key papersKey paper

Appropriate use criteria for prostate-specific membrane antigen (PSMA) PET imaging

A panel of cancer and imaging specialists agreed, scenario by scenario, when a PSMA PET scan for prostate cancer is a good idea and when it usually is not - a reference clinicians and insurers use to decide who should get the scan.

Following FDA approval of the first PSMA PET tracers (68Ga-PSMA-11 and 18F-DCFPyL) in 2020-2021, SNMMI convened a multidisciplinary panel - with the American College of Nuclear Medicine, American Urological Association, ANZSNM, ASCO, EANM and American College of Physicians - to produce appropriate use criteria (AUC) for PSMA PET in prostate cancer, using a RAND/UCLA-style consensus process. The panel scored defined clinical scenarios from 1 (rarely appropriate) to 9 (appropriate).

PSMA PET was rated appropriate (score 8-9) for staging newly diagnosed unfavourable-intermediate, high- or very-high-risk prostate cancer (including when conventional imaging is negative or equivocal), for working up a PSA rise after prostatectomy or radiotherapy (biochemical recurrence), for non-metastatic castration-resistant disease on conventional imaging, and - critically - for confirming eligibility for PSMA-targeted radioligand therapy (score 9). It was rated rarely appropriate (score 2-3) for detecting or characterising the primary tumour in men with suspected but unbiopsied prostate cancer, or in very low/low/favourable-intermediate risk disease.

The document became the reference used by payers and referring clinicians to decide when a PSMA PET scan is billable and clinically justified, and its scenario 11 (eligibility for PSMA radioligand therapy) directly operationalises how VISION- and TheraP-style PET selection criteria are applied in routine practice.

GuidelineChanged practice111 citations

Authors

Jadvar H, Calais J, Fanti S, Feng F, Greene KL, et al.

Published

Journal of Nuclear Medicine, 2022

Full text

doi:10.2967/jnumed.121.263262 PubMed 34531258

Findings

PSMA PET rated appropriate (score 8) for staging newly diagnosed unfavourable-intermediate, high- or very-high-risk prostate cancer.
PSMA PET rated appropriate (score 9) for PSA rise after prostatectomy or radiotherapy (biochemical recurrence) and for confirming eligibility for PSMA-targeted radioligand therapy.
PSMA PET rated rarely appropriate (score 2-3) for detecting intraprostatic tumour in men with suspected but unbiopsied cancer, and for very low/low/favourable-intermediate-risk disease.
Panel included representatives from SNMMI, American College of Nuclear Medicine, American College of Physicians, ASCO, American Urological Association, ANZSNM and EANM.

What it means

This guideline tells doctors and insurers exactly which clinical situations justify a PSMA PET scan for prostate cancer - mainly staging higher-risk disease, investigating a PSA rise after treatment, and checking that a patient's cancer will respond to PSMA radioligand therapy - and which situations do not.

Caveats

Appropriate use criteria reflect expert consensus and the evidence available in 2022; they are updated periodically and score some scenarios only as 'may be appropriate', reflecting genuine uncertainty rather than a firm answer.
Scores were assigned per clinical scenario, not per specific PSMA tracer; the panel treated different PSMA PET agents as broadly equivalent.