After prostatectomy and radiation therapy, my PSA is increasing quickly though at only .13 as of a couple of weeks ago (see bio). My Radiation Oncologist is in no hurry to get me on hormone therapy. He says we can do a scan around .5 I'm wondering if I should be getting on HT now. How much would HT reduce the accuracy of a PSMA scan?
I'd like to get an opinion from a Medical Oncologist , but I'm in the biggest network in the area (Charlotte) and my RO won't give me a referral to a MO in this network at this PSA. A referral is required if you're already in the network.
Also, please let me know if you know of a MO in the area that you'd recommend.
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You should only do a test if you really really want to know the result, understand the implications and it is likely to change management. Otherwise what is the point other than making money for someone??
It seems that there are mets. At a PSA value of 5.0 you will almost certainly detect them. If you then want to start ADT, you do not need a PSMA PET. If you want to combine radiation of the mets with ADT, a PSMA PET makes sense. Here is a trial for that situation: urotoday.com/video-lectures...
I highly question the benefit of doing a PSMA pet scan at <0.5 PSA. It's highly likely it will miss most of the cancer spots.
In a meta analysis at < 0.2 it only has an average of 33% sensitivity which means there's a 66% chance it will miss existing small tumors. Even at 0.2-0.5 it's only 45% sensitive.
Also keep in mind as soon as you start ADT you start the clock ticking of when the cancer eventually changes to being androgen insensitive and have to move on to more powerful drugs with typically more severe side effects.
I'm not sure I follow the logic of your action plan at that low of a PSA level, post salvage. If I were in your shoes I'd opt to wait until my PSA hit 2.0 (or at least 1.0), start ADT then and then do the PSMA pet scan which at that level is on average 91% sensitivity. You could then much more reliably identify targets for spot radiotherapy.
If your salvage therapy has failed unfortunately that typically means you are now incurable and have a chronic disease to manage. My opinion is that it may be premature to take any action with PSA at such a low level in a post salvage setting. I'm no Oncologist so would definitely get at least 2-3 opinions. Out of pocket costs if your insurance don't cover it are not exorbitant for just a consultation relative to treatment costs covered by insurance unless you've met your out of pocket maximum already in which case everything is basically free until the end of the year.
I'm kind of in the same boat. I had an RP that failed and then salvage radiation with concurrent ADT. It, too failed.
My post-SRT PSA nadir was 0.11 and now, 27 months after SRT ended, it's 0.69. I had a PSMA PET scan when my PSA was 0.37 and it was inconclusive.
Back in February, after the PSMA PET scan, I met with my urologist and a medical oncologist to discuss ADT. Interestingly, the urologist said she wouldn't start ADT until metastasis was evident; the medical oncologist said she would start ADT at a PSA of 2.0.
I believe you're correct in that, when ADT drives your PSA down, it would make it more difficult for a PSMA PET scan to detect anything.
The other concern that my urologist and MO expressed was that some prostate cancer can become resistant to ADT after extended use, and they were reluctant to start too early because you may get to resistance sooner.
Even though I tolerated the six-month dose of Eligard pretty well during the SRT, I'm in no rush to experience it again.
We're going to retest PSA in 3 months and then maybe try another PSMA PET scan and go from there.
I tend to agree with you. For example if you are getting it for Sox months. Two months prior; 4 months post radiation. Same formula for longer duration.
(1) Your PSA is not going to be stable for a while. So it will not be a reliable indicator of chit.
(2) Never ever voluntarily join a compulsory network. Once you join an advantage plan you and you have a preexisting condition, except for a very few states they own you forever.
WHY DO YOU THINK THEY ARE SO CHEAP????
(3) You can get a second opinion for less than what you have paid a plumber for a big job in the past.
Get on a plane and get some second opinions from one or more major medical centers of excellence.
you may want to consider going for radiation therapy even now (with or without PSMA). Some studies have shown that having salvage radiation before psa reached 0.2 has a better cure rate.
I think you have time. I had an Axumin PSMA scan that found nothing at .7, but 6 months later I had the Pylarify scan when PSA was 1.6, and it found the cancer in a presacral lymph node. It took several years for my PSA to climb enough to find the mets. Had 28 days radiation in spring 2023, and 6 months Eligard. My PSA has been <0.01 for over a year now -- first time I've been at undetectable! This was my 3rd round. Robotic prostatectomy at age 44 in 2007, 40 days radiation and Lupron in 2017, then the 28 days and Eligard in 2023 at age 60. But it looks like they really knocked it out...for now. Best wishes. (I'm in Maine)
As others have said, the lower the PSA, the less likely a PSMA scan locates recurrence. For my medical team and I, our decision criteria on when to image is PSA between .5-1.0. Last year my PSA met that criteria, we imaged, it showed a single lymph node, we were able to use SBRT on it and added 12 months ADT - Orgovyx. My PSADT may have played into the scan locating recurrence.
What is your ROs issue with referring you to a MO?
As others have said, perhaps just see one, pay for the consult yourself. Likely it's less than a repair bill for your car, plumbing...and it's your life.
As I've said before, a question you have to ask yourself on starting ADT now is would waiting for it to rise to a point where you increase the statistical probability of it locating the recurrence and thus informing a treatment decision carry any risk? Most on this forum would say no.
My clinical history says you can wait...but, that's me.
Thanks for the feedback everyone. I feel less in a rush now with the consensus being wait until the PSA is ~1.0 to get a PSMA scan, then go from there.
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