Widespread Skeletal Metastatic

@ctsenior The U.S. recommendation against routine PSA screening was loosened but not rescinded. Unfortunately, many U.S. men (both here in the forum and in touch with me privately) still do not get routine PSA screening offered to them, or were talked out of it when they asked. As here in Canada, it really depends on your doctor.

And the variety of prostate cancer that spreads aggressively to bones can move *very* fast. It's not like the slow-moving kind that affects mainly elderly men and takes years or decades to spread. You can have PSA in normal range, then suddenly have bone metastases 1–2 years later.

As for PSMA-PET, it's available in Canada, but not used as first-line imaging because there's no significant evidence (yet) that its higher-resolution imaging actually leads to improved survival or delayed progression.

Still, I would support making PSMA-PET more widely available here in Canada, with the following caveats

1. It's not very effective for those of us already on ADT and/or ARSIs (like the lutamides), because they inhibit PSMA uptake.

2. It's a very "noisy" scan that produces lots of false positives: your bones, lungs, lymph nodes etc might light up like a Christmas tree on a PSMA-PET scan when there's little or no actual cancer there, which is why they need to confirm with other indicators (PSA, biopsies, alternative imaging methods, etc).

Cheers!

@northoftheborder Here in the States, perhaps not in Canada, PSMA PET scans are considered a game changer. Upon registering a BCR, a PSMA PET scan is ordered to seek out mets. Without this method, the second best technology of bone scans and CAT scans are far inferior.

Most Americans who get a PSMA PET scan do not use alternative imaging methods to confirm. We believe it is that good.

@ctsenior I know that PSMA-PET is very popular in the U.S., for various reasons (mostly health-related but also some business-related — you can't let an expensive machine sit idle, not generating billings). We have it too here in Ontario — even right in the city where I live — but we tend to use it only for specific situations, like when PSA starts rising again after treatment.

The world is still waiting for the evidence that the better resolution of PSMA-PET actually improves prostate-cancer outcomes, though, which is why most other rich countries use it more sparingly. That's not to say that the evidence won't appear; just that no one has been able to demonstrate an survival or progression advantage yet in a major trial.

In my situation, I probably wouldn't be prescribed a PSMA-PET scan even in the U.S. I have stage 4 castrate-sensitive prostate cancer that has been fully suppressed with ADT + Apalutamide for over 4 years (PSA < 0.01 on the ultrasensitive test), so it's unlikely I'd get much PSMA uptake, if any: MRI, CT, and bone scans have lower resolution, but can "see" potential lesions, even if they're dormant, and blood tests like PSA and ALP (for bone lesions) can confirm whether they're likely something or nothing.

Hello,
So utterly sorry to hear of this. I’m just curious…no need to reply if you don’t want to…did you actually have a radical prostatectomy? If so, it started with a biopsy, so…what was your original Gleason score? If you had the RP, what did the surgical pathology report reveal: EPE? Surgical margins? Cribriform glands?; Seminal Vesicle invasion? And after your RP did you just forget or choose not to do your follow-up PSA’s through the months or years. Or…
Is this your very first awareness that you have prostate cancer? A lot of men delay exams and PSA testing for numerous reasons, but unfortunately a lot of them delayed too long…once diagnosed it is extremely diffuse, having spread to lymph nodes and their bones.
Please fill us in. Good luck to you.

@northoftheborder You may be waiting a long time for the large study for PSMA PET scans. But I can tell you in the States, we rely on it every day. There is nobody in this world that would rather opine on a grayscale bone scan rather than a PSMA PET scan. Post treatment with contained PSA will still call for a PSMA PET scan. The chief cause of castrate resistance is too much use of ADT. It is much better to locate the lesion and target with radiation than to slog it with ADT and or chemo.

@northoftheborder Excellent points all, North, and also because the US is the most litigious country on earth; so if there’s a scan available - even an imperfect and possibly erroneous one - you MUST use it to cover your butt.
Not saying that’s the overwhelming reason, but it’s certainly part of the mindset unfortunately.
Phil

@heavyphil I hadn't thought of that. That helps explain why they'll MRI a broken wrist as well. 🙂

But don't get me wrong. If/when I need it, I'm very glad that PSMA-PET is available here in my city. If my PSA starts rising again, then there's a chance that it might help us find tumours that are too small to show up on other scans.

p.s. As far as the "colour vs black-and-white" thing goes, *all* the scans we can get are monochromatic, in that they have just one intensity channel. PSMA PET is coloured in because it has to be viewed over a CT or MRI background to make sense (otherwise, it's just a bunch of grey blobs with no context). By putting the PET scan in colour and leaving the background in black-and-white, it's easier to see which is which. But PET is no more a "colour" scan than any other.