Dr. Weeks’ Comment: I have been recommending this test to assess prostate health and many insurance companies try to refuse reimbursement but the trend is positive so do consider this.
PSMA PET: Prostate Cancer Staging Revolution Awaits RCT Data
February 20, 2026
Over the past decade or so, prostate-specific membrane antigen (PSMA) PET/CT has increasingly replaced conventional imaging in men with biochemical recurrence after radical prostatectomy.
PSMA PET/CT is far more sensitive than bone scans and CT, often detecting lesions that the older techniques miss. What’s less clear is how clinicians should act on what they see, and whether tailoring treatment to those findings ultimately improves patients’ outcomes.
Randomized data from the ongoing PSMA SRT trial comparing PSMA PET/CT with conventional imaging could be published later this year. In the meantime, a new single-center study adds to a growing body of observational data supporting PSMA-guided salvage radiotherapy.
The study, published in the Journal of the National Comprehensive Cancer Network, retrospectively analyzed data on 113 men with biochemical recurrence who were treated at the University of California, Los Angeles, between 2016 and 2021. All underwent PSMA PET/CT imaging for restaging and began salvage radiotherapy within 3 months.
With a median follow-up of 5 years — among the longest reported for a PSMA PET — guided radiotherapy cohort — progression-free survival was 48.7%, while freedom from distant progression was 72.4%. Most patients, 82.7%, had not initiated systemic therapy, and overall survival was 97%.
The findings also suggest how PSMA PET/CT staging might be used to guide treatment. “Step by step, little by little, we are learning how to act on this new staging information,” senior investigator Jeremie Calais, MD, PhD, a UCLA nuclear medicine and cancer imaging specialist, told Medscape Medical News.
For instance, among men with disease confined to the prostate bed (TrN0M0), whole-pelvic radiotherapy was associated with improved progression-free survival (adjusted hazard ratio [HR], 0.12; P = .035). Meanwhile, for patients with nodal disease or distant metastases, the addition of androgen deprivation therapy (ADT) was similarly associated with longer progression-free survival (adjusted HR, 0.37; P = .024).
The median prostate-specific antigen (PSA) level for the group was 0.4 ng/mL, and most patients had levels where CT and bone scans would usually be negative, Calais noted.
“PSMA PET nevertheless identified disease in a substantial proportion of men, and in many cases outside the prostate bed,” he said.
The findings suggest that PSMA PET “meaningfully changes staging and that acting on those findings matters clinically,” Calais said.
In an accompanying editorial, Edward Christopher Dee, MD, of Memorial Sloan Kettering Cancer Center, in New York City, and colleagues wrote that the findings align with other PSMA-based series and support more individualized treatment planning.
“Seeing where the cancer is, even at low PSA levels, may meaningfully shape treatment decisions and could potentially influence long-term outcomes,” Dee said in an NCCN press release. “It’s a step forward in making prostate cancer care more precise and effective.”
Still, Dee and his colleagues sounded a note of caution in their editorial. While PSMA-PET/CT provides “unprecedented risk stratification,” they wrote, the impact on patients’ outcomes remains to be proven in randomized trials.
That point was echoed by the new study’s lead investigator, John Nikitas, MD, a radiation oncologist now with the University of Pennsylvania in Philadelphia.
“We all certainly hope that the higher sensitivity for detecting disease leads to better patient outcomes,” he told Medscape Medical News. “We won’t know until we get randomized data.”
UCLA was one of the first US centers to use PSMA PET/CT for patients with recurrent prostate cancer, according to Calais. Men in the current study all underwent imaging using 68Ga-PSMA-11 as a radiotracer (the FDA has since approved additional options).
Overall, PSMA PET/CT staged 40.7% of the patients with no visible disease (T0N0M0),16.8% of those with TrN0M0 disease, 28.3% of those with positive nodes but no metastases, and 14.2% of those with metastases.
Treatment decisions — a mix of radiation to the prostate bed, pelvic nodes, whole pelvis, and/or metastases, with or without ADT — were left up to treating physicians.
The heterogeneity of treatment approaches precluded any firm conclusions, but exploratory analyses suggested that the benefit of treatment intensification depended on specific PSMA PET/CT findings.
Among the findings: In contrast to patients with TrN0M0 recurrences, those with T0N0M0 disease saw no improvement in progression-free survival with whole-pelvic radiotherapy. ADT, meanwhile, was not associated with better progression-free survival among men with TrN0M0 or T0N0M0 disease. For men with N1/M1 disease with a clear prostate bed, prostate bed irradiation was significantly associated with improved progression-free survival (adjusted HR, 0.25; P = .0051).
Dee and his colleagues highlighted some of the open questions going forward, one being the optimal management of patients with PSMA-negative scans.
While 41% of patients in this study had no visible disease, they noted, the cohort still had favorable outcomes with salvage radiotherapy. Whether prostate bed irradiation alone is sufficient for those patients, or whether elective nodal coverage offers additional benefit, is unclear.