second Opinion?

[HKKWL]

75yo with RARP(Oct2019), Gleason 3+4, stage 2b with positive surgical margin. This was followed by SBRT 1 year later(Sep2020) because of rising PSA despite surgery. PSA continues to rise regardless.

By 2023, PSA 0.17 (Apr2023), 0.24(Jul2023), 0.23(Aug2023), followed by a negative PSMA-PET(Oct 2023).

PSA 0.28 (Apr 2024), PSA 0.36 (Aug2024) and 0.50(Feb 2025).

I saw my radio-oncologist yesterday who proposed to repeat PET scan should PSA increases to 1.0 by Aug2025, but has no plan in starting ADT if scan is negative — only to target visible lesions if detected.

My understanding is that ADT should be initiated if doubling time<6 months and if PSA is beyond 0.5.

Should I look for a second opinion? A medical oncologist, maybe? I am in Toronto, Canada.

[Tall_Allen]

"My understanding is that ADT should be initiated if doubling time1, and short-term advanced hormone therapy. But you are fine for now.

[HKKWL in reply to Tall_Allen]

Sorry for not understanding your reply. What do you mean by doubling time “1”? And what about “short-term advanced hormone therapy”?

[HKKWL in reply to Tall_Allen]

Do you mean doubling time of 1 “month”?

[Tall_Allen in reply to HKKWL]

Sorry - my reply got screwed up somehow. What I originally wrote was this:

"My understanding is that ADT should be initiated if doubling time<6 months and if PSA is beyond 0.5." IMO intermittent hormone therapy using an ARPi+ADT should be initiated if PSADT1. But you are fine for now.

[HKKWL in reply to Tall_Allen]

Sorry Allen, still don’t quite get your “PSADT1”. Did you mean “intermittent hormone therapy using an ARPi+ADT should be initiated if PSA > or = 1?

[Tall_Allen in reply to HKKWL]

IDK why it shows that -it's not what I typed. I'll try it without the symbols. What I typed was: "" IMO intermittent hormone therapy using an ARPi+ADT should be initiated if PSADT is less than 9 months and PSA is at least 1.0."

[HKKWL in reply to Tall_Allen]

Thank you very much. Very clear now! 🙏

[Conlig1940]

@HKKWL I am 85 years young and live near Toronto - Where did you have your surgery ?

I note you are on Dutasteride , I assume for BPH . Are you aware if you are on this medication , as I am for 5 years , YOU HAVE TO DOUBLE YOUR " LAB PSA RESULTS " .

I.E. If your lab result , (probably LifeLabs ) PSA is say 0.02 the true psa is 0.04 . This is more important when tracking your doubling time .

A 2nd opinion is always helpfull if you are constantly concerned or 2nd guessing your primary care giver . I feel you are searching for peace of mind . I know many Urologists and Oncologists at Princess Margaret and Sunnybrook .

[HKKWL in reply to Conlig1940]

Thank you for your concern. I have stopped dutasteride back in 2018 before my dx of PCa.

My surgical oncologist Dr Finelli has recently resigned from PMH and heads up the surgical department of Trillium Health Centre.

At present I do not have a medical oncologist in either PMH or Sunnybrook. My radio-oncologist who supervised my SBRT 4 years ago appears to be more interested in treating any PMSA-PET identifiable lesions and treat it radiologically. When being questioned about ADT, he did not even appear to be interested in offering any opinion.

I chatted with my colleague who has a few patients of his under the care of other oncologists at PMH, but on researching, they are all radio-oncologists too. I do not know any medical oncologist at Sunnybrook, and I have no intention of upsetting my radio-oncologist either. So I have to seek a second opinion quite diplomatically.

Would love to get some names from you if I may.

[Conlig1940 in reply to HKKWL]

@HKKWL Haave you ever read : Dr Patrick Walsh's book " Guide to Surviving prostate Cancer " ? A must study and highly recommended by others on this forum . It states , as in other publications , that surgeons ( Urologists ) have thick skins and are NOT offended when ask by a patient for a second opinion . You feel your doctor would be upset .

A further recommendation by Dr. Walsh and other physicians , including members on this forum , is " " If he feels offended or upset -- CHANGE DOCTORS .

It's your health and well being at stake here . Not your doctors ego .

For reference : Dr. Nathan Perlis at PMH , Dr. Luke Fazio Head of Urology at The Humber River Hospital and The Clinic at Beverly Hills , Toronto , Dr Jack Barkin the Former Head of Surgery and Urology at Humber and still practices there . His practice is on Keele Street , Dr. Laurence Klotz at Sunnybrook , a member of the research team , under Dr. Gupta ,who discovered TULSA - PRO at Sunnybrook . He still performs TULSA - PRO .

Dr. Andrew Bayley and Dr Andrew Loblaw , Dr. Morton Oncologists at Sunnybrook . All world leaders in their profession .

Do not be shy about asking for a 2nd opinion -- Insist on it . I personally have never had a problem . I had a 2nd and 3 rd opinion of my Biopsy Gleason Score results , in addition to a 2nd opinion of my MRI Results . I am going for a 3rd opinion , on April 23rd , with regards to me perhaps going off active surveillance and having : 5 Fraction Monotherapy SBRT .

I already have opinions from PMH and Sunnybrook regarding SBRT . A different Urologist suggested NanoKnife which was another option I considered .

Good luck .

[HKKWL in reply to Conlig1940]

My radio-oncologist is Dr Morton

[Conlig1940 in reply to HKKWL]

HKKWL None better .

[ron_bucher]

Adding a medical oncologist to your team is a good idea for any recurrence. My oncologists suggest PSMA scans every 6 months if PSA is rising, and sooner if PSA doubles. PSMA scanning has a 50% chance of showing a tumor when PSA is 0.50.

My oncologists have seen a lot of success with SBRT and no ADT on oligometaststic cases.

[j-o-h-n]

Get a Medical Oncologist, Like spelling the word Mississippi. the more eyes, the better.

Good Luck, Good Health and Good Humor.

j-o-h-n