<p>The use of prostate-specific membrane antigen positron emission tomography (PSMA PET) scanning has burst onto the prostate cancer scene, and there are now multiple commercially available tracers that perform similarly. The results of a PSMA PET scan can play an important role in the initial staging of prostate cancer, and before and after radical prostatectomy.</p>

Between the pre–radical prostatectomy, post–radical prostatectomy, and newly diagnosed workup settings, the demand for PSMA PET scanning has exceeded the supply, at least at my center at Duke. Many hospital nuclear medicine departments are on the smaller side and may have limited staff. So, sadly, it sometimes can take several weeks or longer to get a patient on the schedule for a PSMA PET scan because it is in such high demand.

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PSMA PET is extremely useful in patients with newly diagnosed prostate cancer and higher-risk features. In these patients, you can perform a PSMA PET scan to replace the traditional bone and computed tomography scans with greater accuracy. The area in which I personally use PSMA PET most often is the post–radical prostatectomy setting. I think that it is really useful when I am working up a patient with rising prostate-specific antigen levels following radical prostatectomy. Some people want to use preoperative PSMA PET scanning to help determine who should receive a nerve-sparing surgery, but, in my experience, I do not think that we have a high enough degree of accuracy yet with PSMA PET to recommend its use for surgery planning. However, it is useful for planning pelvic node resections.

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In high-risk prostate cancer, where the cancer may be outside the confines of the prostate, the PSMA PET scan can help detect metastasis in the pelvis, which can change treatment. As a surgeon, I think about whether I can really be of benefit to a patient if he has disease outside the prostate. Radiation therapy can often expand the field and may be more appropriate for treating locally advanced disease found on a PET scan, especially in older patients who may not be ideal candidates for surgery. I often still perform radical prostatectomies in younger patients, particularly in those who are very young, even if the PET scan shows some activity outside the prostate. The thinking is that younger patients might benefit from getting the majority of their cancer out, and then you can consolidate their therapy with radiation and hormone therapy.