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Axumin scans and expertise

hesno
Posts: 11
Joined: Jul 2016

PET/CT scans using Axumin tracer, approved by fda last year and newly approved by medicare in some areas, are starting to be done at different locations.

Its supposed to be more sensitive/specific than NaF and other older scans, and comparable I think to Choline or Acetate (lots of studies and info on the web) and can perform well at lower psa, ie 2.0.

Its just starting to be rolled out so many/most facilities  that are doing it, don't have a lot of experience yet with it as to number of patients doing it so far - and that would apply to experience of technicians doing the scan or injecting the isotope or doctors analyzing the results.

===> Do you think that its important for facilities to have more experience in general with doing a new scan/isotope like this beyond lets say 6-10 patients ? (this would really apply to any new scan or procedure)

For myself, I would not be able to go get choline or acetate and thus limited to PET/CT Na Fscan  locally and regular CT with contrast -- if I did not do the new Axumin scan, which has just started locally.

 

I *think* but not sure that the Axumin scans can discover things in bone and soft tissue outside prostate, besides in prostate, but I am not experienced in reading studies.  If so, it might mean one might not need separate bone scan or CT, but I realize that is up to doctors evaluation as well. (Na F is just about bones)

 

My own details are that psa is now 3.1, having risen fromvery  low values after IMRT only (no surgery) 5 1/2 years ago; psadt is about 8 months, G7(4+3) multiple cores.

Several doctors I saw said to get baseline scans at recurrence value (for me that was 2.0); which I think is the standard like nccn,  one said to wait until 5 due to existing scans in my area (pre-Axumin) not being as good at lower psa.

But now am getting nervous that perhaps I should have baseline now, IN CASE those scans would show something and thus that treatment might begin.  (even though at the 3.1 psa it might not show things)

Thus I can ask my dr about this and see about getting scans now,  BUT now there is this new Axumin scan and am concerned with the accuracy
 of it given the facility and its staff and drs have only done 6 of these so far -- which leads to my question above of  would you go ahead with it or wait until more expertise had been obtained ?

 

 

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3313
Joined: May 2012

henso,

I've had a lot of CTs and PETs, but am not familiar with the particulars of Axumin. But in general, any technicians performing any form of scanning require certification with any and all of the agents (contrasting agents, etc) involved.  Usually such certification comes from the device manufacturer.    

Back when I was considering IGRT (an updated technology past IMRT) the doctor offered to let me be one of the first at his clinic to receive Calipso telemetry, which was being added to their Varian machine.  He said that a certain number of patients had to be treated by his staff under direct supervision of the manufacturer's own training staff to become "certified" to use Calypso by themselves. 

If a hospital is offering a test, their should be a presumption that they are certified. The legal liabilities are enormous.   But I would ask about it.

Me, I would go ahead and get the baseline scan.  Like all other writers here, I claim no medical training or expertise.

hesno
Posts: 11
Joined: Jul 2016

Max,

Thanks for your reply.

I was told that the manufacturer did do training, perhaps in person and perhaps online, it was not clear. And the clinical trials have been done and this is now FDA approved and Medicare at least in some areas.

But my thought/concern was that like with any new test or procedure, it can take some time for an individual or facility and its staff to get more experienced, there is always a learning curve once training has happened.  Thus its that concern that I have which makes me wonder if I should wait until they see more patients. The down side is that that could take some time as that scan is still not done that much due to folks not knowing about it and large out of pocket cost if ins does not cover, which might be more common at this point.

Yes I agree with you that I should get it, esp since as mentioned can't go to get the choline or acetate or psma.Thus I realize its up to me to be comfortable with doing it here even though just a few done so far or wait until more have been done.

BTW, in 2011 I had imrt using the calipso process - urologist put in 3 transponder beacons/fiducials.  The fiducials, i think like other fiducials, do show as an artifact during prostate mri but i don't know how much that affected the overall view of the prostate mri. (that was done when psa was just 0.6 as a pre-baseline just to make sure nothing was visible at that time)

Thanks again for your reply.

