How PSMA Revolutionizes Staging for
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- čas přidán 2. 07. 2024
- The sensitivity and specificity of the PSMA PET scan makes it one of the most important developments in the history of prostate cancer management. However, its use in the United States is still not universal for men diagnosed with prostate cancer. Moreover, since the scan has just now become widely available, it could be many years before studies are completed that will determine how, exactly, physicians should interpret and act on the new information it has made available. For example, can a newly diagnosed man with Gleason 8 prostate cancer reduce the duration of hormone therapy if he has a negative PSMA PET scan, or is the negative scan a false sense of security? Here, Dr. Scholz--a medical oncologist specializing in the treatment of prostate cancer--explains how we can think about this information in an era before we have an authoritative, thorough, and scientific understanding of the information and all its implications.
0:07 What are PSMA PET scans and why are they important?
1:23 What is the difference between "PET-CT" and "PSMA PET scan?"
3:38 After treatment, what is the lowest PSA at which the PSMA PET scan would be able to detect the location of the recurrence?
4:17 Other than cost, is there any reason why a person would not have a PSMA PET scan after a prostate cancer diagnosis?
5:05 Does PSMA detect all forms of prostate cancer or does it miss some cancers?
5:58 What is the protocol for avoiding the possibility of having a type of prostate cancer if it does not show up on PSMA PET?
6:28 If cancer shows up on a PSMA PET inside the prostate, what is the negative predictive value of there truly being no metastases?
7:18 Does extracapsular extension mean "locally advanced" prostate cancer?
8:45 Can a PSMA scan be done once hormone therapy has been initiated?
10:15 Can the information from PSMA PET scan help determine the optimal amount of time a patient should spend on hormone therapy?
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It is a sad fact that an informed prostate cancer patient sometimes knows more about his disease and treatment possibilities than does his urologist.
I can tell you this: My doctor follows the same cookbook approaches he probably learned 10-15 years ago. Sadly, I’m caught in the middle of that as of now, and am probably not getting optimal treatment
I have fired more than one urologist. And walked away from several others.
Same experience here in CA. You need to be fully educated on what is the latest and best. Things like Metformin are never prescribed.
I went to Mayo Clinic which was a good experience, however, my doctor cannot communicate and the team is disjointed. I’ve gone from RP to chemotherapy to Active Surveillance, all while each team member has drawn difference conclusion (typically with no explanation).
Amen. I’ve gone through several. My experience with Kaiser Urology has NOT been good. They don’t like informed patients or those that ask questions.
Thank you for being here. It’s because of this channel that I fought to have a PSMA Pet scan when my Dr had no idea what it was. He has been replaced. Because of the plandemic I was told to stop getting my quarterly PSA tests post surgery, it had fallen from 10.6 to 0 after DaVinci. 8 months later PSA was 0.6. My Dr. said wait 3 months and take it again. 1.4 He didn’t know what “doubling time” meant. His office insisted that my PSA had to be over 3 for insurance to approve a Pet scan. At 1.4, we found two common iliac lymph nodes lighting up. Just a few centimeters. Incorporated them into the salvage radiation plan. Started Lupron right after radiation. PSA went to 0. Has been for 3 quarters. With no educated council to rely on I put myself on a 18 month plan. Two shots to go. Would love to stop. Haven’t had a nights sleep in a year. I would have been lost without this channel.
Hi Im happy to hear you were proactive, I was hoping I could ask you some questions? What was your gleason score? Mine was 9 which sucks, I had 10.8 psa before davinci and 0.04 2 months after the surgery, I also had pelvic lympnodes and seminal vesicles removed, did you have this as well? I had a psma scan prior to surgery that showed no spread and localized pc but did end up having some epe in the final pathology .. it sounds like you were not able to get a psma scan before your surgery? I have another psa test for the three month mark on 2/15 and praying its still undetectable, I hope you are doing well and still have a low psa. Cheers
My urologist performed a random needle biopsy without even an MRI. Pathology was Gleason 7. I went to radiation oncologist and pressed for a PSMA PET. He said he’d ask but insurance wouldn’t pay for it. WRONG! After approving the scan, got a PSMA PET using Pylarify. It was so accurate, identified the exact location of the cancer. I’ve spent hours a day educating myself and am shocked at how behind most specialists are with current technology. I can’t overstate the need to educate yourself once you are told your PSA is high and you MAY have cancer before moving on with treatment. Many doctors stick to their old ways because they KNOW what pays. I’m now moving forward with Cyberknife treatment and am confident with my choice.
