PSMA PET Use Rapidly Expands for Prostate Cancer Staging in US Veterans

Key Clinical Summary

• Prostate-specific membrane antigen (PSMA) PET adoption in the US Veterans Health Administration (VHA) surged from near zero in 2021 to 70% among high-risk prostate cancer cases by 2023.
• Among 31 838 newly diagnosed veterans, 14% underwent PSMA PET staging; positivity rates increased with disease risk.
• Findings support PSMA PET’s value for high-risk prostate cancer while calling for refined criteria in intermediate-risk patients.

Use of PSMA PET imaging for prostate cancer staging has expanded swiftly within the VHA, according to a new analysis published in the Journal of Nuclear Medicine. The study provides real-world data on PSMA PET uptake and positivity rates among newly diagnosed prostate cancer patients in an integrated national system.

Study Findings

Researchers identified 31 838 veterans diagnosed with prostate cancer between June 2020 and August 2023. Of these, 4538 (14%) underwent PSMA PET staging. Utilization increased dramatically—from virtually none in early 2021 to approximately 70% among patients with high- or very-high-risk disease by mid-2023.

The study reviewed 1994 PSMA PET scans, including 657 from patients with low to intermediate risk disease. Among patients initially staged as N0/M0 on conventional imaging, PSMA PET revealed metastatic (N1 or M1) disease in 5.9% of favorable intermediate-risk cases, 8.2% of unfavorable intermediate-risk cases, 14% of high-risk cases, and 34% of very-high-risk cases.

These data represent the largest cohort to date evaluating real-world PSMA PET staging in US veterans, according to the authors. They noted that positivity rates were lower than 10% among intermediate-risk patients, suggesting selective benefit in this population.

Clinical Implications

PSMA PET has transformed prostate cancer staging by improving detection of locoregional and distant metastases compared with traditional bone scans or CT imaging. Within the VHA, the rapid adoption of PSMA PET underscores clinicians’ recognition of its diagnostic precision.

However, as PSMA PET becomes increasingly available, its use in intermediate-risk disease warrants caution. Low positivity rates in this group may lead to unnecessary imaging, additional costs, and potential overtreatment. These findings highlight the importance of refining patient selection criteria and aligning practice with National Comprehensive Cancer Network (NCCN) guidelines, which currently recommend PSMA PET for unfavorable intermediate- or higher-risk prostate cancer.

For veterans’ care teams, understanding when PSMA PET provides meaningful staging information is key to balancing early detection benefits with judicious resource utilization.

Conclusion

PSMA PET imaging has quickly become a cornerstone of prostate cancer staging in the US veteran population. While highly effective for detecting advanced disease, future research should focus on optimizing its use in intermediate-risk cases to ensure precision and value-based care.

Reference

Miller SR, Gonzales RT, Jackson WC, et al. Rates of PSMA PET staging and positivity in newly diagnosed prostate cancer in a national health care system. J Nucl Med. 2025;66(1):75-83. doi:10.2967/jnumed.124.268555