PET Scan or not yet?

A study published in the Journal of Nuclear Medicine demonstrated that using PSMA-PET/CT imaging to locate disease before salvage radiotherapy significantly improves overall survival (OS) for patients experiencing biochemical recurrence (BCR) compared to treating based on PSA levels alone.Previously, doctors knew PSMA-PET was excellent at spotting exactly where cancer had returned, but they lacked concrete data proving that finding these spots actually helped patients live longer.

Traditional salvage therapy is often "blind," radiation is targeted broadly to the prostate bed based purely on a rising PSA. PSMA-PET reveals the exact coordinates of the recurrence, allowing radiation oncologists to aggressively target the true source of the cancer.
All this being said, this is clearly being debated and as is everything, one size does not fit all. Certainly each individual needs to be looked at, but patients on here have had their BCR found in other parts of the body besides the prostate bed, so radiation to the prostate bed without the direction from the PET scan would not have helped. All these numbers about Overall Survival are just that, because one that says 75% or one that says 80% does that really matter in regards to your thinking about quality of life. ADT destroys quality of life for many and if you don’t need to go on it for even an additional year, isn’t that worth it, if the outcome does not change. The statistics that 500 might be in this group or that group, is from thousands and thousands. Active Surveillance or Watchful waiting with lymphoma is not for everyone, especially high anxiety types. Their are many people diagnosed with Gleason 6 hearing cancer and cannot live with that thought and want surgery or radiation now. Their is also a debate about calling Gleason 6 cancer. Regardless of watching your PSA doubling time, I think what is important is the end overall survivability with your quality of life intact for as long as possible if it won’t affect the end result. The debate over PSA driven and Scan Image driven treatment for BCR reflects that scan image is becoming more prevalent and as even more long term studies come out, my belief is it will become standard. Remember ADT was once required 24 months, then 18, now even 6. Also everyone believed Gleason 6 had to be treated immediately also. It is up to each individual and their Oncologist to discuss these matters, but to believe any treatment will be the best in this ever changing environment whether the cancer guidelines say so do not take into effect current studies and the ever changing environment. These guidelines change based on what the studies show and if you are just locked in on what those statistics say, you might be missing out.

@wheel1
As you say, this is being looked into, but there are some definitive studies. I saw another study which talked about the fact that people with advanced prostate cancer cases had much lower overall survival if they didn’t get salvage radiation.

Investigators identified an increased risk of mortality among patients with at most 1 high-risk factor who initiated salvage radiotherapy with a PSA level of over 0.25 ng/mL vs patients whose level was 0.25 ng/mL or less (adjusted hazard ratio [aHR], 1.49; 95% CI, 1.11-2.00; P = .008).
https://www.cancernetwork.com/view/psa-cut-point-indicates-when-to-start-salvage-radiotherapy-in-prostate-cancer

@jeffmarc

I know Jeff, I do not know if people are actually reading studies ?

This subject is not about "opinions" or "anxiety", it is about multiple studies done over the years that continually proved one and the same thing over and over again - salvage before uPSA reaches 0.25 gives significantly better results, it is not even a question.

ADT - most people here had either short or long term ADT and most are doing just fine, some had zero SA during short term ADT and besides, what has to be done has to be done.

By the same token one can argue that no treatment should be done at all in any stage since treatments effect "quality of life" ?

If one has indolent cancer and a luxury of "observing" it over the years inching from 0.10 to 0.11 in a year , than of course - go for it !

@surftohealth88
Quality of life is pretty significant. ADT is no walk in the park and that is why you are seeing a push to reduce the months on it. As said earlier this is about one’s individual cancer circumstances. A publicized Scandinavian study out of Denmark published in The Journal of Nuclear Medicine noted that researchers tracked nationwide, data collected over an eight-year period (2015 to 2023) to see if getting a PSMA-PET scan before salvage radiotherapy (sRT) actually translated to longer life. The study confirmed that men who received a PSMA-PET scan before radiation had a statistically significant improvement in overall survival (OS) compared to those who did not. Researchers evaluated 844 patients across Denmark facing biochemical recurrence after surgery. They compared patients who had a pretreatment PSMA-PET scan against those who did not.5-Year Overall Survival: The overall survival rate at 5 years was 98.1% for the PSMA-PET group versus 93.8% for the non-PSMA group.Reduced Mortality Risk: Patients who skipped the advanced scan and went straight to conventional salvage therapy had a 3.3 times higher risk of death during the follow-up period Recurrence-Free Benefit: The 3-year biochemical recurrence-free survival was also superior (74.9% with PSMA-PET vs. 69.4% without).Why the Scan Improved SurvivalAs noted by lead author Anna Mogensen from Aalborg University Hospital, the data suggests that PSMA-PET allows doctors to meticulously select the right patients for local radiation. If the scan reveals the cancer has already jumped to distant bones, doctors can pivot to systemic treatments, saving the patient from ineffective localized radiation while aggressively targeting the actual spots. Critics will argue this is just a small study, but the anecdotal evidence and preliminary studies are pointing this way. Since PSMA-PET is recent when looking long term, critics will also argue it is to soon to know. Personally having participated in clinical trials i know the benefit when looking at preliminary results and deciding whether to go forward as it is up to each patient to decide their course. The NCCU guidelines are guidelines based on prior studies, but before NCCU guidelines begin to account for a real change in their guidelines their has always been evidence pointing in that direction years before an actual change is made.

@wheel1

"The study confirmed that men who received a PSMA-PET scan before radiation had a statistically significant improvement in overall survival (OS) compared to those who did not. "

Did you mean to say "men who had positive PSMA scan" ?

I do not understand purpose of this study otherwise ? WHO in the world has salvage RT without first having PSMA done 😵‍💫 ?

Regarding official guidelines - I mostly read studies and make my opinion based on them. Unfortunately doctors are following "standard of care" and can not prescribe novel therapy unless it is approved. So yes, some things are outdated but some show very clear picture in randomized trails and from multiple institutions across the world. One of those is : early salvage (before 0.5) regardless of PSMA being negative with RT to the whole pelvic floor PLUS nodes , PLUS ADT shows much superior results for majority of patients.