Thank you PCRI for being a big part of jumpstarting my research!
I did the Pylarify PSMA PET CT Scan one month ago as part of my 3+4 staging.
(MRI had spotted something on both pelvis joints so this was to rule out spread…turns out I have some sort of degeneration in both pelvis joints unrelated to any cancer)
PSMA scan did not spot any PC outside the Prostate. Good news. And within the Prostate the scan showed increased ‘avidity’ in the left side (location of my tumor BTW). But wasn’t any more detailed than that within the prostate itself.
Good news. Because I’m a worry wart I’m hoping it would have spotted ANY PC outside the Prostate (be it ECE, SVI, Lymph nodes, etc).
You are a good example of how to take charge of your own health and decisions
Did you consider Proton therapy, and why did you select Cyberknife? I'm at a crossroads on that issue, and even considered HDR Brachy therapy as well. Would appreciate your thoughts. Thanks!
@@wsweger No due to the additional cost and insurance coverage. Now, 4 weeks after my treatment with Cyberknife, my numbers have already been cut in half. I realize it’s older tech and the additional step required to insert fiducials but I also demanded SpaceOAR placed. Happy with my choice. Do what you’re comfortable with and ask lots of questions and educate yourself. The experts are not always up to date. My urologist told me they did PSMA Pet scans all the time and he didn’t think they were worth it. When I asked, he told me what radio pharmaceutical they were using. I told him he needed to update himself to at least 2020. Needless to say, he is no longer my urologist.
@valenpa01 my Urologist doesn't want to do a radical prostatectomy on me because I have had prior pelvic radiation. Also since I cannot have any further radiation, I asked if he had any thoughts about the TULSA procedure. He said he never heard of that. Wtf it's all over the internet.
It is huge news in the prostate cancer/ bph world.
58 year old with next to zero presenting symptoms. I had blood work work regularly for PSA and in a period of 2 years it increased from 1 to 3. The incumbent physician was content these readings were “in range” for my age. (He is correct)
Read about the great work and technology available at UTSW Dallas and requested my PMP make a referral. One MRI and biopsy later i’m about to embark on a journey i wouldn’t wish on anyone. I’m in good hands….. This channel has been very informative and I thank you.
I hope they caught things early , sending prayers your way.
I too had a PSMA-PET last year because of Dr Schulz presentation of U-Tube in Feb 2022. Medicare paid for it. I had low intensity EBRT over 45 days in April to July. Had the Space-Oar (Sp?) gel which I think helped reduce urethra and rectum damage; there was irritation about weeks 4-6 but all that was gone by October. PSA dropped to 1.3, bounced to 2.08, then dropped to 1.37 this January. I’ve had low Testosterone for 20 years. Should I request or consider another PSMA scan or hormone therapy? I’m still tired all the time and Cialis kinda works but makes me more tired.
Keep up the excellent U-Tube videos. ❤
Great information. Thank you.
Thank you
Nice tie!
I love dr Shultz and I love his ties he should market them
I left a major Cancer Treatment Hospital because, after 4 years on 2 hormone meds for metastasized prostate cancer, I was delegated to a physician assistant (PA) who was basically punching a time clock (my constant low Test and PSA levels) and not addressing my concerns. I was told a PSMA scan could not be covered. // I went to a different cancer center Hospital and my out-of-pocket payments for Lupron were lower PLUS I have already had 2 PSMA at no cost.
Glad I had a PSMA Pet scan pre-treatment which showed nothing outside of the prostate… Decipher test graded “high risk” so was worried about results… Will be choosing SBRT but rejecting any ADT as an initial treatment..
My doctor has me on ADT. I hate the hot flashes.
Prostate cancer is heterogeneous but in my situation I was given the option of SRBT + HDR Brachytherapy (one treatment) or SRBT + 6 months hormone.
I have 3+4 (less than 5% 4 but there is a possibility of ECE).
I’m leaning towards the former.
@@robertmonroe3678 did you have a PSMA PET?
