A multidisciplinary approach to managing non-metastatic castration resistant prostate cancer: Insights from a...

Non-metastatic castration-resistant prostate cancer (nmCRPC) progresses despite androgen-deprivation therapy (ADT) however metastases remain undetectable on conventional imaging. PSMA PET/CT may enable earlier metastasis detection, but its clinical use remains limited. This study assessed the alignment of French clinical practices with nmCRPC management guidelines.

A two-part survey was conducted among 61 healthcare professionals, including urologists, oncologists, and radiation oncologists, to assess their imaging and treatment approaches for nmCRPC. The survey explored diagnostic imaging strategies, treatment decisions, and responses to two clinical case scenarios reflecting different PSA doubling times.

Results showed variation, with 65% of respondents initiating enzalutamide only after conventional imaging confirmed metastases, while 57% would do so after molecular imaging detection. PSMA PET/CT was used by 41% for patients with a 6-month PSA doubling time. Treatment decisions were influenced by both imaging modality and PSA kinetics. In clinical case 1 (6-month PSA doubling time), 41% chose TAP CT or bone scan as initial imaging, 35% used [18 F] fluorocholine/[18 F] fluciclovine PET/CT, and 24% used PSMA PET/CT. In clinical case 2 (12-month PSA doubling time), 66% ordered imaging, while 29% favored monitoring without imaging. Imaging delays varied from 3 to 4 weeks, reflecting regional disparities in access.

This study highlights variability between guideline recommendations and clinical practice in nmCRPC management in France. Although PSMA PET/CT is crucial for detecting metastases, its cost and accessibility remain suboptimal and require further improvement, despite recent advancements. Clearer guidelines and improved training are needed to reduce inconsistencies and avoid loss of therapeutic opportunity for patients.

6 as per Melnyk and Fineout-Overholt 2023.