PSMA PET and treatment intensification in mHSPC

Author(s):

“The main challenge at the moment is patients are being diagnosed with metastatic disease far earlier than they would have been otherwise, and therefore [are being] considered for combination systemic therapy potentially years earlier than they would have been if we just looked at conventional imaging," says Dr Louise Kostos.

In a recent study in European Urology, investigators sought to review data regarding combination therapies for the treatment of locally advanced and metastatic hormone-sensitive prostate cancer.¹ In their paper, the authors touched on the integration of prostate-specific membrane antigen (PSMA) PET imaging leading to earlier detection of metastatic disease. In an interview with Urology Times®, study author Dr Louise Kostos was asked whether she felt this might affect the balance between treatment intensification and de-escalation strategies, especially in terms of minimizing overtreatment and long-term toxicity.

“That's a really good question, and one we don't have a clear answer to at the moment. I guess what we know about PSMA PET scans is that they are more sensitive compared with conventional imaging, but they also have a lower false positive rate compared with CT and bone scan,” said Kostos, a medical oncologist and PhD candidate at Peter MacCallum Cancer Centre in Victoria, Australia.

She added, “The main challenge at the moment is patients are being diagnosed with metastatic disease far earlier than they would have been otherwise, and therefore [are being] considered for combination systemic therapy potentially years earlier than they would have been if we just looked at conventional imaging.”

During the interview, Kostos also made note of the LIBERTAS trial, “which is looking at patients with metastatic hormone-sensitive prostate cancer who go on to start ADT [androgen deprivation therapy] and apalutamide [Erleada], and use PSA [prostate-specific antigen] as a biomarker. [They’re looking] at the whether patients have an undetectable PSA at 6 months, and if they do, they get randomized to stop the ADT or continue with the doublet. And importantly, that study also incorporates PSMA PET into the baseline staging as well,” Kostos said.

REFERENCE

1. Azad AA, Kostos L, Agarwal N, et al. Combination therapies in locally advanced and metastatic hormone-sensitive prostate cancer. Eur Urol. 2025 Feb 12:S0302-2838(25)00023-5. doi:10.1016/j.eururo.2025.01.010