Recommendation for NHSScotland

•  Implementing non-FDG PET-CT in Scotland for restaging patients with suspected prostate cancer recurrence has potential cost and infrastructure implications. All the evidence identified on non-FDG PET-CT restaging in prostate cancer patients addressed diagnostic accuracy, therefore no conclusions can be drawn about the effect on treatment decisions or patient outcomes in this population.
• A small number of studies suggest ⁶⁸Ga-PSMA is more accurate in detecting recurrent disease compared with cholines.
• Large, prospective, multicentre studies are necessary to evaluate the cost effectiveness, diagnostic performance, impact on patient management and place in the patient care pathway of new non-FDG tracers (¹⁸F-FACBC or ⁶⁸Ga-PSMA) in PETCT restaging of patients with suspected prostate cancer recurrence.

NHSScotland is required to consider the Scottish Health Technologies Group (SHTG) advice.

What were we asked to look at?

What is the most clinically effective and cost effective non-FDG tracer for use in PET-CT for staging and assessment of patients with suspected recurrent prostate cancer?

Why is this important?

Prostate cancer recurs in up to one in three men who have undergone treatment with curative intent for localised disease. Biochemical recurrence is initially demonstrated by a rise in total serum PSA, often despite normal findings with conventional imaging. Early detection and precise localisation of the site of recurrence is critical in informing further treatment decisions. 
Functional imaging with PET-CT has primarily used 18F-2-fluoro-2-deoxy-D-glucose (FDG) as a radiolabelled tracer for oncological indications. For cancers, such as prostate cancer, where glucose metabolism is low, several non-FDG tracers have been developed. In Scotland choline tracers are currently used in PET-CT restaging of patients with suspected recurrent prostate cancer and there is growing interest in using anti¹⁸F-FACBC or ⁶⁸Ga-PSMA.

Referred by

Scottish PET-CT Working Group