Role of PSMA-PET Expands in the Treatment of Prostate Cancer

David Albala, MD

As imaging technology evolves, the expanded use of prostate-specific membrane antigen (PSMA) PET scans has become a focal point of interest for prostate cancer field. Ahead of the 2022 Large Urology Group Practice Association (LUGPA) conference, David Albala, MD, highlighted the significance of the imaging practice as well as its advantages over other screening techniques. Albala will be participating in a question-and-answer session on PSMA-PET at the conference.

“The prostate cancer imaging field is changing,” Albala said. “We’ve come a long way from conventional imaging with CT scan and bone scans. [PSMA-PET] is a new imaging modality that offers an increased sensitivity and specificity compared with other agents that are out there.”

In an interview with OncLive^®, Albala, the chief of urology at Crouse Hospital in Syracuse, New York, discussed integrating PSMA-PET imaging into the clinic and determining the patients who are prime candidates.

OncLive^®: What topics will be covered in PSMA-PET session?

Albala: This is a timely panel that Neil Shore, MD, has put together to talk about recent advances in imaging and the hot topic right now is PSMA imaging. We are going to go over the indications for newly diagnosed patients with prostate cancer and those with recurrent prostate cancer [and] discuss how one will incorporate that into the workflow of your practice.

Traditionally, we have used conventional imaging with bone scans and CT scans in these patients. This opens a new era of how we can look at these patients and make treatment decisions based on real data. [Clinicians] have been disappointed with the conventional imaging that we have had and our panelists that are going to be talking about how we can incorporate it in our practices and workflow.

How does a clinician determine when to perform PSMA-PET imaging for patients with prostate cancer?

The largest experience with PSMA imaging has been with recurrent disease. Those patients that have had either definitive treatment with surgery or radiation and then they present back to the office or clinic with a rising prostate-specific antigen. In those patients, we have [previously used] next generation imaging or a targeted type of imaging. We are going to be [examining] how we look at the historical perspective of using agents such as fluciclovine or sodium fluoride, even prior to that, and now we have migrated into PSMA testing. That is an exciting group of patients that has been around for quite some time and this type of imaging works quite nicely in.

We are also going to look at patients with intermediate-grade or high-grade prostate cancer that have not had definitive treatment and try to see if they have metastatic lesions before we recommend definitive treatment. There are patients who will present that way and treating them properly right out of the box makes a big difference—this type of imaging allows us to do that. That is the exciting area that we are going to see an extreme amount of growth in [over] the next few years.

What advantages does PSMA-PET provide over other screening techniques?

The sensitivity and specificity of this type of imaging at picking up prostate cancer that is outside the prostate is the best imaging modality we have at present. We have relied on conventional imaging where bone scans and CT scans with fluciclovine imaging were a nice step forward, progressing and advancing the science.

With PSMA, we are going to start to see a whole new era open and that is the exciting thing being a urologist. Understanding how to incorporate it in your workflow, when do you do it, how do you do it, what it entails, how well the radiologists reading are these images, all must be taken into consideration. It is very promising and is going to be the wave of the future.

What are the financial implications of using PSMA-PET?

We now know that this imaging is becoming much more commonplace and, as it becomes more commonplace, insurance companies are looking at the science to make sure that we can get the payment for this type of imaging.

That is the challenge to develop the science, understand the science, and then that will translate into the financial picture. What is important is that we get the studies approved so our patients are not suffering any further economic burdens by having this new type of imaging being put forward.

How frequently is PSMA-PET used in clinical practice?

The decay of the agent is in some respects the rate-limiting step. [So,] it is used, but there are a number of agents that now have been approved by the FDA. If you are living in a city such as Los Angeles, [California], you have 2 agents that are readily available. But, if you are living in rural upstate New York, [for example], where these agents [have time to] decay, getting the agents to the hospitals where the studies can be performed is more of a challenge. [We are] trying to understand how we can get these different agents spread out [because] there are different agents, different half-lives, and different imaging quality [available].

What is the main takeaway of this session you would like to impart to colleagues?

There are places and indications for these types of studies. We started seeing migration to sodium fluoride studies, we then saw fluciclovine, but now we have kind of reached a newer plateau with PSMA.

The takeaway message is stay current. This is a great opportunity to learn about how you can incorporate this into your practice, and how important it is for patients to undergo this type of imaging when you have these concerns, because you may change the way treatments are rendered based on this type of imaging.

Are there any other presentations you are looking forward to at the meeting?

[Dr] Shore has put together a great educational program, it is varied and has multiple areas of interest for many different types of urologists. The health policy work that is going to be discussed at the annual meeting—what has been done in Washington, [DC], what is the health care climate [like]—that is exciting.

The LUGPA health policy group is very active on [Capitol Hill] and doing a lot to help preserve independent urology practices around the country. [Additionally], there are some great keynote speakers to talk about, James Carville Jr, for example, is going to be a lively speaker to discuss the political landscape.