The Impact of PSMA PET Imaging on Staging and Treatment Decisions in mCSPC

This segment focused on how the advent of PSMA PET imaging has transformed the definition and management of metastatic castration-sensitive prostate cancer (mCSPC). Panelists noted that while pivotal trials were based on conventional imaging—CT and bone scans—PSMA PET now identifies metastatic lesions previously undetected, creating ambiguity in defining “metastatic” disease. They discussed how this shift has changed clinical practice, often revealing patients with PSMA-positive but conventionally negative findings, raising questions about treatment escalation. The panel referenced EMBARK trial data supporting doublet therapy with enzalutamide and ADT in PSMA-positive, high-risk patients, and debated whether intermittent therapy might be appropriate for select responders. Participants also highlighted the challenge of reconciling high- and low-volume disease classifications derived from older imaging standards. The discussion underscored the need for updated guidance and integration of biomarkers to refine staging and treatment decisions in the era of advanced molecular imaging.

Panelists noted that abiraterone, apalutamide, and enzalutamide demonstrate overall survival benefits, while darolutamide primarily delays progression. They discussed side-effect profiles and monitoring needs—highlighting the need for liver function monitoring and steroid co-administration with abiraterone—and emphasized that treatment selection often depends on balancing efficacy, toxicity, and clinician comfort.