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Where Do We Stand and What is Missing in PSMA PET diagnostics for Men with Biochemical Recurrence of Prostate Cancer - Beyond the Abstract

Prostate cancer care faces multiple challenges in terms of decision making along the course of treatment. While definitive treatment options, including radical prostatectomy and radiation therapy, are considered in patients with a curative intent, a non-negligible number of patients returns with biochemical recurrence. With the aim of personalizing care as one of the highest goals in modern medical research, prostate specific membrane antigen positron emission tomography/computed tomography (PSMA-PET/CT) has rapidly evolved in order to detect the source of these recurrences. Our review comments on clinically important aspects of PSMA PET/CT diagnostics in the landscape of biochemically recurrent prostate cancer:1

Our work certainly highlights the superiority of PSMA PET/CT over other diagnostic tools used within this scenario, especially in patients presenting with low PSA-levels below 10ng/ml. Detection rates in these patients reach up to >70%2,3 suggesting even distant disease in some of the patients.4 How do we have to deal with these results? Do we have to change our management? Current research says yes; we summarize how positive and negative results on PSMA PET/CT result in changes in the patient management.
However, are the results reliable enough to justify these changes? How accurate does a diagnostic tool need to be to confidently base your treatment recommendations on its findings? While our review summarizes the actual body of knowledge surrounding PSMA PET/CT diagnostics, it also emphasizes what is genuinely missing: Most studies lack reporting long-term outcomes of clinical importance. Does PSMA PET/CT lead to better clinical outcomes in the long run? In other words, are the expenses for this high-cost imaging modality worth the investment?

While PSMA PET/CT seems to be the best diagnostic alternative for men with biochemical recurrence of prostate cancer, we also believe, that the optimal space in which PSMA PET/CT operates best is yet to be found.

Written by: Marieke J. Krimphove MD1,2, Philipp C. Mandel MD, PhD1, Felix K.-H. Chun MD1
1. Department of Urology, University Hospital Frankfurt, Frankfurt, Germany
2. Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

References: 
1. Krimphove MJ, Theissen LH, Cole AP, Preisser F, Mandel PC, Chun FKH. Performance and Impact of Prostate Specific Membrane Antigen-Based Diagnostics in the Management of Men with Biochemical Recurrence of Prostate Cancer and its Role in Salvage Lymph Node Dissection. The world journal of men's health. Mar 5 2019.
2. Eiber M, Maurer T, Souvatzoglou M, et al. Evaluation of hybrid 68Ga-PSMA ligand PET/CT in 248 patients with biochemical recurrence after radical prostatectomy. Journal of Nuclear Medicine. 2015;56(5):668-674.
3. Afshar-Oromieh A, Holland-Letz T, Giesel FL, et al. Diagnostic performance of (68)Ga-PSMA-11 (HBED-CC) PET/CT in patients with recurrent prostate cancer: evaluation in 1007 patients. European journal of nuclear medicine and molecular imaging. Aug 2017;44(8):1258-1268.
4. Rauscher I, Duwel C, Haller B, et al. Efficacy, Predictive Factors, and Prediction Nomograms for (68)Ga-labeled Prostate-specific Membrane Antigen-ligand Positron-emission Tomography/Computed Tomography in Early Biochemical Recurrent Prostate Cancer After Radical Prostatectomy. European urology. May 2018;73(5):656-661.

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