Why would a radiologist deny me a PSMA PET scan ordered by my urologist and approved by my insurance?
PET Denied: Why would a radiologist... - Advanced Prostate...
PET Denied
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Pelican8020
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44 Replies
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Why indeed? What reason did your RO give you?
No reason given. Appeal by urologist being considered. Otherwise, will proceed with bone scan and CT scan.
So did he just refuse to answer you when you asked?
No. The radiologist who denied the case notified the person who was trying to schedule me for the scan. He in turn told my urologist's office. The scheduler was not given a reason. My urologist is considering an appeal.
PSMA PET is newer to the hospital we attend. Do you know how long it's been available where you are trying to go?? Try another venue!
Just got word that the appeal was approved. PSMA PET scan is scheduled for next month!
What is your PSA now?
Do you have MO?
I have seen here on HU, multiple times that Pylarify is not accurate with PSA below 2.0. I am in your exact position, where URO has ordered Pylarify, and RO has scheduled, in mid August (waiting list), but my .04 PSA has not come up. I don't want to waste resources. It will be intersting where this goes. Thanks, Mike
Do you have pain? Otherwise PSMA PET scan will not show anything with your PSA. And better if you save yourself a radiation from the PET scan.
I think with PSA 0.1 you have only 30% chance that the PSMA PET scan detects something.
PSMA scan threshold is somewhere around 0.5ng where it is useful. Even then it can only see lesions >4mm... I'm not a doctor so I'm not saying what's useful not not. But I believe if your PSA is 0.0# anything... I'm not sure what it's going to see! Good Luck
And oh, I would get a new radiologist of they are doing something and have the feeling they don't need to explain their actions to you. Sorry, but I'd move on!
Best Regards
Just heard from McBride at MSKCC. Yes, he agrees to hold off on PSMA PET (pylarify). Said not much data on castrate sensitive Men with low PSA. Said best to use bone scan and CT scan to compare with 2 previous scans, as I have never had a PSMA Scan. ✔️✔️Mike
I am HSPC and had PSA of 0.20 in 2019. Had PSMA PET at UCLA which revealed 2 small pelvic LNs. Led to prompt pelvic SRT. Bone scan and CT are the old standard and no longer can be considered adequate IMO. Castrate sensitive PC mostly expresses PSMA. And that is the time to find and treat it. Not to wait for castrate resistance.
MSKCC is ordering nuclear medicine bone scan and CT scan in order to monitor the effectiveness of the prescribed drug like Xtandi. Or to determine your eligibility for Nubequa. I think a reason behind is that we are still using lot of knowledge from the STAMPEDE style clinical trials, and lot of decision charts are based on this scans used during STAMPEDE study. I agree with you that PSMA PET scans are better if you have a PSMA positive cancer. I think only 80% of the cancers are PSMA positive. I personally wish to use a Nano MRI to determine the cancerous lymph nodes.
I am still waiting for the information about the PSA. I believe it is undetectable, but i don't know until the poster inform us. I just know that if you don't have a pain and if your PSA is undetectable than there is no real purpose for the PSMA PET scan.
I think MSKcc can order PSMA PET scan when PSA is only 0.2.
My oncologist wants me to have a scan, but I am waiting for the PSA to rise to 2.0. i don't want to radiate myself for no reason. Plus it cost me money. I will rather save my money for therapy or future scans when it will be more important to have one. I already had 4 PSMA PET scans for the medical science without a need to have one. I believe that they are ordering the scans just to satisfy their medical curiosity. They also want me to pay for the liquid biopsy. Liquid biopsy make more sense when the PSA is above 5 or even better 10. My PSA is now still only 0.9.
I’m 68 yrs and on Medicare. Medicare will pay for one PSMA PET per year. Mike
I ran into that on my PSA tests. I called MEDICARE and they said that’s for routine tests, but if the test is considered necessary by the Dr. and submitted as Medical Necessity they will cover it. PSA and PET scans are routine once a year and DEXA scans are every 2 years. Now when my oncologist orders a test I let the nursing staff submitting the order know it has to be submitted as medical necessity or Medicare won’t pay. I haven’t had any issues yet. If you want to be sure you can call MEDICARE and confirm.
This has also been my experience (with Medicare). I’ve had two PSMA PETs so far this calendar year, and my MO is willing to schedule a 3rd if-when my PSA gets high enough. It appears to hinge on “medical necessity” … ftm the radiation department gets insurance authorization anyway, so there are no surprises.
Waiting to 2.0 is a mistake in my opinion... Again, that threshold of I recall correctly is 0.5, but is better than other scans still at 0.8ng. Why wait until PSA progresses 2x past that?
Don't take it from me, do the research, the information is out there! Get the scan, but use it where and when others fail. At 2.0ng almost ANY scan will work, just sayin.
"Why wait until PSA progresses 2x past that?"
To avoid false negatives.
You want to do it only once, and get it right.
Well any scan would work then. The point of using the ultra-sensitive scan is to detect at an earlier stage of progression where others wouldn't. At 2.0ng you could take you pick of scans... Do the research on sensitivity at 2.0ng, what's the difference...? Only thing the PSMA scan would be superior in then would be the size of the lesions it could see, as it would detect the smaller ones, again, only above 4mm.
This is what I remember... Correct me if I'm wrong, I'm always open to enlightenment and learning new things!
Best Regards
Different scans do different things.
