Prostate cancer PET tracers
Choline and Fluciclovine PET: — Are They Still Used?
If your doctor or a report has mentioned choline or fluciclovine PET, you may be wondering whether you are being offered an older test when a better one exists. In most cases, PSMA PET has replaced both — but knowing what each tracer does, and why, helps you ask the right questions.
Medically reviewed by Dr. C. Raghavendra Reddy, Medical Oncologist, MBBS (Gold Medal) · DNB · DM (Medical Oncology, Gold Medal) · Last reviewed September 2026
- Largely superseded — PSMA PET has higher sensitivity and specificity for prostate cancer recurrence than either choline or fluciclovine, according to ASCO, NCCN and EAU guidance.
- Not wrong, but often not first choice — Both tracers were once the standard of care and remain valid where PSMA PET is not available.
- Fluciclovine is rarely available in India — Choline PET exists at some major Indian centres but is no longer the recommended first-line scan. PSMA PET is widely available.
- PSMA PET is coordinated through CION — PSMA PET is arranged through CION partner imaging centres for patients referred through a CION oncologist.
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Choline and fluciclovine PET were the main imaging options for prostate cancer recurrence before PSMA PET arrived. Both are now largely replaced in guidelines from ASCO, NCCN and the European Association of Urology. PSMA PET detects cancer sites that neither choline nor fluciclovine reliably finds at low PSA levels.
PET-CT at CION starts from Rs 10,499 — among the lowest published prices in Hyderabad, with no hidden charges. Indicative price, as of September 2026.
How do choline, fluciclovine and PSMA PET compare?
| Feature | Choline PET | Fluciclovine PET | PSMA PET |
|---|---|---|---|
| What it targets | Choline uptake in rapidly dividing cells | Amino acid uptake in cancer cells | PSMA protein expressed on prostate cancer cells |
| Sensitivity at very low PSA | Limited — often misses disease below certain PSA levels | Better than choline, but still limited at very low PSA | Higher than both choline and fluciclovine, including at low PSA levels |
| Current guideline status | No longer recommended first-line by ASCO, NCCN or EAU | No longer recommended first-line by ASCO, NCCN or EAU | Recommended first-line for recurrent prostate cancer by ASCO, NCCN and EAU |
| Availability in India | Limited; some major academic centres only | Rarely available in India | Widely available, including through CION partner imaging centres |
| Indicative cost in India | Varies; not widely offered | Not widely available in India | Indicative ₹23,999 through CION partner centres (subject to change) |
Are choline and fluciclovine PET still used?
Both scans are still used in some parts of the world — mostly where PSMA PET is not yet available or where protocols have not yet been updated.
Fluciclovine (also known by the brand name Axumin) was FDA-approved in the United States in 2016 and was widely adopted there. Head-to-head studies subsequently showed that PSMA PET detects more cancer sites at the same or lower PSA levels, and guidelines in the US, Europe and India now reflect that finding.
Choline PET has an even longer history and was the standard in Europe for over a decade. It is now rarely recommended for new patients when PSMA PET is accessible.
If you have been referred for a choline or fluciclovine scan, it is reasonable to ask your oncologist whether PSMA PET is available in your situation and, if not, why.
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What do these terms mean?
- Choline
- A naturally occurring nutrient that cancer cells absorb rapidly. Radioactive choline is injected before the PET scan so the camera can locate where cells are most active. C-11 choline uses a short-lived isotope that requires an on-site cyclotron; F-18 choline is more stable and easier to transport to smaller centres.
- Fluciclovine (Axumin)
- A synthetic amino acid labelled with fluorine-18. Cancer cells absorb it through amino acid transporters. It was developed specifically for prostate cancer recurrence and was the most sensitive approved tracer in common use before PSMA PET became widely available.
- PSMA
- Prostate-Specific Membrane Antigen — a protein that sits on the surface of most prostate cancer cells. PSMA PET uses a radioactive molecule that binds directly to this protein, which is why it is more specific to prostate cancer than either choline or fluciclovine.
- Biochemical recurrence
- A rise in PSA blood levels after treatment — surgery or radiation — with no cancer visible on conventional CT or bone scans. This is the clinical situation in which choline, fluciclovine and PSMA PET have been most extensively compared.
What does this mean for you?
If your oncologist recommends PSMA PET, that is consistent with current international guidance. If you have been offered choline or fluciclovine instead, it may be because PSMA PET is not available at your local centre, or because your specific situation calls for a different approach — and your oncologist can explain which.
Ask directly: which tracer is recommended for my situation, and if it is not PSMA PET, is there a reason specific to my case? That question has a short, clear answer.
CION coordinates PSMA PET through partner imaging centres for patients referred by a CION oncologist. Choline and fluciclovine PET are not part of the CION imaging pathway.
CION does PET-CT in Hyderabad from Rs 10,499 — among the lowest published prices in the city — including an oncologist-reviewed report and a free Rs 950 consultation. Indicative price, as of September 2026.
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Common questions
Frequently asked questions
Why did doctors use choline and fluciclovine if PSMA PET is better?
PSMA PET was not available when choline and fluciclovine were developed. Choline PET was the best available tracer in Europe for over a decade, and fluciclovine was developed as an improvement on it. PSMA-targeted tracers reached wide clinical use later, and the head-to-head evidence comparing them accumulated over several years. Guidelines follow that evidence, and they have now shifted. This is the normal pace of progress in nuclear medicine, not a failure of care at the time.
Can PSMA PET miss prostate cancer that choline PET would find?
In a very small proportion of prostate cancers that do not express PSMA strongly, this is theoretically possible. In practice, PSMA PET detects considerably more disease overall than either choline or fluciclovine, across a broader range of PSA levels. Current guidance from ASCO, NCCN and the European Association of Urology is clear about the preference. If your oncologist has a specific reason to consider a different tracer in your case, they will explain it.
Is fluciclovine available in India?
Fluciclovine is not widely available in India. It was developed and approved primarily for the United States market, and distributing F-18 radiopharmaceuticals requires centres close to a cyclotron production site. Most major Indian cities now have access to Ga-68 PSMA or F-18 PSMA PET, which is the preferred test. The absence of fluciclovine is not a meaningful gap for most patients in India.
My PET report from two years ago mentions choline. Does that mean the scan was wrong?
No. Choline PET was the appropriate, guideline-concordant test when it was performed — it was not wrong, it was the best available option at that time. What has changed is that subsequent evidence showed PSMA PET to be more sensitive, and guidelines were updated accordingly. If you are now being restaged or assessed for recurrence, your oncologist may recommend PSMA PET for the new scan rather than repeating choline PET.
Does PSMA PET cost more than choline or fluciclovine PET?
In India, PSMA PET is the standard prostate-specific tracer in use, and its indicative cost through CION partner imaging centres is ₹23,999. This figure is subject to change and your team will confirm the current amount at the time of referral. Choline PET costs vary by centre. Fluciclovine is not listed because it is not part of the standard imaging pathway in India.
Will my health insurance cover PSMA PET?
Coverage varies considerably between insurers, policies, and the specific clinical indication. Some policies cover PSMA PET for prostate cancer recurrence; others require pre-authorisation or do not cover it at all. Check with your insurer before the scan is booked, and ask your oncology team for a clinical justification letter, which most insurers require. The CION billing team can advise on the documentation typically needed.