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. 2025 Jul 8.
doi: 10.1007/s00259-025-07431-8. Online ahead of print.

Increased incidence of primary metastatic prostate cancer in the era of PSMA PET/CT: a population-based analysis

B L Heesterman  1 , M Peters  2   3 , D E Oprea-Lager  4 , A J A T Braat  5   6 , I G Schoots  7   8 , C C Loeff  9   4 , P J van Leeuwen  10 , R C N van den Bergh  11 , D A Palma  12 , K K H Aben  9   13 , W S C Eppinga  2
Affiliations

Increased incidence of primary metastatic prostate cancer in the era of PSMA PET/CT: a population-based analysis

B L Heesterman et al. Eur J Nucl Med Mol Imaging. .

Abstract

Purpose: To evaluate the effects of prostate-specific membrane antigen (PSMA) PET/CT use for primary staging on nationwide stage-specific prostate cancer (PCa) incidence rates and treatment patterns.

Methods: For this population-based cohort study, all men diagnosed with PCa in the Netherlands from 2010 to 2023 were identified in the Netherlands Cancer Registry. Year of diagnosis was used as proxy measure for PSMA PET/CT availability and use for primary staging. Overall and stage-specific European age-standardized incidence rates (ESR) and estimated annual percentages change (EAPC) were calculated. Among patients with ≥ 1 high-risk feature, logistic regression was performed to assess the association between year of diagnosis and detection of pelvic lymph node and/or distant metastases. Exploratory analyses were conducted to assess changes in treatment.

Results: From 2010 to 2023, the ESR of PCa declined slightly (EAPC=-0.2%, p = 0.64). Meanwhile, the ESR of pelvic node-positive only and distant metastatic PCa increased (EAPC = 4.6% [p < 0.001] and 4.1% [p < 0.001]). Patients with ≥ 1 high-risk feature were more often diagnosed with pelvic lymph node and/or distant metastases in the years with increasing (OR = 1.33) and widespread (OR = 1.65) access compared to the period with limited access to PSMA PET/CT for primary staging. Meanwhile, the proportion of patients that received systemic therapy increased from 38.7 to 42.0% (OR = 1.15).

Conclusion: The implementation of PSMA PET/CT in clinical practice, appears to be associated with a substantial stage shift towards pelvic node-positive and distant metastatic PCa. Exploratory analyses also suggest more frequent treatment with palliative, rather than curative intent. Further research is needed to evaluate effects on clinical outcomes.

Keywords: Incidence; Metastases; PSMA PET/CT; Primary staging; Prostate cancer.

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Conflict of interest statement

Declarations. Ethics approval: According to Dutch law, approval of an institutional ethics committee was not required. This study was approved by the Privacy Review Board of the NCR (K20.314/25-00998). Competing interests : The authors have no relevant financial interests to disclose. D.E. Oprea-Lager is chair of the PSMA Forum NL Foundation.

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