PSMA Scan as part of pre-treatment evaluation

An old friend of mine just got diagnosed with G7(4+3) via MRI guided biopsy and is just digging into treatment options. His urologist now has him scheduled for a PSMA PET scan in September.

Question - Is a PSMA scan now being considered for pre-treatment diagnosis? It was not long ago you could not get a MRI before diagnosis. The approvals were for post primary treatment situations with possible cancer spread as I recall. He is on Medicare so it would be great precedent for others although I think he might get some insurance push back. The only other thing that comes to mind is if the MRI showed something more that needs investigation. Thoughts?

Was there something suspicious for mets/nodes on the MRI? What is his PSA? I'm thinking there may have been some finding that pointed to the scan being worthwhile.

Djin

mattam said...
I seem to recall a couple of posters within the past year reporting the early use of one of the highly sensitive scans. It does make sense to me that if pre-treatment mets are detected from such a scan, the patient might be sent directly to ADT, skipping surgery or radiation primary treatments.

Yes, it does make sense to find out as much as one can prior to treatment, whether contemplating surgery or radiation.

JNF - Have you heard much about PSMA scans before initial biopsy? I have a friend who is getting one and quietleaf's post seems to indicate that he got one also. Both seem to have had MRI's as well.

Mumbo, I have heard of some of this that just a few years ago wasn’t considered due to the payors wanting the traditional biopsy first. Now the biopsy cost appears to rival the lower end of MRI costs. With the National biopsy rate of only 50% positive, a lot of money appears to be going into needless biopsies. My uro is very bullish on the expanded use of pre-biopsy MRI and his group is working to help define the patient conditions that should be present to use the MRI ahead of the biopsy. Based on his work, his group practice of more than 75 uros have raised their positive biopsy rate into the 70% range eliminating a considerable number of potentially unwarranted biopsies. As I remember about 5% of biopsies have complications resulting in additional treatment. Payors also look at this when considering the overall cost benefit of a procedure versus alternatives.

Good distinction Mumbo. Our discussion really wasn’t specific to the MRI or PET scans, but that more sensitive scans in general being used initially in the diagnostic process. Starting with a scan to help determine whether a biopsy should be done and if so how targeted the biopsy might be based on the scan results. He mentioned both types and posited that he sees the time when some PCa will be treated without needing a biopsy.

Just had a discussion with the doctor. We are scheduled for October for the surgery and Sept for the PSMA scan. He says depending on the PSMA scan and what it shows will confirm if the cancer is outside of the prostate. If outside of the prostate then radiation maybe the way to go.

They do the IGRT radiation at their hospital, he did not know of anyone doing the SBRT. I see one hospital in the cities that does the SBRT.

The recommendation from the RO was hormon treatment then after a month start the radiation for 5 weeks.

We'll have to see how the PSMA scan looks.

Prostate specific membrane antigen positron emission tomography in primary prostate cancer diagnosis: First-line imaging is afoot (2022, Full Text)

"Highlights

• PSMA PET has outperformed than conventional imaging in detection of PCa; the patients with suspected PCa need receive PSMA PET for better biopsy.

• PSMA PET and mpMRI have complementary effect on T staging of PCa; Both imaging (or PET/MRI) should be performed for more accurate T staging before RP.

• PSMA PET has better performance than conventional imaging in N staging of PCa by detection of smaller LNMs, facilitating precise extent for PLND.

• PSMA PET has much better ability than bone scan in M staging of PCa for more accurate radiotherapy; Once PSMA PET is done, bone scan can be omitted.

• PSMA PET can greatly impact diagnosis and treatment of PCa because of its new information; it may be used as first-line imaging for PCa in clinics.

Abstract
Prostate specific membrane antigen positron emission tomography (PSMA PET) is an excellent molecular imaging technique for prostate cancer. Currently, PSMA PET for patients with primary prostate cancer is supplementary to conventional imaging techniques, according to guidelines. This supplementary function of PSMA PET is due to a lack of systematic review of its strengths, limitations, and potential development direction. Thus, we review PSMA ligands, detection, T, N, and M staging, treatment management, and false results of PSMA PET in clinical studies. We also discuss the strengths and challenges of PSMA PET. PSMA PET can greatly increase the detection rate of prostate cancer and accuracy of T/N/M staging, which facilitates more appropriate treatment for primary prostate cancer. Lastly, we propose that PSMA PET could become the first-line imaging modality for primary prostate cancer, and we describe its potential expanded application."

Thanks Djin & IsItSerious - Still need to figure out how Medicare and commercial insurance are dealing with pre-biopsy PSMA imaging for most people now although more seem to be reported it lately. The pre-biopsy MRI was a big coverage deal just a few years ago and this seems to be the same thing in concept. I would love to think that they would defer to the doctor's expertise but that has rarely been the case and the appeal process is hit & miss with most of the work falling on the doctor.