What is the BEST Way to See if Prostate Cancer Has Spread?

[@mm12201]

Thank you for sharing. I was diagnosed with PC approximately 4 weeks ago. Prior to my upcoming PSMA Pet Scan today, my results were uploaded on my patient portal approximately 5 days prior to my follow up visit to discuss the biopsy results. Of the 12 core samples, (2) 3+4=7 and (6) 3+3=6 were diagnosed as Adenocarcinoma. As I continued my due diligence I located one of the Gleason 6 scores indicated Perineural Invasion. First time I was aware of this result. After reviewing numerous presentations on youtube, I became concerned. I was able to continue researching options on PNI. I did review your presentation (very well by the way). Thus, in preparation for my follow up visit I decided I would have a prostatectomy. My Urologist reviewed several procedures to combat PC. The Urologist was very positive and stated "this is very curable" 🙂. He did not discuss a PSMA Pet Scan. I brought the scan up and asked how do we know if the cancer metastasized? Collectively, he agreed to order a PSMA Pet Scan. I'm praying that this has not spread. If it has not spread, I will continue with the Prostatectomy. I appreciate you Dr. Ahdoot for sharing this valuable information.

[@cancerbetter]

Happy I could help and it sounds like you are on a good path.

[@Eclectic_RN]

I would be quite happy w/ your Gleason scores as mine are G-4+4. I too have perineural invasion and extra-prostatic "bulge = ?" as well as involvement with the R side neurovascular bundle. My PSA was 54, and the predominant tumor is large (~5.1 CM3). However, I will not have a prostatectomy. Consider getting a 2nd opinion from one of the centers of excellence such as Johns Hopkins. Consider one of the newer RT methods with or without seeds, and consider both cure rates and adverse effects. Remember the adage: "To a hammer, everything is a nail," and to a surgeon.... Consider finding a urological oncologist, or even if you can find one, a prostate oncologist. I suspect, as time goes by, RT will become the predominant treatment, in most cases. Check out Mark Scholz vids. Best of luck.

[@steviebe8982]

As somrone facing radical prostatectomy, I very much appreciate this information. I like to be informed and appreciate Dr's that are aware of developments. Thanks so much.

[@lamarrdavis7723]

Thanks for sharing this information. It was very helpful to increase my knowledge. I had a PSMA/PET scan in 2023. And, was found to have the cancer to mastastasized to the pelvic & ribs. However, the great news was it was located early, and was non detectable after the first round of three radiation treatments. The technology is life saving & has given my wife & I peace of mind ❤❤❤🎉

[@pankajb3214]

How many spots it showed in PSMA/PET? My father is also in same situation.

[@cancerbetter]

Thank you for sharing your experience! So happy to hear you are getting good treatment

[@stevegannaway1787]

Thank you for this excellent video. You are a very good teacher. We are gathering information to help us decide what to do. On a sincere note. Please get more rest or have your liver checked. Your eyes are very dark underneath and that ,as you know, is a sign of something very wrong. Good health to you too doctor.

[@cancerbetter]

Happy the videos are helpful.

[@robbujold7711]

Clear, thorough explanation of specificity, sensitivity, and negative predictive value. Thank you.

[@cancerbetter]

Very welcome. Hope it helps

[@croyland11]

Excellent explanation awaiting your discourse on what happens if the cancer is not treated. Thanks.

[@cancerbetter]

I have a video on that. Check it out

[@patrickmoran687]

Well done doctor. You speak to men in language we ca understand!

[@nvan78]

Good information. Recently had a PSMA Pet scan as part of a clinical trial for an FDG contrast agent that is approved by the FDA but not yet by Health Canada (BC Cancer Agency). My PSA has remained high even after TURP surgery last July hence the decision to have the scan. Interestingly, the scan indicated Gleason 6 cancer is confined to the prostate, but did pick up a suspicious 2.1 cm thyroid nodule

[@Jack-2day]

I am in the same boat here in B.C. Since it is not yet approved by Health Canada (BC Cancer Agency) could you pass on which route you took to receive the scan and cost? Much appreciated!

