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Transformative Impact of PSMA PET Imaging on Patient Management


Key opinion leaders discuss how PSMA PET CT tracers, including gallium 68 and fluorine 18, are revolutionizing prostate cancer patient management and with accurate and early detection of disease spread.


Shadi Abdar Esfahani, MD, MPH: Dr Kella, I would like to ask you about the impact of PSMA-targeted imaging modalities for the management of the patients. How do you think, based on the available data, these 2 compounds…either gallium 68–labeled or fluorine 18­labeled tracers, and overall, PSMA [prostate-specific membrane antigen] PET [positron emission tomography] scans, have changed the management of the patients?

Naveen Kella, MD: Thank you, Dr Esfahani. So…right now, as you alluded to earlier, there may be some differences between the PSMA PET-CT tracers. Currently, there’s lots of research being done. There [are] more tracers, apparently, that are coming down the pike out of research and potentially into practice. The current standing for the AUA [American Urological Association] and for the NCCN [National Comprehensive Cancer Network] is that there is no superior agent at the moment. And 1 PSMA PET-CT tracer could be used along with the other without any patient detriment. And there have been studies…for the gallium [68] and the fluorine [18] PSMA PET-CT tracers that have looked at, well, okay, if you get imaging, is this going to change anything from the provider standpoint or for the urologist or for the radiation oncologist?

And in the gallium [68] literature, there was a group—Osmany et al—they did a study where they actually were just getting imaging, conventional imaging, for patients for all sorts of various reasons. And it was an investigator-initiated study that then gave the patient also PET-CT imaging afterwards. And there is a questionnaire that the ordering physician then was provided, and it asked them, well, based off that PET-CT, does this change your management for the patient? And it did over half the time. For example, there are patients who are getting conventional imaging after radiation therapy for their prostate cancer, and they then got PET-CT, and the PET-CT findings were positive many times, even though the patient was not meeting what we call the Phoenix criteria for recurrence after radiation, where their PSA [prostate specific antigen] nadirs, and then it goes up to points. These patients did not meet [those] criteria. But on PET-CT, it was evident that their disease had spread. So that's something…remarkable. And it calls into question if we should be modifying, and I believe we will, things like the Phoenix criteria for radiation failures.

There's another study with the gallium [68] literature also looking at this by Mueller et al, and his study was a retrospective study where they were looking at patients…with PSA recurrence after definitive therapy. And they found that these patients, who are in line for treatment, once you've got the PSMA PET-CT, these guys were going to get systemic therapy, but then it decreased once you got the results. Instead of getting systemic therapy, which was the plan for 60% of the patients, it dropped by half because of the PET-CT findings. So, what I mean by that is patients were found to have oligometastatic disease, small amounts of disease, that perhaps you could treat with focused treatment. So, it changed patients’ treatments from systemic to a more oligometastatic-targeted approach. And what was also interesting with this is that those patients who were getting the focused treatment, when you follow them, half of them who had focused treatment were still disease free with complete response 6 months later. So that's an early study looking at outcomes.

And I think you're going to get more and more of those types of studies as time goes on…. With the literature looking at fluorine [18], you see similar things where they looked at a study with patients with biochemical recurrence and these patients were slated to get salvage therapy. Then they also ordered a PSMA PET-CT, and it changed management over half the time, where now, patients who were potentially going to get salvage treatment, actually, it was boosted to systemic treatment. You saw disease outside of the intended field of treatment with radiation. And some people who are slated to get observation with their PSA rise moved on to get treatment because disease was noted. So...it's really exciting with how PSMA PET-CT has so quickly come on the scene and is so quickly making management changes for our patients. And...time will tell if these management changes are going to be in the best interest for our patients.

Shadi Abdar Esfahani, MD, MPH: This is very helpful. Thank you very much for all of your helpful information and the insights into the clinical practice and the clinical management of our patients.

Transcript is AI-generated and edited for clarity and readability.

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