Expanding equitable access to care is critical for improving patient outcomes in men with metastatic prostate cancer. Neeraj Agarwal, MD, FASCO, emphasizes the importance of genetic testing and prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT) scanning in gaining access to life-prolonging therapies such as PARP inhibitors and ¹⁷⁷Lu-PSMA-617. He also notes that establishing access prior to radiographic or symptomatic progression is imperative for timely treatment.

Genetic testing for actionable genetic alterations and prompt diagnostic restaging with PSMA PET/CT scans are increasingly important for the timely treatment of metastatic prostate cancer. It is essential that we improve access to currently available life-prolonging treatment options such as PARP inhibitors and ¹⁷⁷Lu-PSMA-617. We should not delay these treatments for our patients.

With regard to genetic testing, we should order somatic and germline testing for patients with metastatic prostate cancer. Germline testing is mostly done using a saliva or peripheral blood sample, while somatic testing is usually done using a tumor tissue sample. These tests should be performed early so that we have the results available whenever a patient progresses on an ARPI, for example. This way, we do not have to scramble at the last minute to get the test results. There are many Clinical Laboratory Improvement Amendments (CLIA)–certified laboratories now, but it can still take up to several weeks to get the results.

Moreover, we should not wait for patients to develop symptomatic or radiographic disease progression before considering a PSMA PET/CT scan. I was recently talking to a community colleague who told me that the nearest PSMA PET/CT scan center is well over 1 hour away from their practice. Now, we are talking about an older patient population that includes people who oftentimes cannot drive themselves and may need significant support from family and friends. Fortunately, accessibility is improving, but many patients still do not have access to a PSMA PET/CT imaging center within 30 minutes of their home.

I like to consider PSMA PET/CT early when a patient with metastatic castration-resistant prostate cancer has a rising prostate-specific antigen on an ARPI, particularly when progression appears likely. This allows us to establish PSMA expression and begin planning for ¹⁷⁷Lu-PSMA-617, when clinically indicated, rather than waiting until the patient develops symptomatic or rapidly progressive disease. ¹⁷⁷Lu-PSMA-617 therapy requires a multidisciplinary approach that involves coordination with nuclear medicine and medical oncology colleagues. All this takes time, and if you are at a urology practice, you have to send the patient somewhere else to administer ¹⁷⁷Lu-PSMA-617. I always advise my colleagues to get referrals in place with medical oncology and nuclear medicine so that the patient is already in the system. If you try to do all this while the patient is experiencing progression, it may not happen in time. The patient may already be experiencing symptoms or have a rapidly rising prostate-specific antigen level, and the wait time for a PSMA PET/CT scan might be 2 weeks, for example. By the time you get the results and you preauthorize ¹⁷⁷Lu-PSMA-617, multiple weeks may have already passed. Many patients cannot wait this long.

For those with rapidly progressive or symptomatic disease who cannot safely wait for ¹⁷⁷Lu-PSMA-617, chemotherapy may need to be considered. However, many patients prefer to avoid or delay chemotherapy, further emphasizing the importance of anticipating the logistics of PSMA-targeted radioligand therapy.