[@nvan78]

@@Jack-2day was referred by my urologist, wait times are listed as 6 months + but somehow I was seen within 3 weeks. There are eligibility requirements listed on the BC Cancer Agency website, if accepted there should be no cost.

[@cancerbetter]

Thanks for sharing so others in Canada can learn ways to get these scans up there. I trust these scans will soon be used widely in Canada as well

[@nvan78]

@@cancerbetter so my latest PSA reading is 27, higher than the previous one of 22. I have these tests taken at the same clinic, around the same time of day to try to follow the same protocol prior to the test. Not sure what my urologist will suggest next, but after a previous conversation with a radiation oncologist at BC Cancer we decided to forgo any treatment unless more cores are involved (currently 2 of 12 seem to show up on biopsies). Prior TURP so wouldn't be eligible for brachytherapy,, likely choose radiation if the time comes,.

[@Trailjunkie62]

So glad I found this channel 53 years old and was diagnosed with Gleason 7(30%) in one out of 12 cores 2 months ago. I’m scheduled for a transperineal biopsy in 8 weeks to see if there is any spread or additional cancer that was not detected in the standard biopsy. Thoughts as of now are active surveillance unless the second biopsy shows movement. Thanks for educating us on less invasive treatment options and outcome statistics

[@robwembley]

What were the biopsies like for you. Concerned about the procedure. Many thanks.

[@Trailjunkie62]

@@robwembley honestly it wasn’t as bad as I thought it would be. The clicking sound of the sampler was a little unnerving but I was pretty looped on the Valium. Slightly painful I would say. I had some perineal pain the days and weeks following(dull throbbing ) and be prepared for the presence of blood in the semen because it is surprising but normal for up to three weeks. Prayers for you in your journey of dealing with this and best wishes on the procedure you will be fine.

[@robwembley]

@@Trailjunkie62 Thank you for sharing your experience. It is very sincerely appreciated !

[@cancerbetter]

Check out my newest video on what happens if you don’t treat prostate cancer. I think it will help you make a decision regarding treatment vs surveillance.

[@WallaceDunn]

Gleason 3+4 is different than 4+3, it helps if you show both numbers as far as severity.

[@mikeash7428]

Thanks for smart advice. I like your enthudiasm and caring demeanor.

[@cancerbetter]

Happy I can help!

[@sandybongos3836]

THANK YOU DOCTOR. EXTREMELY ABOUT THIS INFO.

[@cancerbetter]

My pleasure. I’m happy it helps - Michael Ahdoot MD

[@bobtoner9820]

Had a random biopsy, bone and CT scan. I changed doctors and had color doppler ultrasound and 3tmri and psma pet scan. Also second opinion on biopsy at John Hopkins

[@Midnitexowboy]

And??

[@bobtoner9820]

I had HDR Brachytherapy on Aug 9 last year to the whole gland. 17 catheters. First 3 month blood test was good. Waiting to see how the second is

[@Jack-2day]

Good to hear your doing well. Can you tell me what 17 catheters relates to exactly? Thank you sir @@bobtoner9820

[@brucecampbell6133]

Thanks for sharing!

[@okaydokey95]

Thank you for the information!!! This is awesome!!

[@DavidShenker]

I had a prostatectomy 2yrs ago, my Gleason was 8, fortunately margins were clear, and had not spread to lymph nodes. PSA dropped from 9 to less than 0.01 where it has remained for past 2 yrs. I am still concerned with spreading and requested a referral from my urologist to have a PSMA Pet scan but he refused saying PSA is so low there is no cancer - who is right? I totally agree with selecting young eager, proactive doctors who are using today's technology and science.

[@cancerbetter]

When your psa is undetectable the PSMA pet scan will almost always be negative. I’m general PSA is a more sensitive predictor of the presence of cancer. What the PSMA PET scan allows you to do is localize the cancer so you can treat it. In the post prostatectomy space you would really only do a PSMA if your PSA is detectable. Congrats on the excellent outcome of surgery. So long as your psa stays super low you have nothing to worry about.