VascodaGama's picture
VascodaGama
Posts: 3033
Joined: Nov 2010

Surely the interpretation of the exam is conditioned to the expertise of the radiologist analyzing it. In any case, the professionals working at such PET facilities (those that will be responsible for the FACBC F18 shot) should know the details and may be proficient in image reading. You also can send the film/DVD of the scan to anywhere in the world for second opinion (eg; the owner, Blue Earth Diagnosis). This PET/CT exam the whole body including bone (the osteogenic cells lining the bone). Your PSA at 3 doesn't seem so big. You can let it grown further if suspicious of existing micrometastases. These would grow while waiting becoming more prospitious for detection and therefore to be included in the protocol of the salvage (spot) radiation.

Best wishes,

VG

hesno
Posts: 11
Joined: Jul 2016

Vasco,

Thanks for your reply.

Yes, one big question I have relates to what you mention about the professionals knowing the details -

I don't know how much of this scan, both the prep, injection, doing the scan and reading results - is that much different from doing other PET/CT scans where a tracer is injected -                                             thus I don't know the learning curve (am assuming here that the techs and doctors are experienced to begin with)

thus thats part of my dilemma in seeing if should wait until that facility/drs have more expertise.

As to the re-reading or even the first reading - I have read its common for places to just send out the images to reading services, which might be anywhere in the world, so that its not know what real experience a given reader has.  And with something like Axumin this new, I doubt there are many out there who have had any experience at all in reading it.

Yes, I need to find out more about re-read process - I don't think its covered by medicare and also seems I'd need to find a place whose doctors have some experience with reading Axumin scans, and have found that most places so far have not done a lot of them either. 

You mention about this scan looking at the bone, and I think that has what have read or been told - that in addition to soft tissue it can look at the bone,  which is different than NaF which is just for bone.

Finally, thanks for your comment on the psa at 3 not being so big (in context of my statement that am worried about not getting a scan soon in case some scan DOES show something which could call for immediate treatment)

Am guessing the reason for this is that even if something is there now, that waiting a bit for psa to be higher would still not impact usefullness of treatment started a bit later when either things were seen or when psa got to
 perhaps 10, if nothing was seen yet, as per the feedback from the drs I saw. (I know the immediate vs delayed adt topic can be controversial in itself)

I need to educate myself better that one reason for waiting a bit and for getting these improved scans is to see if something can be found that is treatable with the spot radiation, and thus the earlier found the better but balancing that with psa levels often need to be higher for anything to be found. I think the part of me in denial might say that if nothing found thats good, but thats really the opposite of the reality that most men want to know where things area as early as possible.

I think (but still not sure) that if multiple things are found in bone or at soft tissue that has no treatment possibility, that ADT as a first lije treatment would still need to be done, since I think that for a larger number of growths on bone, spot radiation is not done or practical ?  (I feel I am not phrasing my comments here well)

Thanks again Vasco for your replies.

VascodaGama's picture
VascodaGama
Posts: 3033
Joined: Nov 2010

Hesno,

You did not share many details about you and your case. I sense anxiety in your words. Can you tell us what is bothering you?

It seems that you have been diagnosed (by a doctor) or just think that have recurrence from the radiotherapy (IMRT) of 2011. Can you tell if such condition is due to an increasing PSA or if there are other exams/symptoms leading to the diagnosis?

From your descriptions I take the PSA histology starting at 0.6 after RT and then increasing with a PSAdt of 8 months reaching the value of PSA=3.1 ng/ml in the present ( 5 1/2 years later). You still have your prostate gland in place. I wonder what was your PSA before RT and if you have experienced bounce along the years after RT?

PSA bounce is typical in guys that had RT as prime therapy without any neoadjuvant/adjuvant ADT. One may see the PSA climbing and then going down and climbing again till it starts a downwards curve to a nadir. This bounce can take years to be accomplished. I never heard of a 5 years period but I know one case of 4.5 years. Could this be your case?

In your first post you inquire about the FACBC F18 PET/CT exam but you do not specify if you are having it or just plan to wait till it is available at your neighbourhood. I also do not understand your purposes in regards to the test. Are you trying to locate the bandit's hideaways for defining a salvage therapy to tackle the recurrence?

