA PET-CT Imaging Impact on Treatment Decisions

18F-DCFPyL

Results from the phase 3 CONDOR trial (NCT03739684) for patients with BCR prostate cancer revealed a 63.9% change in the intended management plan based on physician responses to management questionnaires before and after PET/CT imaging using 18F-DCFPyL PSMA. A subsequent analysis focused on a subset of 69 men with very low or low PSA levels (< 0.5 ng/mL), showing that 18F-DCFPyL PSMA PET/CT imaging altered the planned management in over 39% of patients. Notably, 74.1% of patients with a change in management had their initial intended treatment intensified as a result of imaging.

68Ga–PSMA-11

In a prospective study of 197 patients, the impact of gallium 68 gozetotide (68Ga–PSMA-11) on treatment management decisions for prostate cancer patients was evaluated. The results indicated changes to the staging of prostate cancer in 69% of patients, with 38% upstaged, 30% downstaged, and 32% unchanged. Management decisions were impacted for 57% of patients, frequently resulting in a shift from systemic to focal treatment for 16% of these individuals. Excluding patients with BCR or presurgical staging, the study emphasized the benefit of PSMA PET/CT imaging on treatment decisions across all clinical scenarios.

Moreover, a study by Müller et al assessed the impact of 68Ga–PSMA-11 PET/CT imaging on the management and outcomes of 223 patients with recurrent prostate cancer. The results confirmed the high detection rate for recurrence related to the use of PSMA PET and demonstrated its ability to guide personalized treatment through precise lesion localization. The study revealed a 60% management change after PSMA PET/CT imaging, with an increase in metastasis-targeted radiotherapy and a decrease in systemic therapy.

Impact of Patient Outcomes

While the long-term impact on patient outcomes of modifying treatment plans based on PSMA PET/CT imaging analysis is yet to be determined, these trials underscore the meaningful influence that PSMA molecular imaging has on patient care until survival data mature.