PSMA PET Staging Shifts Initial Prostate Cancer Treatment Patterns in US Veterans

Key Clinical Summary

• Prostate-specific membrane antigen (PSMA) PET staging in the US Veterans Health Administration (VHA) was linked to higher use of androgen deprivation therapy (ADT) and androgen receptor pathway inhibitors (ARPIs).
• Veterans staged with PSMA PET were less likely to undergo radical prostatectomy, with no significant change in radiotherapy use.
• Detection of nodal or metastatic disease on PSMA PET strongly predicted intensified systemic therapy.

Real-world data from the VHA show that PSMA PET/CT staging may be altering initial treatment decisions for veterans with newly diagnosed unfavorable intermediate-, high-, and very-high-risk prostate cancer. Using observational VHA data from 2022 to 2023 to emulate a randomized trial, investigators compared treatment patterns after PSMA PET vs conventional imaging. Their findings suggest meaningful shifts toward systemic therapies and away from surgical intervention.

Study Findings

In this emulated trial of 9049 veterans diagnosed between January 2022 and December 2023, researchers assessed the causal impact of PSMA PET staging—either ^18F or ^68Ga—relative to conventional bone scan plus pelvic CT/MRI. Weighted Cox regression was used to examine the relationship between staging modality and initial treatment selection.

PSMA PET staging was associated with significantly higher use of frontline ADT (adjusted hazard ratio [aHR], 1.26; 95% CI, 1.19-1.44) and ARPIs (aHR, 1.52; 95% CI, 1.33-1.78). Conversely, men staged with PSMA PET were less likely to undergo radical prostatectomy (aHR, 0.69; 95% CI, 0.56-0.83). Radiotherapy use showed no statistically significant difference (aHR, 1.10; 95% CI, 0.99-1.25).

Disease detected on PSMA PET strongly influenced treatment choice. ARPI use was nearly 7 times more common in patients with PSMA N1M0 disease (aHR, 6.87; 95% CI, 5.41-8.73) and 10 times more common in those with M1 disease (aHR, 10.13; 95% CI, 8.16-12.58) compared with no detectable cancer spread to regional lymph nodes (N0) and no distant metastasis (M0) (N0M0) findings. Veterans with nodal involvement were also far less likely to receive prostatectomy.

The authors conclude that PSMA PET may be driving intensified systemic therapy and reduced surgical management across the VHA prostate cancer population.

Clinical Implications

For clinicians serving US veterans, these findings underscore how advanced imaging technologies are reshaping prostate cancer management in everyday practice. PSMA PET’s heightened sensitivity appears to shift patients toward systemic therapy earlier, particularly when occult nodal or metastatic disease is identified, potentially reducing reliance on prostatectomy.

However, whether these treatment shifts ultimately improve outcomes for high-risk veterans remains uncertain. Intensified hormonal therapy carries additional toxicity considerations, especially in older populations with multimorbidity. The study highlights the need for careful patient selection, shared decision-making, and monitoring of treatment-related adverse effects.

As PSMA PET becomes increasingly integrated into standard care pathways, clinicians should remain attentive to how staging results influence therapeutic intensity and downstream resource utilization within veteran populations.

The study team emphasized the broader significance of these findings: “Widespread PSMA PET staging may be driving important shifts in treatment selection, resulting in both intensified systemic therapy and deintensified local surgical therapy,” the authors noted. “Whether these changes result in improved patient outcomes remains uncertain.”

Conclusion

PSMA PET is reshaping initial prostate cancer treatment across the VHA, with increased use of ADT and ARPIs and fewer prostatectomies. Continued research is essential to determine whether these evolving patterns translate to better long-term outcomes for US veterans.

Reference

Miller SR, Chung DH, Gonzalez RT, et al. Impact of PSMA PET staging on initial treatment in newly diagnosed prostate cancer. J Nucl Med. 2025;66(12):1891-1897. doi:10.2967/jnumed.125.270825