How do you approach imaging in patients with M0 castration-resistant prostate cancer with rising PSA on an ARSI?

I do not use molecular imaging (e.g., PSMA-PET/CT) for patients with CRPC (including both mCRPC and nmCRPC) except as a screening tool for Pluvicto eligibility for three reasons.

1. Most patients have metastasis already. In one study that used molecular imaging in patients with nmCRPC, they identified metastasis in almost all patients. Half of them had M1 disease whereas the others had regional nodal metastasis only (Fendler et al., PMID 31511295).
2. Unlikely to have long-term benefit from a change in treatment. The optimal value of molecular imaging is to select for metastasis directed therapy. Even for those patients with nodal only metastasis, I suspect that metastasis directed therapy will have limited to no benefit. In contrast, we do see ...