Study Overview: Assessing the shift from NaF-PET/CT to PSMA-PET/CT
Researchers in Denmark explored whether replacing F-18 sodium fluoride (NaF) PET/CT imaging with F-18 PSMA-PET/CT would influence treatment decisions for men with newly diagnosed, high-risk prostate cancer. The study involved 160 patients who underwent both imaging modalities within a three-week window. Initially, treatment decisions were based on NaF-PET/CT results, with PSMA-PET/CT findings withheld during early multidisciplinary discussions. Only after comprehensive review were the PSMA-PET/CT results incorporated to reassess disease stage and treatment options.
The central question was whether PSMA-PET/CT’s superior ability to detect soft tissue and bone involvement would lead to meaningful clinical changes, particularly in the context of staging and eligibility for curative vs. noncurative strategies.
Key Findings: Stage Migration and Treatment Changes
Across the cohort, 40 patients (25%) experienced a change in metastatic stage when PSMA-PET/CT data were added to the initial NaF-PET/CT assessment. Among these changes, 38 patients (24%) were reclassified as having more advanced disease, while 2 patients (1%) shifted to a less advanced stage. Overall, treatment plans were revised for 21 patients (13%) of the total group, with 19 moving toward therapies appropriate for more advanced disease and 2 becoming candidates for curative treatment that had previously seemed unlikely.
These results emphasize the potential for PSMA-PET/CT to reveal metastases that NaF-PET/CT may miss, thereby altering the therapeutic trajectory in a meaningful minority of high-risk patients. The authors noted a strong statistical significance for stage migration (p < 0.001), underscoring the robustness of the observed changes.
Clinical Implications: Why This Matters in Everyday Practice
The study highlights a practical consequence: adopting PSMA-PET/CT as a primary imaging modality could prompt earlier and more accurate staging, potentially guiding patients toward systemic therapies, targeted radiotherapy, or definitive treatments when appropriate. Dr. Claus Madsen, the study’s lead author, and colleagues concluded that the shift from NaF-PET/CT to PSMA-PET/CT “has the potential consequences” for daily clinical practice, especially as guidelines increasingly endorse PSMA-PET/CT for primary staging in advanced disease.
In essence, PSMA-PET/CT may offer a more precise map of disease spread, particularly in lymph nodes and bone—a crucial factor in planning interventions for high-risk, newly diagnosed prostate cancer. The improved diagnostic accuracy of PSMA-PET/CT aligns with broader moves by professional bodies toward using PSMA imaging in initial staging, echoing recommendations from the European Association of Urology and the Society of Nuclear Medicine and Molecular Imaging.
Context Within Guidelines and Future Directions
While PSMA-PET/CT has already demonstrated superior accuracy over conventional imaging for initial staging, this study marks the first prospective analysis to quantify stage migration and the potential shifts in clinical management when replacing NaF-PET/CT with PSMA-PET/CT. The authors stress that these findings are important as PSMA-PET/CT becomes more integrated into international guidelines for primary staging in advanced prostate cancer.
Ultimately, the study supports a paradigm shift: moving toward PSMA-based imaging could refine treatment planning, reduce overtreatment, and tailor therapies to more precisely defined disease burdens. Ongoing and future prospective studies will be essential to confirm these results across diverse populations and to quantify long-term outcomes such as progression-free survival and overall survival in relation to imaging-driven treatment changes.
Bottom Line
The Danish study provides compelling early evidence that replacing NaF-PET/CT with PSMA-PET/CT can alter disease staging and influence treatment decisions in a significant subset of high-risk, newly diagnosed prostate cancer patients. As PSMA-PET/CT becomes more widely adopted in clinical guidelines, its impact on patient care and health-system planning is likely to grow, reinforcing the importance of imaging advances in the management of prostate cancer.