Patterns of Care after Ga-68-PSMA-PET in Patients with Radiorecurrent Localized Only Prostate Cancer

Purpose/Objective(s)Utilization of molecular imaging in men with recurrent prostate cancer after definitive treatment is rapidly increasing. However, randomized data to guide preferred treatment approaches after molecular imaging are lacking, particularly for men with radiorecurrent, localized-only disease. We sought to evaluate patterns of care in these men, in order to understand the referral patterns and care plans implemented as a result of molecular imaging.Materials/MethodsFrom 2018-2020, 822 men were enrolled at a single institution on a prospective study (NCT03396874) assessing the diagnostic performance of 68Ga-PSMA-11 PET (PSMA) in men with biochemical recurrence after initial definitive therapy. Among the 196 (24%) treated with upfront definitive radiation therapy (RT), 58 had an isolated local recurrence and form the cohort for the present analysis. We evaluated the patterns of care including specialty of ordering provider, patterns of consulted specialties after PSMA, and subsequent management.ResultsFifty-eight men had PSMA positive radiorecurrent localized-only disease (n=58/196, 30%). PSMA for these men was most ordered by medical oncology (38%), urology (36%), and radiation oncology (24%). Median PSA at time of PSMA was 4.6 ng/mL. Median interval between initial RT and PSMA was 9 years. After PSMA, 101 consultations were completed, 40 urology (40%), 33 radiation oncology (32%), and 28 medical oncology (28%). Twenty-one percent of men saw all three specialties (n=12), 38% two (n=22), and 41% one (n=24). Thirty-nine men (67%) underwent prostate MRI, and 35 (60%) had a prostate biopsy. In total, 26 men (45%) underwent local therapy, which included salvage RT in 14 men (54%) [brachytherapy (n=9), SBRT (n=5)], cryotherapy/HIFU in 11 men (42%), and salvage prostatectomy for one (4%). Among the 28 patients (48%) not undergoing local therapy, 32% (n=9) were poor local therapy candidates due to poor GU/GI quality of life or prior focal therapy and received systemic therapy alone. Approximately one-third of patients underwent observation (n=19), driven frequently by patient preference rather than local therapy eligibility or age-related comorbidities (n=12/19). Patient management and treatment varied by the specialty ordering the PSMA and subsequent referral patterns.ConclusionOur data demonstrate significant heterogeneity in the management of patients with PSMA radiorecurrent localized-only prostate cancer. Treatment varied by ordering physician specialty and subsequent referral patterns after PSMA. As molecular imaging becomes more ubiquitous, our data demonstrate the need for multidisciplinary discussion as well as randomized trials in these patients to help guide the optimal treatment approach for this population.