Advancements in Prostate Cancer Imaging, Minimally Invasive Approaches Require Cohesive Screening Recommendations to Optimize Patient Outcomes

Significant technological advancements, including prostate-specific membrane antigen (PSMA) PET imaging, focal therapy, and minimally invasive surgical approaches, are dramatically improving disease localization and personalized management for patients with prostate cancer; however, this progress is incongruent with the widespread confusion and misinformation surrounding PSA screening, which is contributing to an increase in advanced prostate cancer diagnoses, according to Paul Gellhaus, MD.

“Prostate cancer is a controversial thing to be screened for…but there have been improvements [in PSA screening] that have made the process better for everybody,” Gellhaus shared in an interview with OncLive® during prostate cancer awareness month. "We're able to not only diagnose prostate cancer better, but have improved our ability to stratify who needs treatment and who doesn't. We [also] need to detect these cancers at a lower stage and a smaller volume so our focal therapies have a better chance of working.”

In the interview, Gellhaus discussed misinformation and confusion surrounding the value of PSA screening in prostate cancer; how PSMA PET imaging has improved prostate cancer detection, allowing for better patient stratification and subsequent decision-making; and exciting developments with focal therapy and other minimally invasive surgical platforms that effectively target tumors while preserving urinary and sexual function.

Gellhaus is a urologic oncologist, the medical director of Robotic Surgery, and an associate clinical professor in the Department of Surgery at City of Hope Cancer Center Phoenix, in Arizona.

OncLive: What are the most pressing unmet needs or gaps in prostate cancer care today, both in early-stage and advanced disease?

Gellhaus: Prostate cancer is a controversial thing to be screened for. There have been a lot of confusing guidelines that have swung the pendulum for screening vs against screening, so there's a lot of confusion out there amongst patients and other physicians, particularly primary care doctors, about what to do. No one wants to add more work to their plate or perform unnecessary diagnostics, like prostate-specific antigen [PSA] screening, if it's not going to help the patient. With this decrease in PSA screening, there has been an increase in advanced cancers presenting late. If we're not catching things early, they will progress into a later stage.

What could be done to help combat this misinformation about PSA screening and establish a consensus for its evolving use?

One of the biggest shortcomings has been just the misinformation about the value of PSA, the value of prostate cancer screening, including PSA. There are some technological improvements that have made the process better for everybody. We're able to not only diagnose prostate cancer better, but we've also learned and improved our ability to stratify who needs treatment and who doesn't. There was a US task force that made a Class D recommendation [against] prostate cancer screening [in 2012].1,2That has since changed [to a Class C recommendation in 2018], but it [led to] some of this misunderstanding of the value of PSA, and that is in disagreement with most cancer organizations and the American Urological Association.2 [We need to] get together more and [ensure our screening recommendations are] more in line with data-proven recommendations. That could [allow us to] be more cohesive [in our messaging], which is more helpful to patients.

How has the integration of PSMA PET imaging into clinical practice changed the way that clinicians diagnose and treat patients, particularly those with biochemically recurrent disease?

PSMA PET imaging has improved our ability to locate prostate cancers in 2 different settings. One is the pre-treatment setting, where patients potentially have options of surgery or radiation. If they are diagnosed with metastatic disease, those interventions are not curative. [Adjusting] what we do—e.g. favoring radiation over surgery—depending on the person and the clinical data [available] matters in those settings.

The other setting [includes] patients who have a biochemical recurrence after treatment, such as surgery or radiation. PSMA PET can localize disease; that can [inform treatment] and hopefully [help] prolong survival. Conversely, if someone has more disseminated disease, [we can] focus [treatment] more on systemic therapies instead of localized therapies.

What factors do you consider when recommending surgery for patients across different disease stages?

I'm a surgeon, so I am biased toward surgery, but the general trend in practice [is to recommend surgery to men] who are 60 [years of age] and younger. We tend to favor surgery because it is not only generally safer for someone in a younger age group, but they'll recover better from a urinary and sexual function standpoint. They tend to [have better fitness] pre-treatment, and so they have a greater chance of being better post-treatment. As far as urinary control, the neuromuscular pelvic floor is just stronger and more facile [in someone younger] than someone older who has less muscle mass and less ability to control their pelvic floor.