[@DavidShenker]

@@cancerbetter Thank you

[@randallsample1005]

@@cancerbetter This is very reassuring to me, since my circumstances are nearly identical to Mr. Shenker's. Thank you.

[@douglasrickert1051]

@@cancerbetter 5:53

[@hayesracing43]

My delt with this.... His urologist kept giving him reassuring news that his cancer was well in check since his PSA was so low. PET scan in February came back great. My dad died that September and was FULL of cancer. Doctors said they never saw it coming. What could have gone wrong here? He was treated for a year and a half with ADT and was told all was well ... Any closure you can offer would be wonderful.

[@bryanmanderville4196]

Great video I am going for this scan in a few days

[@cancerbetter]

Good luck!

[@foropera]

In France it is just Forbidden to use PSMA for first line evaluation. The doctor can ask for it only in recurent cancer. 😢

[@josephmarchioni8065]

Ce n'est plus le cas .Le PET SCAN PSMA peut être prescrit en bilan d'extension.

[@foropera]

@@josephmarchioni8065 d'accord, tant mieux. Mais en février 2024 à Hartmann, c'est ce qu'on m'a répondu.

[@cancerbetter]

Give it time. This will change as it did in the USA.

[@glennoc8585]

Same in Australia

[@chicagomike]

Thank you dear doctor. I have a lump on my prostate test psa was 1.0

[@cancerbetter]

The low PSA is reassuring. Most of the time prostate cancer is unlikely at this psa.

[@EmpireSlaveofMind8131]

I have colorectal cancer. I git a false negative on a PET scan which only caused setbacks and delays in my treatment. It was undetected because it's a slow grade cancer and combined with that the location & fasting on water for 24hrs all caused it to show a false negative. MRI remains the safest & best option that doesn't put unnecessary risk on the patient.

[@cancerbetter]

It’s important for the viewers to understand the PET scan used for prostate cancer is different than the one used for colorectal cancers.

[@EmpireSlaveofMind8131]

@cancerbetter the PET scan is a versatile machine. The difference doesn't lie in scans it lies within the tracer. Regardless, an MRI remains the safest alternative, less expensive & doesn't expose the patient to unnecessary amounts of radiation, especially if radiotherapy or later scans are needed. Magnetic resonance is the best solution when identifying and dealing with cancers. Biopsies and radiation therapy are inherently flawed.

[@BigZWD]

Thank you sir for your posting. I wished 😪 I had the PET scan approximately 3 years ago. My standard of care was of course the soft tissue pelvic scan, followed with tge skeleton imaging 3 weeks later. It did not show any metastasis anywhere. Opt for radiation treatment, 60/20

[@cancerbetter]

I hope you are doing well

[@BigZWD]

​@cancerbetter Thank you for checking up on me. Just saw my urologist on the 19th. I was able tobget the PET SCAN when my numbers shot extremely high after 3 months of very low psa numbers. But it shot up to over 8. They were thinking that it was a reoccurence and not a bump. The PET SCAN didn't show anything so we just continue to monitor, so after the numbers started to trend down and now it's just above 1.0. My urologist stated that he do not need to see me for 6 months. It had been about every 2 months. I do have a standing about every 3 months with my radiation treatment team.

[@BLUESKYS4EVE]

I think I just found my go-to source for up-to-date information.

[@cancerbetter]

Thank you very much. I appreciate the he recognition : )

[@davidbuha9132]

I agree this site is excellent. The Prostate Cancer Research Institute videos are also excellent.

[@khubaibjilani8986]

Very helpful stay blessed doc

[@cancerbetter]

Glad I could help

[@toppie5700]

here in south africa the psma pet scan is damn expensive and the medical aid dont want to pay for it yet ,it will probably take a bit longer to catch on

[@cancerbetter]

Expensive in the US as well. Typical cost is about $6000 without insurance is what I’m told.

[@largentmark]

Great content. I'm not sure where other men might be having a psma pet but here in Florida the cost without insurance was billed to my BCBS $89000. That's not a typo, almost $90k is just mind boggling to me when I saw the insurance eob

[@cancerbetter]

That’s crazy. I believe the cash price for this kind of scan is about 8k. Wonder what the others have found?