My recommendation is for you to consult a radiologist (maybe the one that did your IMRT of 2011) because SRT may be possible in your case (RT patient), if recurrence is confirmed and if the cancer is located in areas that can absorb more radiation. Our body tissues have limits in absorbing radiation so that you would need info on your previous RT isodose plan. Do you know details of the IMRT of 2011?

Surely any salvage treatment done with the intent of cure will be dependent on the location of the cancer, therefore requiring an image exam done with the latest and most reliable testing means. I think you doing it well in researching and procuring the best. At present, the most reliable images to detect prostate cancer (PCa) are those produced by PET scans using radiopharmaceuticals as tracers. FACBC F18, Gallium Ga68 and C11 or F18 choline are the most recommendable in systemic cases. Some newer radiopharmaceuticals have also proved capabilities of treating PCa killing it directly on the spot. This is called "Molecular Radiotherapy". This treatment is already available in Europe, using Lutetium (177 Lu) which is also used as a contrast agent in PET scans. In fact there is an ongoing clinical trial which could be the means you are looking for. The trial subject is image study of neuroendocrine tumours, suits your status (I think) so that you should discuss with your doctor about possibilities in participating. Here is the information;

https://clinicaltrials.gov/ct2/show/NCT02609737

Regarding the professionalism of the staff and radiologists in charge of PET exams; the preparation and administration of the shot is equally done as in any other injected contrast agent and the proficiency in interpreting the image would be expected to occur at creditable facilities other wise such contrast agent would not be available. Special care are needed with these radiopharmaceuticals so that not all radiographic facilities handle the test. Only proper nuclear departments do the exam, and you can request a second opinion (second reading) from an independent professional, in particular one of those involved in the clinical trials (recommended by the contrast agent manufacturer). 

The use of tracers and image equipment varies in accordance with the purposes. A localized image is better done with a MRI or CT. PET is commonly used for whole body images. It is proper for systemic cases. However, the type of tumour also influences in the choice of a tracer. For instance, NaF-18 sodium fluoride acts well in bone osteoblast and osteoclast (bone formation) therefore it may be the best to look for metastases in bone (better than Axumin). Ga68 is also better than Axumin to identify PCa at certain organs (as commented by the manufacturer). The good in Axumin is its long half-life (no need of a cyclotron, whicht is a requirement in choline based agents) and the negligible uptake in the urinary tract that could influence false readings (a problem of C11). It is also well metabolized in liver.

One aspect that you need to consider in your next step is to be clean of any substance that could interfere with the properties of the radiotracer. For instance, 68Ga attaches to areas of inflammation where rapid cell division occurs, such as cancer cells, therefore hormonal therapies (turning these cells indolent) should be avoided. In other words, you should start ADT only after the PET/CT exam is done. Your present PSA level allows you time to study and research, and find out about your other health issues that could interfere/proibit the test. Make the best decision on your next step but do not sleep on the matter. Get consultations and move forwards coordinately and timely.

Best wishes,

VGama 

hesno
Posts: 11
Joined: Jul 2016

Vasco,

Thanks for your replies and questions. I will do my best to answer embedded below at different places, to keep it all in context.
I have put three asterisks (***) at beginning of lines in which are my comments.

Hesno,

You did not share many details about you and your case. I sense anxiety in your words. Can you tell us what is bothering you?

It seems that you have been diagnosed (by a doctor) or just think that have recurrence from the radiotherapy (IMRT) of 2011. Can you tell if such condition is due to an increasing PSA or if there are other exams/symptoms leading to the diagnosis?

***  Yes, diagnosed by doctors that it is a recurrence; no other symptoms as far as I know that am now often thinking some muscle ache or effect of walking or light weight lifting might indeed be related to pca spread instead.  No scans done so far and that relates to the topic of the post, in context o should I get axumin scan now if specific imaging center has only done 6 of them so far -- or do I wait until they have done more to build my perception of their expertise in doing that scan.

