You are right: SAFOV is old technology. And you are right too on initial costs.
A few thoughts;
COST: Here are 3 scenarios
Group A: Brand new centre that needs a new PET scanner. IMO, they are better off with a LAFOV if they can afford it!
Group B: An active centre whose scanner is close to its End of Life. I think they are better off with a LAFOV if they can afford it!
Group C: An active centre whose scanner still has plenty of life left, and are not actively looking for a replacement. Until the time, need or desire for a machine upgrade comes, these folks may just change tracer and use 64Cu-SAR-bisPSMA to achieve better performance than before. When t
(If the results from Albert et al are to be replicated in practice)! The improvement gained by changing tracer to 64Cu-SAR-bisPSMA could potentially be even better than those using a LAFOV paired with the Pylarify (Lantheus) or Illuccix (Telix) tracer, on 2 minute scans.
IMPROVED PATIENT THROUGH-PUT: I still have some questions!
The average scan time on the old tech (SAFOV) is 16 minutes.
As per Albert et al, a LAFOV + SOC tracer (current SOC) can achieve the same SAFOV + SOC tracer level of performance in under 2 minutes (1.5minutes for 18F-FDG tracer): 10X is a huge advantage for sure!
But, to get the best quality image on the same LAFOV using the SOC tracers is 10 minutes (not 2 minutes)! If that was adopted, it would reduce the advantage to less than 2X! In this (Albert) study, this increased time (of 10 minutes) did not seem to lead to better lesion detection though - so maybe the under 2 minutes time will remain for now!
But - if SAFOV paired with 64Cu-SAR-bisPSMA picks up so many more lesions, to the point of influencing clinical decisions, how will a 2 minute LAFOV + current SOC survive, if its performance at that time point is only equal to a 16 minute SAFOV!
Hence, how long is the idea of better patient throughput going to be sustained for, if that includes accepting a performance that is inferior to a SAFOV used with a better tracer?
MY BET IS;
LAFOV + 64Cu-SAR-bisPSMA pairing: I see this becoming the best in many ways due to tracer super powers, and those of LAFOV too: the detection of lesions when others can't, and to do this 6 months earlier than the others can, as well as detecting more lesions than others can! LAFOV will add what it adds, but that's a good start for LAFOV! I would leave patient throughput to LAFOV (which it does well). Anything else - a bonus!
SAFOV + 64Cu-SAR-bisPSMA pairing: I see this as the next best situation. I do not think you can out-do a good tracer. The detection of lesions, doing so 6 months early, and improved lesion count, were found using the old technology. But patient throughput will be at SAFOV level - so not fast.
LAFOV + Ga68 /F18 pairing: This is presented in the Albert paper. The images will look better, but the lesion pick up (per that paper) might not improve - especially at 2 minutes. I do not think you can out-do a good tracer! Tracer performance will keep dragging LAFOV down. How far? I don't know.
LAFOV + Ga68 /F18 pairing: This is what we have now - an ok result for today!
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