New Evidence Supports a Shift in Prostate Cancer Imaging
Researchers in Denmark have found that replacing F-18 sodium fluoride (NaF) PET/CT with F-18 prostate-specific membrane antigen (PSMA) PET/CT could meaningfully influence treatment decisions for men with newly diagnosed high-risk prostate cancer. In a prospective, within-patient comparison, the study suggests that PSMA-PET/CT not only improves diagnostic accuracy but also drives changes in how the disease is staged and managed.
Study Design: Direct Comparison Within the Same Patients
The study enrolled 160 men with high-risk, newly diagnosed prostate cancer who underwent both F-18 NaF-PET/CT and F-18 PSMA-PET/CT within a three-week window. Initially, staging and treatment plans were based solely on the NaF-PET/CT results. Later, multidisciplinary team discussions integrated the PSMA-PET/CT findings to reassess staging and consider alternative therapies.
Key Findings: Stage Migration and Treatment Implications
According to lead author Claus Madsen, PhD, these results show substantial stage migration when PSMA-PET/CT data are added. Overall, 40 of 160 patients (25%) experienced a change in metastatic stage after reviewing PSMA-PET/CT results. Notably, 38 patients (24%) were reclassified to a more advanced stage, while only two patients (1%) moved to a less advanced stage (p < 0.001).
Most importantly for patient care, treatment plans were altered for 21 patients (13%) after incorporating PSMA-PET/CT data. In 19 cases, decisions shifted toward therapies appropriate for more advanced disease, reflecting a move to more aggressive systemic or targeted management. In two cases, patients initially considered for curative intent were reclassified to noncurative treatment options based on the PSMA findings. Among the 69 patients initially deemed candidates for curative approaches, eight (12%) were redirected to noncurative strategies.
Clinical Implications: Toward a PSMA-First Staging Paradigm
The investigators emphasize that these findings highlight the practical consequences of adopting PSMA-PET/CT as a primary staging modality rather than relying on conventional imaging such as NaF-PET/CT, bone scintigraphy, CT, or MRI. PSMA-PET/CT’s higher sensitivity for soft-tissue disease and nodal involvement appears to drive more accurate assessments of metastatic spread, which in turn informs more appropriate treatment selection.
As PSMA-PET/CT becomes more integrated into international guidelines, professional bodies like the European Association of Urology and the Society of Nuclear Medicine and Molecular Imaging are recommending its use for primary staging in men with advanced disease. The Danish study is noted as the first prospective analysis to specifically evaluate stage migration and the clinical consequences of replacing NaF-PET/CT with PSMA-PET/CT in this setting.
Bridging Research and Practice
While the results are compelling, the authors caution that the findings reflect a single-cohort, prospective analysis. Broader validation in diverse patient populations and real-world clinical settings will be important to confirm the reproducibility of stage migration and the downstream impact on long-term outcomes, such as progression-free survival and overall survival. Nonetheless, the demonstrated potential for PSMA-PET/CT to refine staging and treatment planning signals a paradigm shift in prostate cancer management.
Conclusion: A Paradigm Shift in Prostate Cancer Staging
In summary, the Danish study indicates that switching from NaF-PET/CT to PSMA-PET/CT for primary staging in high-risk prostate cancer can alter metastatic classification and subsequent treatment plans in a meaningful subset of patients. As clinicians increasingly adopt PSMA-PET/CT in guidelines and practice, this imaging modality could become a preferred first-line tool for accurate staging and personalized therapy planning.
