PSMA PET and the Evolving Imaging Landscape in Prostate Cancer

Oliver Sartor, MD, director of the Transformational Prostate Cancer Research Center at East Jefferson General Hospital in Metairie, Louisiana, opens by reinforcing when radium-223 remains the right choice: for patients with osteoblastic bone-only metastatic disease, it should still be actively considered. He shares that he prescribed it in exactly this scenario just the prior month, underscoring its continued clinical relevance even as newer radiopharmaceuticals emerge. The combination with an ARPI, supported by the PEACE III data, is likely appropriate in eligible patients, though further study is needed.
The 2026 guidelines also included imaging updates, and Sartor makes a definitive statement: PSMA-PET has become an indispensable tool in prostate cancer care. The updated guidelines expand its use to include not only initial staging of unfavorable intermediate-risk and higher-risk patients but also biochemical recurrence scenarios—including second biochemical recurrence, which is addressed in a newly added section. PSMA-PET is now essential across multiple decision points: defining oligometastatic disease for stereotactic body radiation therapy (SBRT) or metastasis-directed therapy, selecting patients for PSMA-targeted radioligand therapy, and more accurately staging high-risk disease at diagnosis.
Sartor closes by reinforcing that better molecular imaging, broader implementation of genomic testing, and more precise use of isotopic therapies and SBRT represent the convergent evolutionary forces shaping prostate cancer care today. These are not isolated updates—they are interconnected advances that together define a new standard of precision oncology in prostate cancer.