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

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.