The PSMA-PET Conundrum: A Survey of UK Prostate Cancer Surgeons and Their Use of PSMA-PET Prior to Radical Prostatectomy

Prostate-specific membrane antigen-positron emission tomography (PSMA-PET) has significantly improved sensitivity and specificity for detecting metastatic disease in prostate cancer compared to traditional computed tomography and bone scans. It is now recommended by the European Association of Urology for staging intermediate and high-risk disease, however, there are no recommendations on its incorporation into practice due to lack of long-term survival data. We aimed to identify the current use of PSMA-PET in high-volume prostate cancer centres to see whether there is standardisation in its use and interpretation prior to robotic-assisted laparoscopic prostatectomy (RALP). An anonymised SurveyMonkey® was sent to multiple high-volume surgeons across the United States (UK), with all questions optional. Participants were asked about their personal practices for PSMA-PET staging, for both intermediate and high-risk disease, and how it would change their management if considering RALP. Thirty-one participants responded across 17 different UK centres. 11/31 (35%) used PSMA-PET a lone as primary staging for high-risk prostate cancer, with 6/30 (20%) using it for intermediate staging as well. Of the 23 surgeons that routinely perform lymph node dissection (LND) in high-risk cases, 13/23 (57%) would obviate performing it if the PSMA was negative. If a patient was found to have positive nodes on PSMA-PET, 12/31 (39%) surgeons will still offer RALP. Individual answers also varied within same centres. The current interpretation of PSMA-PET for staging and treatment before RALP varies widely amongst surgeons, particularly regarding LND. A national consensus statement is needed to help standardise treatment practice for patients until robust long-term survival data exists.