Alongside the emergence of PSMA/PET scans as a new-generation diagnostic tool for prostate cancer, we have the study published in 2020 in Clinical Chemistry, 66:1, p. 161-168 ("Tumor-Associated Release of Prostatic Cells into the Blood after TRUS Biopsy") confirming that prostatic tumor cells are released into the bloodstream during needle biopsies and further confirming that such release is directly correlated with subsequent tumor metastasis and worse progression-free survival in patients whose biopsies confirmed prostate cancer. Why then does current clinical practice require a patient to undergo a needle biopsy in order to receive any treatment for his prostate cancer? We are effectively forcing prostate cancer patients to put their lives at risk in order to obtain treatment, and doing so unnecessarily. Currently mpMRI scans, coupled with the growing number of non-invasive biomarker tests now available (e.g., Exosome ExoDx, OPKO 4K Score, SelectMDx, phi, and miR Sentinel), and most recently with PSMA/PET scans, are fully capable in most cases of providing the requisite diagnostic information to guide prostate cancer treatment (and doing so not only without risking patients' lives but also with greater accuracy than needle biopsies). Why has clinical practice not kept up with the science?
Your point on needle biopsies puncturing the prostate capsule directly into a tumor is well taken.
Ditto your idea that combining data from 3T MRI and Genomics and PSMA PET CT might give you a good idea that you have (or do not have) some degree of some variety of Prostate Cancer.
But that info may not be sufficient to adequately stage the cancer and determine best practices for treatment (from active surveillance on up).
@@robertmonroe3678 To quote the authors of the mentioned study (Clinical Chemistry, 66:1, 2020, pp. 161-168) "The main effect of having a biopsy was a highly significant increase in CTC's in the blood (p.163) ....Furthermore, we observed a worse progression-free survival of cancer patients who were diagnosed with an increase in tumor cells after biopsy (p. 165). ... "We do not advocate abandoning diagnosis by tissue biopsy; however, further investigation on the effect of released CTCs on prognosis is required. Our current results might induce the design of future clinical trials to improve current diagnostic strategies: The ongoing development of blood- or urine-based biomarkers ("liquid biopsy") and the improvement of imaging procedures might help reduce the number of prostate biopsies and/or limit the biopsies to the suspect regions of the prostate; furthermore, drugs that prevent CTCs from extravasation might be a future outlook for short-term intervention around the time of biopsy, similar to the concept of using antibiotics perioperatively to avoid the spread of germs (p.166)." Although this article appeared over two years ago (and before the recent advent of PSMA/PET scans) it appears to have fallen upon deaf ears and as a result thousands of PC patients are unnecessarily having their lives put at risk as a result of scientifically outdated diagnostic practices. The authors did not call for the complete abandonment of tissue biopsies in cases where a tissue biopsy was the sole potential source of specific diagnostic information required to guide treatment. But the combination of mpMRI, liquid biopsy techniques and PSMA/PET scans should be sufficient to substantially reduce the frequency of tissue biopsies, and in those remaining cases we should be looking at short-term administration of drugs which can prevent CTCs from extravasation at the time of biopsy.
@@robertmonroe3678 I want to get a genomics test before I decide on treatment for 3+4 Gleason. can you post a link to specific tests and sources?
My 3T mpMRI was negative PSA was . 3 after Tulsa Pro. I had planned PSMA test due to travel during COVID. 3 months after Tulsa the PSMA PET showed SVI which was treated with ViewRay SBRT.
How are you doing? (Hope you are not having any side effects etc) Am looking at the same procedure, any information/recommendations would be greatly appreciated,
In my case, PSMA PET CT Scan indicated no PC spread (“PSMA expression”) outside the prostate. Extraordinarily helpful in terms of initial staging (and planning treatment) following a 3+4 diagnosis.
I’m just not sure it has the level of detail to detect any regional PC spread that might be just beyond surgery margins/typical beam field.
With PSMA being the “new kid on the block” it would be helpful to know when mpMRI or PSMA is the best diagnostic tool. When riding the edge between Active Surveillance and a treatment decision would PSMA provide useful information?
My question too. I had my first biopsy 18 months ago at 71 years old which showed 3+3. My PSA tests have fluctuated around 6 and 7 and a dip to 4.9 once. I'm not looking forward to doing a second biopsy. I wonder if it PSMA would be a good next step instead of the second biopsy.
@glenrose7925 how many positive cores were there? They labeled mine 4+4 from a single positive core out of 12.
If you had several cores positive and all were 3+3 I would not worry about it unless my psa took a big jump to 9 or something.
I had 2 MRIs. 1st was deemed inconclusive. 2nd had a 14mm pirads 4 lesion which turned out to be benign.
Then there was a positive biopsy core that was out of the area of suspicion.
My faith in MRI is diminished.
