In prostate cancer, the year 2021 will be remembered as the year of PSMA coming to fruition on both the imaging and therapeutic fronts.
Despite the fact that the promise of the PSMA PET scan has been discussed for some years, in 2021 the FDA has provided broad nationwide approval for PSMA PET imaging1 and the lives of many men with prostate cancer are being impacted in a positive way. PSMA PET has the capacity to improve the accuracy of prostate cancer staging, thereby ensuring that clinicians’ decision-making can be optimized.2,3 There is much work left to do, and clinical validation needs to extend beyond impacts on clinical decision–making and biochemical outcomes. Regardless, the widespread availability of better imaging is a critical step forward for patients and their physicians.
PSMA PET also serves as an imaging-based biomarker for those patients selected for PSMA-targeted radioisotopes. In men with far-advanced, difficult-to-treat, metastatic prostate cancer, PSMA-targeted 177Lu has now been demonstrated to improve survival and health-related quality of life in a large phase III pivotal trial.4 FDA approval of 177Lu-PSMA-617 is anticipated in 2022. Unlike other biomarker-driven therapies, PSMA-targeted radiation will be applicable to the majority of prostate cancers progressive despite prior treatment with a novel hormone and a taxane. Studies are now underway to ascertain if PSMA-targeted radiation can improve outcomes for men with earlier stages of disease. These trials are critical to expand the use of this novel therapeutic class as many men with prostate cancer never receive chemotherapy.
Perhaps it is a pipedream, but maybe one day castration can be replaced (or durations mitigated) by the use of PSMA-targeted therapies.
As our population continues to age, prostate cancer will globally remain an issue for many millions of men over the next several decades. Applying new clinical trial designs dedicated to diminishing the use of castrating therapies and improving quality of life is imperative for the field to move forward. The time to start thinking is now.