[@garyq531]

@@cancerbetter Free in Australia, just had one and all clear

[@cancerbetter]

@garyq531 very interesting they are free

[@garyq531]

@@cancerbetter government subsidised

[@voiceofreason33916]

Great information! Thank you.

[@ctchye53]

Thanks

[@BLUESKYS4EVE]

Very Informative. So, I see online that Medicare will offer a rebate for the PSMA PET scan as of July 2022. You state that it is now a full pay starting in early 2023. Am I correct?

[@cancerbetter]

Medicare pays for PSMA pet scans with little exception when there is an appropriate indication. The private insurance companies sometimes accept the claim and sometimes don’t. It’s a hassle but you doctor can try to petition the insurance company to accept the bill. While I do this for my patients it’s an annoying and time wasting process that we do not get paid for. Some doctors have give up on fighting with insurance companies.

[@bvrod]

Curious to know what the PSA cutoff is before you think that the scan likely would not see the cancer. In other words what PSA level is required before the negativity result is statistically correct 75% of the time. I used 75% but maybe there is a better way to pose the question of what level of PSA should we NOT perform the PMSA scan?

[@cancerbetter]

Do you mean after prostatectomy or before?

[@bvrod]

@@cancerbetter after

[@bvrod]

@@cancerbetter after

[@RichardCook-u2h]

My PET scan was negative for anything outside of my prostate. However, the PET scan failed to detect some areas that were biopsied and were positive for cancer. I was told they were going to do additional deciphering tests on the remnants of biopsy samples. No results yet. One thought I had was what if the cancer I have developed is not sensitive to the PET Scan? Could it have already migrated out of my prostate into other areas of my body and simply be undetected because it is not yet sensitive to the PET Scan? Am I overthinking this? Thanks.

[@cancerbetter]

This is actually a common finding. Many of the less aggressive prostate cancers do not produce PSMA receptors which is the protein that the PET tracer attaches to. This is commonly seen in Gleason 6 and 7 prostate cancer. This just means PSMA PET does not work great for your individual cancer.

[@JimLewus]

Thank you

[@cancerbetter]

You're welcome

[@hsays2980]

Great video. Is a PSMA Pet scan more advanced when compared to a 3T - Multiparmetric MRI? I have had 2 3T's and I am scheduled for a 3rd. Should I investigate getting a PSMA PET scan instead. Have Gleason 3+3 2 cores. PSA has risen in the last 2 years from 11.8 to 15.3. I am on active surveillance. 68 years old. Looking forward to the next video.

[@cancerbetter]

That is a very interesting question. When it comes to prostate cancer diagnosis MRI followed by MRI targeted biopsy is the current gold for prostate cancer diagnosis. That being said there have been small, very recent studies looking at PSMA PET scans to identify prostate cancer in the prostate and direct biopsies. While the early data is limited it suggests PSMA PET scans may be a good way to detect high Gleason score prostate cancers…perhaps even a little better than MRI. However, given how limited the data are and the cost of PSMA pet scans, it can be quite challenging to get an insurance company to cover a PAMA pet scan for prostate cancer diagnosis at the current time. The only way realistically to use a PSMA pet scan now to try to diagnose prostate Cancer would be probably in a clinical trial.

[@hsays2980]

@@cancerbetter Thank you very much

[@patriciareynolds2729]

ED, glad to see u are still kicking, in same boat! my PSA has grad. incline to .36 now.

[@johnnyjames7139]

This is all wonderful, but my prostate cancer had already spread to 15 places in my bones when it was first discovered 27 months ago. What I want is a cure! Fasting ?

[@cancerbetter]

We currently do not have cures for metastatic prostate cancer but we do have many medications that can stop the growth of the cancer and even cause regression of the cancer. The medications can keep working for many years and there are various types of medications that can be helpful. Research is always active being done to find better and better treatments. Every year I attend numerous medical conferences where we discuss the treatments in development and there are many exciting treatments on the horizon.

