Next step: input requested please

[AMT4566]

Hi all,

I have been under Active Surveillance since August 2023. GS 3+3 according to JH (second opinion). You can see the detailed history of my case in my profile

The latest results show PSA 6.93 and MRI result PI-RADS 3.

I am seeing my radiation oncologist in a week or so. Based on my history, and latest PSA and MRI results, I would appreciate if you can share your thoughts and let me know what the best next step would be in my situation. Thank you very much in advance. Your input is highly appreciated.

[Justfor_]

How old are you ? Any lab counts of T and DHT? Lipid panel labs?

[AMT4566 in reply to Justfor_]

I am 58. T counts within normal range but on the lower side. LDL around 85 and Lipid results all normal. Hope this helps, thank you

[Justfor_ in reply to AMT4566]

You can try for 6 months the mildest hormonal intervention available. Avodart. It will rise your T and lower your DHT which is the prefered nutrient of the cancerous cells. Have labs before and after and check if DHT declines in absolute terms. In percentage it will decline either way as the total T will go up. If you are in the US the Avodart box will have a black label claiming that it increases the risk for more agressive PCa. In the rest of the world we are concidered smart enough to know that it will lower the PSA and adjust the "magic" number of 4 accordingly. It is not a "cure" of any short. Only making tougher for the cancerous cells to source their semi-baked energy supply. It will only buy you some extra time compared to doing nothing. With an ADC of over 1000 you are not for any definitive treatment IMO.

[AMT4566]

Thank you. Is any biopsy or targeted biopsy warranted? That's my main question at this point. Any point of waiting before having one?

[Justfor_ in reply to AMT4566]

If the question is directed to me, my expressed opinion is that the multi parametric MRI that you periodically take combined with a PSMA PET/CT provide more consistent staging info than any biopsy that suffers a higher ambiguity risk. But, here you will hit the stone wall put up by urologists defending their professional practices. They will not surrender them to radiologists. On top of that, insurance will probably deny reimbursing the PET scan. So, it is hardly an option.

[AMT4566]

Thank you very much again for your valuable insights and time taken to address my case. In the absence of PSMA PET/CT, would you think a combinations of PSA measurement and MRI in say 6 months would be adequate with not a lot of risk? What are your thoughts on that route. For your information and if that may help, my AS is being followed up by a radiation oncologist and another prostate cancer oncologist at UCLA. The other question I have is: given the small size of the lesion and the state of my case, do you think PSMA PET/CT detection would be highly reliable and still the best to detect in a meaningful way?

[Justfor_]

Tough question! I am a retired engineer and as such a 95% probability, which in medicine is assumed as a relative certainty, is in-admissibly risky in my profession. I feel comfortable with 3 or better 5 nines (99.9% or 99.999%). To do my best, I calculated your PSA doubling time that came out to almost 3 years (35 months). Certainly not bad, but also not 99.9% reassuring. The nitty-gritty is that the the log regression coefficient is a bit higher than the linear one indicating that the PSA rise is governed more by PCa than by benign sources. If it were the other way round I would agreed with you that it is ok to wait for another 6 months doing nothing. If it were for my shelf I wouldn't. Sorry.

Regarding the PSMA PET/CT, the scenario to wish for is to detect nothing, not the opposite. MpMRI is good for looking inside the prostate gland. Outside it, i.e. lymph nodes and seminal vesicles, when MRI registers them as invaded the disease has already progressed very-very much. There are a number of prostatectomy cases dubbed "persistent PSA" which is just that. PCa had escaped the gland but this was made evident after its removal.

AMT4566

[AMT4566]

Interestingly, I am an engineer too and I do understand where you coming from. Thank you so very much again for your analysis and insights.