Then we can consider more individual factors. For example, if someone in their 70s, for whom radiation would generally make sense, has really bothersome voiding symptoms, [we may not recommend this course of treatment]. [Their symptoms are] likely going to get worse after radiation because of the irritative effect, and then it is really tricky to treat. The treatments that we have for patients without radiation who are having these symptoms just don't work as well, and it can really lead to a significant loss of quality of life with that treatment. [This is a patient for whom] we would potentially favor doing surgery. Although they may leak urine more, they'll [experience] less irritative voiding symptoms or difficulties with urination due to an enlarged prostate, etc.

Then there are 60 year olds who might think that surgery sounds great, but they have a medical comorbidity that makes it unreasonable or unsafe. For example, they [may] have heart problems where a perioperative myocardial infarction could happen, or they have a clotting risk factor where holding blood-thinning medicines during that perioperative period means the risk for clotting [is no longer] worth the [risk with] surgery if there's an equally efficacious non-surgical option, like radiation.

What are some of the advantages vs limitations of focal therapy for prostate cancer, and how could this technology be further improved?

Focal therapy is a very exciting field, because we get to treat the cancer and not have to have all the adverse effects of surgery or whole-gland radiation. Focal therapy is very interesting, [especially in terms of] how we do it—which energy source we use, whether we're freezing, we're burning, we're doing electroporation, where we lyse cells using a strong magnet, etc. There's light therapy that has been [in development]. There's even surgery to partially remove the gland, which is all very exciting.

The limitation, though, is that prostate cancer is sometimes multifocal. Some of that multifocality is not clinically significant because it's lower-grade disease, but it does cloud the picture. Additionally, the imaging is discrepant from what is seen in the pathology, the histopathology. That is a challenge for us; [we have] to use MRI and then hope we get the cancer based on imaging guidance when the biology is a little bit different than what we expect in the geometry of the prostate.

As imaging techniques improve, PSMA and MRI could be the right combination for us to be more accurate diagnostically. That way, we can be more accurate when we deliver some form of therapy to do a focal removal or ablation of the tissue. When we do surgery, we forever change the anatomy of the pelvis in a dramatic way, which can result in a loss of urinary sexual function. The more we can do these partial, less invasive maneuvers, the less the patient has to give up to get those benefits. With screening, we need to detect these cancers at a lower stage and a smaller volume so that these focal therapies have a better chance of working. Now, if [the tumor is] more advanced, something like surgery may be required because we need to do more to [entirely] remove the cancerous tissue.

Are there any exciting surgical innovations coming down the pike?

Some of the robotic surgical platforms that are exciting include those that allow single-port use and a transvesical approach. Instead of going through the abdomen or through the anterior abdominal wall in the extraperitoneal space, it goes one step further: it can actually go directly into the bladder and remove the prostate through there.

The morbidity to the patient is very, very low. In fact, I've been told the surgeries are being done through spinal anesthesia, and patients go home the next day—or even the same day—with a catheter for a very short period. This is really exciting, as it is pushing the limits of minimally invasive surgery. We do have to look at the outcomes and [verify that] we are getting negative margins to ensure that patients are benefiting from this more technical approach.

What is the importance of recognizing Prostate Cancer Awareness Month?

Prostate cancer is extremely common. One in 8 or 1 in 6 men, depending on which statistics you look at, will develop prostate cancer.3 It's a disease that touches not only a lot of people, but a lot of people's loved ones. With such a common disease, we need good ways to manage it. We want to make sure we're diagnosing the right people, and then also treating the right people—where we're not overdoing it and causing the burden of repeated unnecessary steps, unnecessary diagnosis, and evaluation alongside treatment.

References

1. Moyer VA; U.S. Preventive Services Task Force . Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157(2):120-134. doi: 10.7326/0003-4819-157-2-201207170-00459
2. Burgess L, Aldrighetti CM, Ghosh A, et al. Association of the USPSTF Grade D Recommendation Against Prostate-Specific Antigen Screening With Prostate Cancer-Specific Mortality. JAMA Netw Open. 2022;5(5):e2211869. doi:10.1001/jamanetworkopen.2022.11869
3. Key Statistics for Prostate Cancer. American Cancer Society. Updated May 30, 2025. Accessed September 23, 2025. https://www.cancer.org/cancer/types/prostate-cancer/about/key-statistics.html