*** age 70 now, G4(4+3) in 4 cores, 90-100%

From your descriptions I take the PSA histology starting at 0.6 after RT and then increasing with a PSAdt of 8 months reaching the value of PSA=3.1 ng/ml in the present ( 5 1/2 years later). You still have your prostate gland in place. I wonder what was your PSA before RT and if you have experienced bounce along the years after RT?

*** last psa before RT started was 2.9; the  bounce happened within 1 1/2 years and was from <0.1 to 0.2 and 0.3 and then back to 0.1 over a few months.
drs have not described this current rise as a bounce; i wish it was.

PSA bounce is typical in guys that had RT as prime therapy without any neoadjuvant/adjuvant ADT. One may see the PSA climbing and then going down and climbing again till it starts a downwards curve to a nadir. This bounce can take years to be accomplished. I never heard of a 5 years period but I know one case of 4.5 years. Could this be your case?

*** as above, I don't think so nor do doctors.

In your first post you inquire about the FACBC F18 PET/CT exam but you do not specify if you are having it or just plan to wait till it is available at your neighbourhood. I also do not understand your purposes in regards to the test. Are you trying to locate the bandit's hideaways for defining a salvage therapy to tackle the recurrence?

*** I've not had it yet - its just started being done in my area (and that is true for most areas all over the US).
yes, the reason is to see if and where things might be, whether for possible spot imrt or just to know for treatment planning
and initiation (I don't think salvage would be doable as rad dr said no more imrt should be given

*** as to if scans are clear, should prostate mri and possible re-biopsy be done if things seen - the salvage options would be limited since had 79gy in original imrt and rad dr said no more - which leaves surgery - high risk and complex and rare for folks who have had imrt, and seeds or the cryo or hifu - I know nothing about tha
but in any case the first step am told is the scans (and I know a negative scan does not mean there is not something there)

My recommendation is for you to consult a radiologist (maybe the one that did your IMRT of 2011) because SRT may be possible in your case (RT patient), if recurrence is confirmed and if the cancer is located in areas that can absorb more radiation. Our body tissues have limits in absorbing radiation so that you would need info on your previous RT isodose plan. Do you know details of the IMRT of 2011?

*** 79gy - and  rad dr said no more - I did not ask about SRT per se, but he said no more radiation in that area would be safe.

Surely any salvage treatment done with the intent of cure will be dependent on the location of the cancer, therefore requiring an image exam done with the latest and most reliable testing means. I think you doing it well in researching and procuring the best. At present, the most reliable images to detect prostate cancer (PCa) are those produced by PET scans using radiopharmaceuticals as tracers. FACBC F18, Gallium Ga68 and C11 or F18 choline are the most recommendable in systemic cases. Some newer radiopharmaceuticals have also proved capabilities of treating PCa killing it directly on the spot. This is called "Molecular Radiotherapy". This treatment is already available in Europe, using Lutetium (177 Lu) which is also used as a contrast agent in PET scans. In fact there is an ongoing clinical trial which could be the means you are looking for. The trial subject is image study of neuroendocrine tumours, suits your status (I think) so that you should discuss with your doctor about possibilities in participating. Here is the information;

https://clinicaltrials.gov/ct2/show/NCT02609737

*** Thanks for the pointer - I am impressed with all the new radiotracer trials and activity.  And that is why the FACBC/Axumin seems so attractive since its in my area now, just started doing it, and hard for me to leave area to go to other trials or choline or acetate
or gallium/psma.

Regarding the professionalism of the staff and radiologists in charge of PET exams; the preparation and administration of the shot is equally done as in any other injected contrast agent and the proficiency in interpreting the image would be expected to occur at creditable facilities other wise such contrast agent would not be available. Special care are needed with these radiopharmaceuticals so that not all radiographic facilities handle the test. Only proper nuclear departments do the exam, and you can request a second opinion (second reading) from an independent professional, in particular one of those involved in the clinical trials (recommended by the contrast agent manufacturer).

