First MO visit

[RedBird713]

Prostectomy in 2017 and radiation in 2020 with no further treatment. PSMA test in November 2023 was negative with PSA of 0.14 at that time. My PSA has now increased to 0.34. I have my first visit with an MO in a couple weeks. Any suggestions or hints as to what to expect for treatments following this visit? I have had input from RO suggesting waiting until PSA hits 0.5 and then doing another PSMA test. Thoughts on waiting until something shows up to radiate vs. ADT treatment right away?

[NanoMRI]

I have learned to not give this beast time and obscurity. Seven years ago I had salvage RT to prostate bed, at usPSA 0.11, without imaging - post salvage RT nadir 0.075; unknowingly to us my cancer had already spread beyond the prostate bed. Instead of ADT/chemo I went abroad for imaging when my usPSA was back up to 0.11. That Ga68 was clear while the Ferrotran nanoMRI identified suspicious pelvic lymph nodes. As my hope is, if it comes to it, to defer ADT and hopefully CR as long as possible, I went for the uncommon salvage extended pelvic lymph node dissection. My investigative strategy now is blood biopsies and comparative imaging methods, Ga68, Pylarify PSMA PETS, choline or fluciclovine PETs for even better, another nanoMRI.

[Tall_Allen]

I agree with your RO. There is no need to treat until your PSA increases rapidly or something is visible on a PSMA PET/CT (at a PSA of 0.5).

[Justfor_]

Your PSADT is quite rapid (3-4 months). Enzalutamide and -possibly- Bicalutamide stimulate PSMA cell expression at their initial phase (2-5 weeks from commencing taking). There are two possibly benefits from start taking either: a) Will slow down progression and b) Increase the detection probability of your repeat PSMA PET/CT. In one line ARSI yes, ADT no.

[dans_journey]

I'm pretty much in the same boat. Had an RP that failed and wanted to locate the cancer before starting salvage radiation, so I had a PSMA PET scan at UCLA 30 NOV 2021 when my PSA was 0.21. It was inconclusive.

By May 2022, my PSA shot up to 0.36 so we went ahead with SRT in July & August 2022 to the prostate bed only and with a concurrent 6-month dose of Eligard. After the ADT wore off, my PSA was 0.11 in May 2023. In October, it nearly doubled to 0.21. By December, it was 0.33 and by January 2024, just before a second PSMA PET scan, it was 0.37—higher than when we started SRT.

The second PSMA PET scan was also inconclusive at 0.37.

I will meet with an MO on Tuesday, 19 March for the first time, and it will be interesting to see what he/she says.

My personal inclination is to let the PSA continue to rise to perhaps as high as 1.0 ng/mL so a third PSMA PET scan can actually detect it and we know what we're dealing with.

I'm scheduled for another PSA test in late April, so it will be interesting to see where it lands. (Maybe the MO will want it done earlier.) Using the Memorial Sloan Kettering PSA Doubling Time calculator, my PSADT is just over 6 months which is concerning.

I'll post a summary of my discussion with the MO on my blog next week.

All the best to you.

[NanoMRI in reply to dans_journey]

Have you thought about trying choline or fluciclovine PETs in case your cancer is not PSMA responsive? I am pondering this for my next imaging step. I have learned imaging, even the Ferrotran nanoMRI, is (very) unlikely to show all the cancer so we just can't know how far the spread has gone. When my ePLND confirmed cancer in one para-aortic node at 0.13, RO and MO docs were surprised it had gone that far. Six years later I am most grateful to date no further indication of spread nor significant growth. All the best to all of us!

[dans_journey in reply to NanoMRI]

Hi Nano,

Yes, I've thought that I may be in that 10% or so of patients for whom PSMA is not responsive. Alternate scans may be appropriate in my case, and it's something that I'll discuss with the MO.

Thanks for your input, and all the best to you!

[NanoMRI in reply to dans_journey]

My three 'clear' PSMA's have me wondering too. With the nanoMRI picking up pelvic mets at 0.13 I lack confidence a clear PSMA is a reliable favorable indicator. But then my focus is very early detection and actions, not waiting for this beast to grow and spread, and if it comes to it, deferring ADT/CR/chemo as long as possible. Best, Keith

[MateoBeach in reply to dans_journey]

You, along with RedBird, could interpret you "inconclusive" PSMA PET scans as showing no evidence of metastatic disease beyond the pelvis. And on that basis go back to your RO and discuss/request salvage radiation to the entire pelvic lymph node fields up to the aortic bifrucation. This is now SOC for salvage RT, not to prostate bed only. Personally I would not wait, the cancer is growing somewhere. And I would ask for clarification of what "inconclusive" was based upon? Did it light up anywhere and to any degree at all? If so go review the images with a RO/raddiologist.

[NanoMRI in reply to MateoBeach]

Seven years ago at usPSA 0.11 I declined radiation to the entire pelvic lymph node field and restricted it to pelvic bed because we were 'blind' - not blind to field boundaries but we had no idea of cancer locations. I then opted for uncommon extended pelvic salvage lymph node surgery because the nanoMRI identified suspicious pelvic nodes at usPSA 0.13 while the Ga68 was clear. Biopsy confirmed cancer at the left para-aortic node (I came to understand this would not have been in the entire pelvic lymph node field).