Pmsa by itself doesn't read all cancers.
The only reason to do a scan at all is to inform a treatment decision. So you need to start with what treatment decision are you using it to inform.
Some prostate cancers don't generate PSA. Some prostate cancers are not picked up by pmsa scans.
Once a cancer has metastisized, you really need to switch to global treatment with one exception...
Cancer that is physically impinging on something important. Most likely the spine.
I'm well aware of all that... thank you. But you mentioned "false negatives" which is alluding to the fact that somehow the PSMA-PET scan being inferior to others. So I questioned "what then" is superior. The sequence of PSMA scanning would require PSMA sensitivity testing prior to using the scan of course, that's a forgone conclusion.
The fact that the PSMA-PET scan is more sensitive than others allows exactly what you prescribe in regard to making treatment decisions, but allows it at an earlier progression timeline which has been associated with better results, ie, catching it early.
I'm looking for validation as to those false negatives in a comparison setting to other scans. And doing it once really doesn't apply as other scans can certainly be introduced if the PSMA-PET scan comes up negative and yet there's activity somewhere or how... Using the PSMA-PET scan does not exclude the use of others if necessity exists. The PSMA naive patient would then use other scans. To my knowledge, the G68-PSMA PET scan is superior and still what all others are measured to. In it's own regard, dismissing the need for glucose or bone sensitive scans of course...
I'm looking to maybe have my 3rd PSMA scan in as many years, so always in the deep end of the pool, want to make sure my vision is clear while swimming under water...
"PSMA-PET scan being inferior to others."
No, inferior to reality
???
I'm not "alluding to the fact that somehow the PSMA-PET scan being inferior to others."
There are more than just one type of PSMA scans. Galium 68, Pylarify, I & T, many more being explored. For example PSMA zirconium 89 is something said to be much better, giving results when the others PSMA scans mentioned show nothing.
Now zirconium 89 is in early investigation in Germany so years away if it makes it that far, unless you want to go to Germany to have it, cost about $2500 euros.
Yes.
Though not all prostate cancer has prostate-specific membrane.
For those cancers none of the PSMA scans can see them.
I think 80 % is PSMA positive
Sounds about right.
But that will differ from person to person.
And from time to time for the same person.
Even if you only have 2%, and you kill off the other 98%, it doesn't take long for that 2% to become 100%.
There are no simple answers to complex treatment decisions. There just aren't.
So what treatment are you undergoing?
What treatment decisions ended up being improved by the annual scans?
They weren't performed as "annual" scans. I mentioned the frequency only as an example of having them. Each time they were used in the appropriate setting, first as part of persistent and rising PSA (<3 month DT) post RP, and then again when RT & ADst failed with persistent and rising PSA (<3 month DT) prior to finding mets inadvertently ... Long story, in my profile.
Every scan has its place, but you still didn't answer my question. Thanks anyway. I'm good!
You are correct in your logic Cooolone. The purpose of PSMA scan is to detect presence of avid sites of disease early when treatment options are better: local, regional or oligometastatic. Even for Lu-PSMA treatments these appear more effective earlier rather than for more advanced disease.Waiting for disease to be more advanced, fully and widely metastatic, just to have a more positive scan is not “useful”. May as well just go onto systemic treatments for mCRPC. We know that is where the funnel leads. All of my own treatment approaches are to prevent, interrupt or markedly slow that progression, staying ahead of it as much as is possible. PSMA scans at low PSA values (0.2 and even below) have made it possible for me to plan and pursue the best possible treatment approaches proactively. Paul
My most recent PSMA Ga-68 scan was done with PSA about 1.8-1.9, and nothing was found. This surprised me, but apparently pervasive micro-mets that produce PSA with rapid doubling times is a thing.
Alternately I’m cured, and the PSA we’re seeing is from a radiation bounce, or prostatitis, or remaining healthy prostate-tissue-generated, or … who knows.
But I’m afraid the more likely scenario (for me) is micro-mets.
Not correct info on the threshold, Mike. Though it is often repeated. 0.20 is a more proper cutoff. Of course there can always be sites too small for detection. The PSMA scan trial at UCLA before Pylarify approval used a 0.20 PSA cutoff, as did the LA Veterans Hospital trial. I personally had scans at both those sites that detected sub-centimeter avid LNs that led to prompt treatment. Waiting for 2.0 would have been harmful and allowed more spread and progression.
You are right about the PSA 0.2 as a recommended cutoff. My oncologist said the same. But I believe Sartor from Tulane recommend to wait with the PSMA PET scan when PSA is above 1 or 2.
I would insist your doc get an explanation before you do anything.
You should get them both done at the same time at the same place if possible.
By someone with a lot of experience doing both.
Sounds like the radiologist is inexperienced with the pet scan.
Why would you not switch facilities?
Pelican, I have several comments since you have a Gleason 9 and Stage 4 metastatic prostate cancer. I don’t know if there is a confusion of terms, however a Radiologist is very different from a Radiation Oncologist; as is an Urologist is very different from a Medical Oncologist. All are specialist, yet their speciality is different, And a general Medical Oncologist is yet different from one who specializes in Geniturologic Cancers.... with this written, see any professional that you want to treat your metastatic postage cancer. I wish you the best in killing all the little bastards......
Gourd Dancer
Is the scan to be done at his facility or medical organization, or at an outside independent facility/organization? That might influence the decision, for more than one reason.
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