*** Vasco, this is helpful information, and I just need to convince myself or not, that even though it is an experienced place
in doing PET/CT with other tracers, but have only done 6 scans so far using the Axumin (which does have a slightly different
prep procedure for patient) -- that 6 sans done  is enough or not forme to believe they  have expertise in doing it and reading it.    I don't want to be someone with whom they are still learning or ramping up - and this is not a clinical trial.

*** I will look into getting a 2nd opinion/read and find out what places still do the clinical trials of it, since now it is released commercially.

The use of tracers and image equipment varies in accordance with the purposes. A localized image is better done with a MRI or CT. PET is commonly used for whole body images. It is proper for systemic cases. However, the type of tumour also influences in the choice of a tracer. For instance, NaF-18 sodium fluoride acts well in bone osteoblast and osteoclast (bone formation) therefore it may be the best to look for metastases in bone (better than Axumin). Ga68 is also better than Axumin to identify PCa at certain organs (as commented by the manufacturer). The good in Axumin is its long half-life (no need of a cyclotron, whicht is a requirement in choline based agents) and the negligible uptake in the urinary tract that could influence false readings (a problem of C11). It is also well metabolized in liver.

*** Now this is an important point, and one I have been confused about - re Na F  being better in finding about bone.  From reading the axumin docs and speaking with some imaging places who do it - it *seems* that it claims that it can
find things in both bone and in soft tissue in and outside of prostate area.
And in other comparisons of scans, I think have read  that Na F was not viewed that good in what it does (bone, not soft tissue)
than other scans like choline, acetate, psma.

*** Thus i assumed/am assuming, that one would not need a further bone scan, ie Na F, if Axumin was done.
Nor that one would need a traditional stand alone CT with/without contrast if Axumin was done.

*** I realize in the past, in my area, there was just the Na F and traditional CT and NaF used for bone and CT for soft tissue -
and I thought that Axumin could preclude the need for those in addition -- but if I am wrong I need to do better planning
as needing to have those additional scans means even more of a dose of radiation than just PET/CT, which is a lot.
Or perhaps with pca, that is just one of the risks in needing to do what is needed ?

One aspect that you need to consider in your next step is to be clean of any substance that could interfere with the properties of the radiotracer. For instance, 68Ga attaches to areas of inflammation where rapid cell division occurs, such as cancer cells, therefore hormonal therapies (turning these cells indolent) should be avoided. In other words, you should start ADT only after the PET/CT exam is done. Your present PSA level allows you time to study and research, and find out about your other health issues that could interfere/proibit the test. Make the best decision on your next step but do not sleep on the matter. Get consultations and move forwards coordinately and timely.

*** Yes, I am not planning on doing any ADT until baseline scans can be done  - either axumin or Na F and regular CT.
And thanks for mentioning abain that my present psa level does allow me some time to study and research about the scans.
Certainly it is that psa level now which is higher than the 2.0 value which defines my recurrence that caused me to look into
looking to get scans now vs at the psa=5 that one dr said, whereas 2 others I saw for 2nd opinion mentioned the standard
get scans at recurrence value guidelines.

*** Vasco, thanks again for taking the time to ask me these questions and provide your suggestions and comments. I only hope my comments have been as clear and detailed as would be helpful.

*** I hope your situation related to kidneys and blood levels (as per your recent post) will resolve soon.

 

 

Old Salt
Posts: 720
Joined: Aug 2014

Have you considered PSMA directed scans? Not routinely available in the US, but there are clnical trials, although I don't know if you would qualify.

Vasco also mentioned that approach

VascodaGama's picture
VascodaGama
Posts: 3033
Joined: Nov 2010

Hesno,

I understand your worries. I believe that many have (or even are) experienced the same frustration in identifying targets for treatment. Back in 2001 I confronted a similar situation when recurrence was declared after my surgery (PSA>0.4 ng/ml). The sequential after RP was salvage radiotherapy but that was done on guessing basis, as there were no reliable means to locate cancer of small sizes (my case was micrometastases). PET scan for PCa was also unreliable (poor contrast agents) and ProstaScint used a tracer/technique linked to many false negatives and false positives. The doctor in charge of PET at Sloan (MSKCC) told me that the results confused PCa with other proteins of the lymphatics.

