Summary; this is an excellent vehicle with which to learn wherein 3 case studies are revealed to a panel of doctors from different backgrounds. The cases are exposed over their respective timeframes revealing initial diagnosis, then proceeding to how each patient was treated. Meanwhile the panel makes its own diagnosis and prescribes treatment regimes, not knowing how the patient was actually treated! What is developed is a plethora of knowledge, treatment options and testing regimes, some of which I have not heard of. Of extra interest are the criteria established for different types of PCa treatments, testing and care…
Of unique interest to me were the following medical terms, conditions and testing which I would have done, or which I plan to do, based on this podcast;
a. Min 6:35 and 23:30; Benign Margins – who knew? Doctors should report and map margins where prostate gland material was left behind, i.e., nerve sparing procedures. I have always wondered if my low PSA count, post RP, was due to prostate cells left behind…I had bladder neck invasion so my surgery was not able to remove ‘margin’ from my prostate base (upper part of gland).
b. Min 15:45; PSA doubling time – how, when and under what conditions should PSA measurements be used to calculate PSADT…key to knowing the rate your PCa is progressing (affects PCSM mortality).
c. Min 16:54; 3D PSMA PET testing – debate that PSMA PET should be denied once a patient refuses sRT…bull is what I say! Get scans early and as often as you think you need to find MET when it starts, not when its established in multiple locations (see Min 31:42 for a counter discussion)…cost should not be an issue.
d. Min 26:48, 30:32 and 42:00; distant metastasis at different PSA values – PSMA PET is rewriting and scrambling the SOC regimes…doctors really don’t know how and when to use this test. This panel admitted that PSMA PET’s are only now revealing "how much we don’t know about PCa!" Finally, current SOC is all based on traditional Bone/ CT Scans…read this over again a couple of times. My read is that PSMA PET should be used earlier, more often and as many times as needed, than is now considered. Cost should be the last consideration in treatment…again, if you hear engine knocking in your car why wait for flames and smoke to reveal where the problem is…get it diagnosed and looked at now!
e. Min 44:32 thru 46:52; genomics versus germ line testing – very good explanation of what both are…I have not had germ line testing, even though I should have…my Father had PCa, my Grandfather had it…so I need to know if I carry the gene, what genes I carry and how those affect my family and future treatment regime.
A very good discussion and method of presentation which reveals a lot about what we know, what we don’t know and how current SOC affects treatment decisions.
Post Script; ED Treatment - absent in this entire excellent, wide ranging, comprehensive discussion of all things PCa was Erectile Disfunction…amazing…as good as these doctors are and as much as they know about their field, not a single mention of this important aspect of PCa treatment…par for the course.
Key minute marks and a summary of discussions;
1. Min 00:21; list of patients with case specifics.
2. Min 00:27 patient 1. 68 years old, PSA 4.6. RP w GS 4+3. All margins and LN negative.
3. Min 2:15; when should you image patients? Before sRT or further any treatment.
4. Min 6:35; Benign margin definition. UCSF identifies both positive margins and those with healthy prostate cancer cells left behind. Novel.
5. Min 9:10; decipher score used to determine if ADT plus sRT will be the SOC. Low decipher scores would not require ADT plus salvage.
6. Min 9:50; prostate bed, post surgery, biopsies. Ultrasound to determine presence of suspicious mass then focal therapy to treat.
7. Min 13:00; psychological aspects of prostate cancer treatment. Absent here, or throughout this entire podcast is any mention of erectile dysfunction. None of these doctors talk about ED.
8. Min 15:45; PSA doubling time, and intermittent ADT treatment. Calculated in the absence of a change in therapy. Done with stable testosterone levels. Exclude the beginning and end portions of the intermittent treatment range.
9. Min 16:54; 3D PSMA PET scan reveals cancer. The patient waited did not get radiation and 3 scans were needed to find metastasis. The doctors comment that this additional testing should not have been done once patient refused salvage treatment, but additional testing finally found the area of cancer, at the moment it started to grow!
10. Min 20:04; positive lymph nodes. Treating the nodal chain, not focal treatment for the areas positive on the PSMA PET. Prophylactic treatment. ADT before radiation is the SOC.
11. Min 21:28; brachial therapy treatment of positive lymph nodes; not SOC. Lymph nodes do not move. Brachial therapy used in areas of movement were beam treatment cannot confidently radiate the same spot repeatedly.
12. Min 22:00; Lymphectomy surgical removal of nodes. Rarely curative or effective for long-term control.
13. Min 22:32; patient number 2. Age 69. RP w GS 4+3, negative margins and SV, but 2/12 LN positive.
14. Min 23:30; ultrasound performed to determine if there is any prostate material left behind after the surgery. This was done in the presence of recurrent PSA post radical prostatectomy.
15. Min 26:48; distant metastasis, at low PSA. Uncommon but only because PSMA PET is only now revealing this possibility. Should be included in the SOC before continuing any treatment.
16. Min 28:26; ribs can produce false positives with a PSMA PET. Osteo lesions produce these results.
17. Min 30:32; need for PSMA PET before surgery even with high PSA. Doctors admit that in the early days of this new scan, they are learning how much they do not understand of this disease. The scan is changing the SOC. This is especially true for Gleason 8 and 9 patience.
18. Min 31:42; Site reduction treatment advantages. Even in the presence of no bone metastasis, high-grade organ confined tumors should be treated to prevent recurrence of the disease in later years.
19. Min 36:15; patient number 3. Age 54 MRI PIRAD 5 w PSA 20. BX GS 4+5 w 12/12 cores positive.
20. Min 40:56; androgen signaling inhibitors all have cardiovascular risk factors.
21. Min 42:00; intensification of treatment decisions are all currently based on treatment that comes out of studies which use traditional scan technology. This would be bone and CT scan. Intensification regimes have not been updated to include the use of and results from PSMA PET scans.
22. Min 42:20 SOC Based conventional scans not PSMA PET,
23. Min 44:00 decipher, is not used for metastatic disease only for localized cases; with caveats.
24. Min 44:32; genomics versus germ line testing. Do both for advance PCa.
25. Min 45:00; 10% of patients with metastatic disease have a germ line which predisposes family members to prostate cancer. Germ line results can also have a therapeutic basis for treatment as genes can guide therapy.
26. Min 45:45; genomics testing is the biology of the tumor. Decipher is an example of a company that provides the testing. The biology of the tumor can be different than the biology of the patient and both need to be understood.
27. Min 46:25; the threshold for doing both genomics and germline TESTING are for patients with positive lymph nodes, those with a family history of cancers, or having rare histology in their particular disease.
28. Min 46:52;concerns for family history would include other types of cancers, not only prostate cancer.
