Updated AUA/SUO Advanced Prostate Cancer guideline emphasizes role of PSMA-PET

In this interview, Kristen R. Scarpato, MD, MPH, discusses 2026 AUA/SUO Advanced Prostate Cancer Guideline amendment recommendations regarding the role of PSMA-PET imaging across the prostate cancer continuum, highlighting its impact on disease detection, treatment decision-making, and ongoing questions surrounding its clinical implications.¹ Scarpato is an associate professor of urology at Vanderbilt University Medical Center in Nashville, Tennessee.

Scarpato explained that PSMA-PET imaging has seen rapid adoption over the past 5 years and is now integrated throughout the amended 2026 AUA/SUO Advanced Prostate Cancer Guideline for patients with both localized and advanced disease. She noted that the availability of FDA-approved PSMA-PET agents has improved clinicians' ability to detect disease earlier, particularly in patients with unfavorable intermediate-risk or high-risk localized prostate cancer and in those with biochemical recurrence after definitive local therapy. The guideline now preferentially recommends PSMA-PET in several clinical settings because of its superior sensitivity compared with conventional imaging.

Although earlier detection is expected to improve patient management, Scarpato emphasized that important clinical questions remain unanswered.

"We know this test has greater sensitivity for detecting metastatic disease. What we don't really know yet is what the impact is on overall survival when we're detecting disease sooner," she said. She explained that identifying smaller-volume disease earlier may allow earlier initiation of systemic therapy, but whether this ultimately translates into improved survival remains to be determined as longer-term data mature.

Scarpato also highlighted how the widespread use of PSMA-PET raises new questions about disease classification and treatment selection. In metastatic hormone-sensitive prostate cancer, she noted that treatment decisions often rely on definitions of high-volume vs low-volume disease established using conventional imaging. Because PSMA-PET detects additional sites of disease, it remains unclear whether these historical definitions should be revised. She added that PSMA-PET continues to play an important role in metastatic castration-resistant prostate cancer, particularly when evaluating patients for radioligand and theranostic therapies such as lutetium-based treatment.

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