I have had my PSA and yearly exams for about 18 years now. I am now 68. On one occasion in early 2000’s my PSA jump up to over 10. My urologist at the time did blood work and treated for an infection. It worked. Fast forward to Dec 2023. PSA jumped to 6.6. I was treated again with an antibiotic. In 3 weeks it reduced to 4.2. My urologist recommended a MRI. It showed a suspicious area. I was given to choice to retest PSA in 4 months or undergo MRI guided biopsy which I have chosen to do. Mainly because my father has his prostate removed in his early 70’s. My urologist said that I made the right decision. So we will see when results come in about two weeks from now. Has anyone in this channel has a similar experience?
Schedule for mine PSMA 1 February.
Ho did it go?
Is the increased surface PSMA after ADT true for both agonists which have a short duration of increased T as well as for antagonists and androgen receptors blockers? Is this effect seen in the salivary glands and other PSMA expressing cells? Might that effect be used to sensitize treatment with Lu-177?
I want to get a genomics test before I decide on treatment for 3+4 Gleason. can you post a link to specific tests and sources?
This discussion should give greater credence to the scan rather than biopsy approach. There are top doctors in England that will not order biopsies because they get more, better, information from scans. Here, that approach is handled dismissively. It should have a more thorough and balanced discussion. American doctors seem addicted to biopsies and unwilling to acknowledge their risk and unreliability.
From my PSMA PET scan report: "There is a focus of radiotracer avidity involving the outer cortex of the medial left clavicle with an associated 4 mm lytic lesion...". My attending radiologist said not to worry. Under Impressions, he writes "No definite osseous metastatic disease. A single radiotracer avid focus in the left clavicle is most consistent with a benign bone lesion, such as fibrous displasia. Attention on followup is advised."
I am now through SBRT and a 6-month course of hormone therapy (GG 3: unfavourable intermediate) but I keep wondering about that lit-up lytic lesion.
Questions:
I was told that if it is prostate cancer, then we'd pick that up with followup PSA tests. Isn't that going to be too late? What else is possible to rule metastasis out?
Sorry for the long question.
There are certain areas typical of benign psma uptake and that clavicle could be one of those idk? Google it!
When comparing mpMRi vs psma pet, it appears as though psma pet may become positioned as a first techy approach for diagnosing PCA and dovetailing into the treatment phase and avoiding unnecessary biopsies. Am I reading this correctly ?
MpMri for me is 1st. So, that maybe I can avoid a biopsy. But if it indicates a Pirads 4+ then biopsy. If biopsy 7+ then get pmsa
I have been on hormone therapy for 5 months now (age 65). I have noticed major sleep issues (tossing and turning a lot) Is there any information on how hormone therapy impacts sleep???
My father has stage 4 bone mets he is taking casodex and he sleeps more
I have a PSA That is 5.57 and a urine test that came back as abnormal that was done after a DRE and my PSA has been building for many years at a rather slow pace but as a regular pace nonetheless and in the last few years it has accelerated a little. My DRE is normal and my prostate is not enlarged should I have a biopsy before a PSMA PET scan? Or should I go directly to a PSMA PET scan? I am 72
How does the size of the prostate affect the accuracy of PSMA Pet Scan, if at all? Mine is 91 grams
PSMA is indeed a game changer. My question is ...can brachytherapy eliminate cancer cells within the pelvis and lymph nodes as well as the prostate capsule?
Do you see false positive PSMA-PET results? For example, my PSMA-PET, showed my known biopsied prostate tumor, plus two spots on my iliac bone. No lymph node or seminal vesicle involvement. No extra-capsular spread. One bone lesion was accessible for a bone biopsy. The bone biopsy showed normal bone elements without cancer.
I am now 57 and I got an advanced pc diagnose during fall 2021 and has been on Procren (Lupron) and Erleada since then. In march 2022 i got 20 shots of radiation aimed at the prostate only. My PSA went down to undetectable and has stayed there since then, but I was able to get a PSMA-PET anyway and the result was that it showed an uptake locally within the prostate (apex left lobe) and nothing else. My question is, can I trust this result or is there most likely more cancer that is not detectable with PSMA due to my undetectable PSA?
Great question…Dr Scholz does not get too specific around 1:05 regarding the amount of cancer that would trigger PSMA detection of regional/distant spread.
