A new study led by researchers at the UCLA Health Jonsson Comprehensive Cancer Center has found that many cases of high-risk nonmetastatic hormone-sensitive prostate cancer may be more advanced than previously thought.
The study, published in JAMA Network Open, found that nearly half of high-risk prostate cancer patients previously classified as nonmetastatic by conventional imaging actually have metastatic disease when evaluated with advanced prostate-specific membrane antigen–positron emission tomography (PSMA-PET) imaging, suggesting that traditional imaging may underestimate how far the cancer has spread in many cases.
To better understand the advantages of PSMA-PET over conventional imaging, researchers conducted a post hoc, retrospective cross-sectional study using data from 182 patients with high-risk recurrent prostate cancers who were thought to have disease limited to the prostate and were eligible for the EMBARK trial.
This clinical trial previously demonstrated that adding enzalutamide, a type of hormone therapy, to androgen deprivation therapy significantly improves metastasis-free survival. However, the trial relied on conventional imaging to classify patients, which researchers believe might have underestimated the disease’s extent in some cases.
In the cohort of patients, the researchers found PSMA-PET detected cancer metastases in 46% of patients, even though traditional imaging had suggested no evidence of cancer spread. Based on PSMA-PET, 24% of the patients even showed 5 or more lesions that had been missed by conventional imaging.
“We anticipated that PSMA-PET would detect more suspicious findings compared to conventional imaging. However, it was informative to uncover such a high number of metastatic findings in a well-defined cohort of patients resembling the EMBARK trial population that was supposed to only include those without metastases,” said Dr. Adrien Holzgreve, a visiting assistant professor at the David Geffen School of Medicine and first author of the study.
These results challenge the interpretation of previous studies, like the EMBARK trial, and support the inclusion of PSMA-PET for patient selection in clinical and trial interventions in prostate cancer in future major industry-sponsored clinical trials. It also highlights the need to reevaluate treatment strategies and opens the door to potentially curative options for some patients, such as targeted radiotherapy, while raising important questions about integrating new imaging technologies into standard care.
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