“Prostate cancer is unique in that not everyone with a diagnosis needs treatment, and active surveillance is the preferred option for some.”^[i] Thirty years ago, this would have been a radical idea!

Since the introduction of the PSA blood test to screen for PCa, our understanding of localized PCa has advanced rapidly in the following areas:

• Identifying diversity in PCa cell lines and how they behave differently
• Knowledge of how PCa evades the immune system
• Development of multiparametric MRI (mpMRI)
• Earlier detection and diagnosis
• Improved treatment methods, including focal therapy for qualified patients

One specific advance has influenced treatment decision-making: the distinction between clinically significant vs insignificant PCa. Clinically significant PCa is defined as needing immediate treatment, whereas insignificant PCa may be safely monitored—maybe even permanently if it doesn’t progress.

Thus, a dramatic evolution is occurring. Patients diagnosed with low risk insignificant PCa are increasingly recommended to go on Active Surveillance (AS), particularly if their life expectancy is greater than 10 years. AS involves adherence to a monitoring program as prescribed by the doctor. It includes prescribed intervals of PSA tests, multiparametric MRI (mpMRI), and needle biopsy (either triggered by a change in PSA/mpMRI, or per schedule).

Patients who are unlikely to comply with the program, or those who psychologically aren’t comfortable with the thought of untreated cancer in their body, are not good candidates for AS even if all clinical features are favorable. In addition, as many as one third go off of AS not because of disease progression but due to anxiety/fear or simply a preference for active treatment.

Doubling up on imaging

Perhaps more AS patients would continue on it if they had greater confidence that imaging would detect early progression to clinically significant PCa, suggesting it’s time to consider active treatment. A poster at the 26^th Congress of the Society of Urologic Oncology (SUO) presented results of a study on combined mpMRI with PSMA-PET (prostate specific membrane antigen – positron emission tomography) scan. For this study, the PSMA-PET radiotracer was PYLARIFY.

The study involved 95 patients who were on AS. Its objective was to determine if combining mpMRI with PSMA-PET improved detection of clinically significant PCa (subsequently proven by biopsy) for men on surveillance. The authors found that the combination had greater sensitivity than mpMRI alone (63% vs 28%, respectively). Sensitivity means correctly identifying clinically significant PCa (true positive) which helps eliminate false positives. Here, 18% of patients with false positives could have avoided a biopsy.

The saying that “two heads are better than one” seems to apply in this case. With both imaging methods together, mpMRI + PSMA-PET, detecting clinically significant PCa was more accurate than with either one alone. It stands to reason that this would boost confidence for patients on AS who hope to continue on it as long as possible. As the poster concludes, “Incorporating PSMA PET/MRI into clinical practice could refine surveillance protocols and support biopsy omission in select men with negative imaging.”

From another standpoint, however, there are two practical challenges to routinely offering mpMRI plus PSMA-PET: accessibility and healthcare economics.

1. Accessibility: Although there are centers nationwide that have the technology and availability of the radiotracer needed for PSMA-PET scans, they are more concentrated in urban areas. Patients in more remote areas may not be able to afford to travel great distances on a regular basis, even once per year.
2. Healthcare economics: Generally, PSMA-PET is covered by insurance for patients with high risk or metastatic PCa. In such cases, it is considered cost-effective since it can guide intervention at earlier stages for greater long-term cancer control. However, at this time routine use of PSMA-PET during AS for low risk localized PCa is unlikely to be reimbursed outside of a clinical trial.

While combining mpMRI and PSMA-PET for better detection of clinically significant PCa during AS sounds very promising, patients on AS should not get their hopes up that this option will become widely available in the near future.

Nonetheless, at the Sperling Prostate Center we like to update readers with promising news in hopes of a rosier future for PCa patients everywhere.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

References

[i] Chakrabarti D, Albertsen P, Adkins A, Kishan A et al. The contemporary management of prostate cancer. CA Cancer J Clin. 2025 Nov-Dec;75(6):552-586.