I've had my two years on ADT, and now I'm 6 months into my "vacation" (iADT)
PSA has hit 2.0, and the plan is to restart ADT when it hits 5.0.
Assuming there are no complications, I'm okay with that plan.
Also assuming there are no complications, my MO says we won't be doing a PSMA scan, or any radiation before we restart the ADT protocols.
I think I understand why my MO and RO will not radiate Mets that are not producing noticeable symptoms.
Assuming that the eventual return to ADT will quell the Mets, we've avoided putting more radiation into my body. We save the radiation for Mets that may cause trouble further down the line.
So here's my question:
Is there a medical reason to have a psma test done before restarting ADT?
I would feel more comfortable knowing as much as we can about the progression of the cancer during my time off ADT. But is that enough of a reason to insist on a scan?
Would there be other benefits to having the scan done?
Written by
Lewellen
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As your PSA went from undetectable to 2.0 after only six months off ADT, I would have some concerns.
As a comparison, mine went from undetectable (May 2023) to 1.9 (June 2024) after 13 months off which is a fairly fast doubling time. I did a CT scan in April 2024 which found nothing and a bone scan in May 2024 which found a metastasis in my right shoulder blade and the likely cause of the quick uptick in my psa.
If I was you, I would ask for some scans to see if it is something that can receive radiation and maybe nip this in the bud or if it is systemic and then have to think about whether to cut the vacation short.
I had a scan with PSA at 0.19 (was falling not rising though)
Still it was v useful to me to decide I'd have further treatment:
From my bio:
PSA pre Chemo 3 is 0.19 on 13th April 2022
Good to see a drop but expecting 20 rounds of radiotherapy is my next step.
End of April scans show no evidence of disease in skeleton but remaining activity in prostate. Scan discs with London MDT for second opinion review on this and next steps.
Back at work, hair thinning but no loss of clumps but seeing it on coat, guess chemo still doing it’s thing.
After Lu-177 x 3 and Docetaxel x 3:
26.4.2022 PET/CT examination with F-18-PSMA-1007 from the top of the skull to the mid thighs, inj dose 269 MBq, imaging started 60 min pi. Comparison with NaF-PET/CT 4/22 and 11/21, F-18- PSMA-PET/CT 11/21 and Ga-68-PSMA-PET/CT 10/21.
No abnormal uptakes are noted in the brain parenchyma. There are a few mild lymph node uptakes in the neck probably reactive. No abnormal lymph node uptakes are noted in the mediastinum and axillaries. No abnormal uptakes are noted in the lungs, neither pleural effusion.
No abnormal metastatic uptakes are noted in the liver, spleen, pancreas, adrenal glands and kidneys. No clear abnormal lymph node uptakes are noted in the abdomen, pelvis and inguinal areas. Abnormal uptakes are noted in the prostate decreased in size and activity compared to the previous PSMA-PET/CT examination 11/21 (SUVmax 18.3, previously 30.3).
Compared to the previous PSMA-PET/CT examination 11/21: marginal diffuse uptake is noted in a lower cervical vertebra and tiny marginal in the III vertebra-rib area on the left, no clear uptake is noted in the rest cervical and upper thoracic vertebrae area; faint uptake is noted in the II rib, no clear focal uptake is noted in the rest ribs or left scapula; faint diffuse uptake (if any) noted in the Th9 (SUVmax 1.5, previously 26.1), tiny marginal uptake is noted in the L4 (SUVmax 2.5, previously 15.6), no clear uptake in the L1; faint uptake remains in the right iliac bone, no clear uptake noticed in the rest pelvic bones, a tiny uncertain marginal uptake is seen in the left iliac bone close to the SI- joint. No clear new skeletal metastatic lesion is recognized.
Impression: The PSMA-activity in prostate decreased in size and intensity; very good skeletal response with only marginal to faint PSMA-activity remaining in only a few lesions.
My annual PSMA is tomorrow along with GUARDANT360 CDx blood biopsy. I do these along with bi-monthly PSA testing to not give this beast time and obscurity to sneak up on me. Five plus years since my one year on bicalutamide following third treatment, salvage ePLND.
If you don't have to pay for the PSMA-PET scan out of your pocket, then you should do it soon. The rise in PSA is concerning. I wouldn't wait until it reaches 5.0. I don't think there is any rule or requirement to wait that long.
Also, you said that your "MO and RO will not radiate Mets that are not producing noticeable symptoms". Meaning that only Mets that are producing symptoms will get irradiated.
I could be wrong about this, but Mets don't generally cause noticeable symptoms. (The exception are vertebral bone Mets, which often cause pain).
I would have another talk with your RO, and insist on getting a PSMA-PET scan. His statement about Mets and no symptoms seems odd to me.
I agree with you. What proper doctor thinks "Let's wait until the patient is in agony due to metastatic bone fractures before we do a scan"?
I have read of situations involving iADT where an ADT vacation continues up until the PSA nears 5.0 and then ADT is restarted until nadir and then the ADT vacation starts again. But I am quite sure that was not for people who hit 2.0 within 4 months of Testosterone having come back (as he wrote that he was on ADT vacation for 6 months and it took 2 months for his T to come back).
I am not yet in your situation. However, my research shows me that the PSMA scan is very useful in deciding next steps in your treatment plan. Proceeding with ADT without the scan gives you no information to go on, other than the PSA. Given the chance, I would always get a scan to tell me if it was spread, is localized or is in remission.
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