PSMA PET has fundamentally changed the way we stage prostate cancer. However, staging systems and risk stratification schemes are slow to catch up. Here, investigators leveraged the global PROMISE PET registry (n=11,154) to build PPP3, a PSMA-PET based risk stratification system predicting 3, 5, and 7 year OS across the prostate cancer spectrum. It integrates clinical disease group with PROMISE imaging metrics (metastatic pattern (M1a/b/c), tumor burden (lesion count or volume), and PSMA expression). Discrimination was strong (c-index 0.83–0.84) and held up in external validation. In head-to-head comparisons, PPP3 matched the STARCAP score at initial staging and the GAFITA nomogram in mCRPC, but outperformed EAU risk stratification in biochemical recurrence and NCCN risk groups overall (AUC 0.84 vs 0.77). A simplified table reproduced the nomogram’s performance with minimal misclassification (~4%), suggesting a clinic-friendly alternative to calculator-heavy models. | Karpinski, Lancet Oncol 2026
