Scanning the best options
Differing opinions surround the management of de Novo M1A PSMA-PET scan positive prostate cancer.
De Novo M1A prostate cancer is a condition with many challenges; knowing the right treatment and management path is perhaps the biggest one.
“For this topic, there have been more questions than answers,” said R. Jeffrey Karnes, MD, a urologic oncologist at the Mayo Clinic in Rochester, Minnesota. “There has not been a position statement from the AUA in treating the primary tumor and/or the metastatic sites in de Novo PSAMA-PET scan positive metastatic prostate cancer.”
Those questions and answers will be the topic of conversation at the 2026 AUA Annual Meeting session, Crossfire: Controversies in Urology: Management of de Novo M1A PSMA-PET Scan Positive Prostate Cancer.
Dr. Karnes, who is the director of the session, said treatment for this kind of cancer has changed dramatically over the years.
“For de Novo metastatic prostate cancer, we do know that we should intensify our systemic therapy,” he said. “With metastatic prostate cancer detected on conventional imaging, no longer is single agent/ADT (androgen deprivation therapy) or castration the only therapy advocated. Usually, there is at least doublet therapy with an androgen receptor pathway inhibitor (ARPI) and, at times, triplet therapy by using an ARPI and docetaxel chemotherapy with ADT. Do we need to intensify such therapy when non-regional nodes are detected only on molecular PET imaging and might be ‘nonsuspicious’ on conventional imaging?”
For the session, Dr. Karnes said he will present a case study and ask the presenters to argue for the therapy they believe is the best approach. He said there are multiple ways to diagnose and manage de Novo M1A. Conventional imaging, such as bone scans, CTs and MRIs, has been supported by much of the high-level data to date, but PSMA-PET scans are showing results beyond what traditional imaging can do. He said the increased utility of PSMA-PET imaging has fueled the growth of detection of metastatic sites.
“PSMA-PET finds more metastases than conventional imaging, so there might be cases where conventional imaging is negative (or at least more favorable) than PET staging alone,” he said. “In Europe, which introduced widespread PSMA-PET staging before the U.S., there was a time when their guidelines recommended against making therapy recommendations based on the PET but rather on the conventional images used to stage the disease. That’s not the case anymore.”
In cases where there are few metastases detected by PSMA-PET, Dr. Karnes said the standard has shifted to directly addressing the primary tumor rather than systemically targeting metastases with surgery, radiation or both.
“There’s even a path to addressing the metastases directly with metastasis-directed therapy (MDT), usually in the form of stereotactic body radiation therapy (SBRT), rather than just the drug or systemic therapies,” he said.
Unfortunately, Dr. Karnes said there is much more research needed into these methods to help clinicians choose the best path for their patients.
“There has been a paucity of high-level data on the management of this controversy,” he said. “These, along with ongoing clinical studies, will be discussed during our session.”
