Real-world use of PSMA imaging in metastatic castration-sensitive prostate cancer: Findings from the CAPRI-3 registry

Since 2019, EAU guidelines recommend PSMA-PET/CT for staging high-risk prostate cancer. However, real-world data on its uptake and association with disease characteristics and outcomes in metastatic castration-sensitive prostate cancer (mCSPC) remains limited. We evaluated real-world PSMA-PET/CT use versus conventional imaging (CI).

This retrospective study included 3,644 mCSPC patients (2016-2021) from 19 hospitals in the Dutch CAPRI-3 registry. Staging within 90 days of diagnosis was classified as CI-only (CT, bone scintigraphy, and/or MRI) or PSMA-PET (± CI).

Most patients were staged with CI-only (63%), but PSMA-PET use rose from 8% in 2016 to 62% in 2021. PSMA-PET-staged patients were younger (72 vs. 76 years) and had significantly lower tumour burden (27% vs. 45% high-volume), more nodal-only disease, and were more likely to have metachronous presentation (29% vs. 22%, all P < 0.001). In the PSMA-PET group, 42% received ADT plus targeted therapy and 23% ADT monotherapy (vs. 45% ADT monotherapy in CI-only). Median overall survival was significantly longer in the PSMA-PET cohort (78.3 vs. 40.0 months).

There has been an increasing trend toward the use of PSMA PET/CT for staging mCSPC in recent years, identifying a population with more favourable disease characteristics and a more favourable prognosis. This shift in patient characteristics, driven by stage migration (the Will Rogers phenomenon), influences clinical management by enabling more refined patient selection for conservative or targeted therapies. Consequently, accounting for lead-time and selection bias is essential when comparing survival outcomes in the PSMA PET/CT era.