Along these years there have been incredible advances in the quality of image studies because of the availability of better more accurate machinery, better analyzing software, newer contrast agents/tracers and techniques (one example is the USPIO using Feraheme as contrast in a MRI exams (similar to Combidex in Europe). Unfortunately these diagnosing techniques all need approval that is subjected to many years on trials before being put into practice, which timing may be already absolute because of other better tracers in development with confirmed better results. Old Salt above is alerting for you to include in the investigation, scans that aim specifically the prostate cancer. One must consider that most of the contrasts/radiotracers involve the diagnosis of several health issues. The pharmas look into the economics of the substance they test and sale. For instance, Axumin (Fluciclovine F-18) is a synthetic amino acid that is taken by many cancers including PCa, which is then compared with surrounding normal tissues. Mistaken in reading can occur.

The glycoprotein PSMA (prostatic specific membrane antigen) is specific of prostatic cells which makes it proper when targeting PCa. ProstaScint claims to be the only one scan approved that aims specifically prostate cancer (Read this). In Europe you can avail already at several places/nuclear facilities the 68Ga PSMA PET but at US this is still in trials on its way for approval. In other words, Axumin can be considered a generalist PET scan for cancers that includes the several types of tissues and bone (without any particular preference), when used with the radioisotope F18 (some nuclear facilities may be using it to prostate cancer clientele).

There is no bad meaning in the above. I think that Axumin is very good because of its easy disposal by the kidneys. The body is clean in a short number of days permitting additional testing latter. Its results can be used anytime for comparison with other tests. The CT involvement in the exam is necessary to specify (pinpoint) the location of the bandit. You need not to be worried with the much radiation absorbed during these tests. You can do it now (if already confident) adding more tests at a later date and get involved in a treatment when you are assured of the targets or when the PSA reaches a pre defined trigger threshold (such as PSA=5.0 ng/ml), similar to the comment of the doctor you consulted.

In regards to the treatment, I would recommend you to consult more specialists. I do not think that a biopsy is required if the radiopharmaceutical scan identifies the cancer. It is true that radiation prohibits to certain extent a superimposed RT dose. However, your 79gy is common and affected tissues recuperate along the years permitting rads again. Dattoli is repeating radiation at prostate bed and localized lymph nodes in patients that had RT as prime or as salvage RT. Moreover, they do it on guessing basis, without positive scans in hand. Three survivors in this forum have such SRT experience with the data from USPIO-Feraheme MRI test. Please have a look into the links of this thread: https://csn.cancer.org/node/296402

You can also call (by phone) to inquire on the procedure directly to these sites;

http://www.dattoli.com/

http://www.sandlakeimaging.com/services-diagnostic-imaging-sand-lake-orlando-fl.html

Overall you need to be confident and feel comfort with the treatment you chose. All the information about your case is necessary to develop a better judgment of your status. What could be the characteristics of your cancer?
In my case I am very involved in the researches on image studies because I believe in the oligometastatic treatment theory (a fewer number of metastases). This is the only means I have for aspiring cure at the present times. Locating the bandit is crutial but even if I manage to find it, such cure can be allusive because of my systemic case with micrometastases. These little baggers are continuously growing so that what cannot be detected today (for its small size) may appear tomorrow as a newer recurrence. In the end, at least I gave it a try.

Thought you have recurred from a previous RT, at the age of 70 you can still aim all means of a therapy with intent of cure. Surgery is also possible if you find a surgeon. You need to be careful with the risks involved. You can also choose a combination of treatments with spot radiation plus ADT. When that is not feasible then you can aim systemic treatments, such as chemo, hormonal therapy or immunologic treatments. These are palliative and can be started at anytime. You can also wait and aim at the newer "Molecular Radiotherapy” when it is available at your place. Meanwhile continue your investigation and get prepared. Check your bone density (DEXA scan) as the bandit loves to spread to weaker bone.

I hope my lay comments are of help to you and that you feel better about the situation. Anxiety is friendly of the enemy. 