Funny enough, I had my PMSA scan pre-treatment and it showed a slightly increased uptake on my left side of the prostate too…and nothing else. [I say ‘increased’ because normal prostate tissue has uptake and cancerous prostate tissue has an increased uptake]. Which was reassuring the scan was working because my lesion is on the left lobe (and I have low-grade favorable intermediate). For my doc this confirmed it was organ-confined and guided my treatment path.
My hope is that (as I had an uptake despite my low PSA) any active spots would have been visible including metastases outsides of my prostate.
B.t.w. I am since almost two weeks now on Docetaxel as a try to get rid of that small amount of PSMA-visible cancer residue, which will ofcourse also reach any undetectable micro metastases.
I am hopeful as I seem to tolerate the chemo well with no alarming side effects so far...
I live outside USA. Can I use your helpline?
I have no idea what the difference is between the scans. My PSA was over 500 and the scan I had clearly had shown my prostate looked like a coliflourer and my lymph nodes where enlarged to look like one mass not individual glands. They never told me what my biopsy was on the largest gland. I guess I really do not have much time. Found too late.
Sorry, but be optimistic &get Tx
I AM rocking an exponential rise in my PSA from 53.1 to 75.4 in 38 days. Pathology report shows a Gleason of 7 with four out of six cores at a 4+3
,I requested a PSMA PETbut was shot down. Getting a bone and partial ct scan a week from today. My pathology used the 53.1 psa factor and not the 75.4
Would this difference affect the Gleason and the Partin table evaluation? Thanks-
Call PCRI hotline, my friend.
You need a new Dr. CT and bone scan are generally a waste of time and money.
@@mperloe How so?
@@SinnerSince1962 The PET scan should be offered. CT and bone scan are far less likely to pick up disease. So a negative bone scan and CT should not have one thinking they are free of disease. I had a normal MRI and a PSA of . 3 but the PET showed significant disease in the seminal vesicle.
@@mperloe So what are my options now that I’m halfway through radiation? I assume you are saying a PSMA PET scan, right?
I am confused about PSA score. I have never had a PSA below 2 even after treatment. Should I test my PSA more often with a score still in whole numbers? I have not heard of a .1 or .2 PSA.
The PCRI Helpline would be a good resource... my understanding is that the PSA should be below 1.0, in fact, probably undetectable or nearly so if you had a prostetectomy. If you had radiation, the PSA will decline more gradually and possibly to a nadir (low) of 0.1-0.4. My PSA is 0.38 at 9 months after IMRT.
Three years ago i was diagnosed with Gleason 9 and 3 oligometastatic lesions. After radiation, and 30 months of Lupron along with 24 months on Zytiga, my PSA stubbornly held between 0.14 and 0.19. My oncologist at Dana Farber ordered a PSMA PET scan which revealed three more very small sites, which had not been detectible by CT and bone scans and which were subsequently radiated. My PSA dropped to 0.10 and I was able to stop all ADT. Get thee to a treatment center that offers PSMA PET asap.
Sounds like you’ve got great docs…and the scan is a game changer for so many folks …
How much does the hospital get reimbursed from Medicare? I have been rejected by uni
. I have Gleason 9 stage 1, PSA 6.4. I am thinking of raising money to pay for scan
Hi, please reach out to our Helpline team so they can help you regarding your specific case: pcri.org/helpline
Does PSMA PET Scan do a great job highlighting psma-expressing cancer cells when the background is psma-expressing prostatic tissue?
Especially low grade/low volume (this is in response to a comment below wondering if it might have a role in active surveillance).
From what I've read, PSMA is more likely to be expressed in higher grade tumors and in metastatic tumors so may not be so good for initial diagnosis of disease.
Agreed. I’m gathering that when spread is suspected (based on MRI or high grade biopsy) it’s becoming more common as part of initial staging for treatment.
The second utility for PSMA PET seems to be the detection of spread after BCR reoccurrence or as a way to pinpoint spread after other treatment.
And, it does have its limits (As Dr S points out).
This stuff is all mind boggling to me . I’ve not been diagnosed with cancer BUT in 3+ year my psa has reached almost 10 . 2 years back had biopsy, CLEAN . Just had mri CLEAN . But psa still rose a lil more in 3 months . NO symptoms, no infections, at 60 slight enlargement. WTF yes urologist seems concerned should I be . ??????????
You are not the first. One thing you can try is one of the new biomarkers, like IsoPSA. It is available and FDA approved. It supposedly can detect if your PSA is caused by cancerous cells based on the kind of PSA in the blood.
Sorry to be critical but please ablate that tie 😂