Thanks for the well wishes regarding my kidney problem. You need to be on the top relentlessly.

 

Best wishes,

VGama

 

hesno
Posts: 11
Joined: Jul 2016

Vasco,

 

Thank you once again for these very helpful and detailed comments and suggestions !

And yes, your comments and support have helped to reduce my anxiety related to this situation

and that in itself is so important.

 

Thanks again.

 

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3313
Joined: May 2012

Vasco,

I have a question regarding a sentence in this post of yours ('My lay opinion'), and hence I suppose it is relevant to this discussion/thread.

You mentioned here (as I have read you do many times before -- always accurately) that your salvage radiation was done "at random," in the sense that it irradiated the adjacent prostate bed area, hoping to kill any micrometastatic cells in the process.   I fully understand this, and know that it is a reasonable thing to do when available scanning cannot identify where the remaining cancer cells are.

But:  how would parts of this this differ from radiation being used as first-line therapy ?  That is, current first line radiation is directied, with great precision at the contours of identifiable tumors. This is true both of fractionated and SBT deliveries. 

What about micrometastatic tumors that have wandered out of the gland, which are too small for any current imaging to detect ?  Do you know how this is addressed, if it is addressable ?  Very possibly, it is NOT addressed, due to the presumption that, based on various specifics (Gleason, volume of disease in biopsy samples, imaging results, PSA level and vector, etc.), cancer has very likely not left the gland.

max

VascodaGama's picture
VascodaGama
Posts: 3033
Joined: Nov 2010

Max,

My (lay) opinion regarding treatments for prostate cancer is that they are all done "at random", unless targets are previously defined. For instance, those cases diagnosed as "contained" are not done at random. These got a target which represents the whole gland itself. Dissecting it or bombarding it with radiation, laser beams or freezing it dead, will most probably achieve the goal in killing the disease. However, cancer that have spread and that due to its size cannot be detected (to provide targets), then the treatment is done in guessing its location. Surgeons only debulk the big tumour knowing that recurrence will exist latter. Radiologists use predefined fields of attack recommended by the NCCN guidelines. These guidance is based on the best results obtained from treatments of identical cases (typically the prostate bed and lymph nodes).

When diagnosed with micrometastases we know that one is confronting a systemic case. To such extent, all therapies are done guessing in the expectancy that one of them hits the target in the dark. These starts with a series of radiation to zipp the "large terrain" (salvage RT) then it comes the chemo that also manages to kill cancer wherever it hides. ADT and imunnologic principles or holistic means are all done to extend the period in dormancy of the cancer. In other words one starts systemic treatment hopping that we live to die from other causes.

Back in 2001, Slovin at MSKCC diagnosed me with micrometastases (I was Gleason 5 (2+3). Eisenberger at JH confirmed the results. A radiologist specialist in PCa in Japan also confirmed the diagnosis but he commented on the so called oligometastases therapy (small number of spots located at places able of being radiated). Detecting those spots was at the time a very difficult task. (ProstaScint flourished)

Without targets one need to follow something. Slovin was doing a clinical study based on past examples to evaluate the limits in times when starting radiation (the first choice in systemic treatment). Earlier was not seen as better in prolonging life but it would prolong chemical recurrence. As the moto was to extend the phases of the attack, I was put on WW (annual MRI, PSA, etc) till reaching the JH set trigger threshold of PSA=4.0. In 2006 I did SRT. In 2010 I started IADT. Mean while newer image exams and molecular therapies started to come out of the drawing boards. These provide us with the dream of killing the bandit. We are hopeful and never give up.

If I may add a note to the above, I realized along the years of researching (and based on own experiences) that the present treatments seem doom to fail because they do not address the cancer itself. They are not the “Silver bullet”. I believe that the investigations done using genomics in the diagnosis and latter in therapies are the path that will take us in the future to reach the ultimate goal of eradicating this disease. PSMA based diagnosis and radiopharmaceuticals similar to LU177 are at this present time the best to deal with cancer cases that turned into a tumour or are still at its cellular formation, such as micrometastases.

Best

VG 

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