[@pinotwinelover]

There is growing evidence that cancers of mitochondria malfunction in ketogenic fasting may be helpful and longevity, and in combination with other treatments

[@MrCcarbaugh]

@@cancerbetter Thank you so much for your most helpful video! I'm 71 years young and have aggressive, (9) metastatic (Bone/Bladder) cancer. (Orchiectomy 1 year ago, TURP 10 months ago PSA- 13 and rising.) I have an appointment for Radiology but if there are medications, I would prefer that - if they are affordable with no insurance. Thank you so very much again - I am from San Francisco but living in Bangkok, Thailand for 16 years.

[@steveweiss7736]

So how do you convince your doctor to order a PSMA PET Scan if they are reluctant to do so?

[@cancerbetter]

Start by asking why they are reluctant. For someone who has had a prostatectomy of your PSA is less than 0.5 PSMA PET will only find something in about half the people. Your psa may be too low to make it worth ordering. Try to understand their perspective. If it doesn’t make sense you could find another provider to get their opinion.

[@texhill6504]

Important!!! My first urologist made the conclusion that because my PSA was 23 he wanted to take 12-14 biopsies without a physical exam via the TRUSS approach. Second urologist with the knowledge of my PSA of 23 did do a physical exam then stated “you have cancer” then ordered a T3MRI with a T3 magnet and concluded the necessity of 12-20 biopsies via the TRUSS procedure. My third urologist reviewed the T3MRI that did identify cancer and ordered a TPP biopsy. (Not the TRUSS procedure) The 25 biopsies revealed cancer. He has ordered a PSMA PET scan to confirm if the cancer has spread through my body. Conclusion: do diligent and forensic research.

[@cancerbetter]

Thanks for sharing your story

[@duski1505]

Really appreciate the education! 58 PSA 5.3, getting MRI , live in SF area, do you provide second opinions via in person visit and all records provided to you.

[@cancerbetter]

Yes. I can offer in person or video visits. As I have a California medical license I can only provide care for people in California. (Silly law I know). I work at Cedars Sinai in Los Angeles. You can call the office at 310-423-4700 to make an appointment.

[@robertmonroe3678]

PSMA PET CT scans are quite a leap forward in detecting metastasis and quite useful as long as limitations are understood. One limitation seems to be detecting ECE on intermediate risk patients when deciding on curative (surgery v radiation) initial therapy. One would imagine that would greatly decrease positive post-surgical margins as those with ECE would go the radiation route. At the same time PSMA is now also used for radiation targeting and even guided surgery.

[@wmbrice]

Very well-explained & very helpful. Thank you!

[@cancerbetter]

Thank you

[@MrMediterrano]

If PSA is high and steadily increasing but neither ultrasound nor MRI show anything suspicious, isn’t it the rational thing to do to first get a PSMA PET/CT scan before deciding whether to get a biopsy? If PSMA PET/CT too doesn’t show anything, then biopsy could be avoided or else, using the imaging from PSMA PET/CT fusioned with the ultrasound and MRI images, a targeted biopsy could be made instead of a systematic biopsy.

[@cancerbetter]

It’s reasonable but it’s a bit novel space that is not adequately studied to be a standard of care.

[@MrMediterrano]

@@cancerbetter Out of personal interest, I have made the research and found the following sources (scientific research and clinical experiences) supporting the use of PSMA PET/CT for initial diagnosis BEFORE a systematic biopsy. GU Cast | PSMA PET/CT prior to biopsy? The PRIMARY Study kzbin.info/www/bejne/jauZpqCHYpijhLs GU Cast | PRIMARY 2 opens - another fantastic randomized trial of PSMA PET/CT! kzbin.info/www/bejne/d2OkZp2ffquSrdU PSMA-Targeted Prostate Biopsy kzbin.info/www/bejne/eYenqKKbrNlkobs Risks & Alternatives | Random Needle Prostate Biopsies kzbin.info/www/bejne/faGafHRqhc9_gpY Prostate MRI: Do You Need a Random Biopsy? | Off The Cuff with Mark Moyad, MD kzbin.info/www/bejne/aai1YmCrZZycd7s Will Imaging Replace Random Biopsy? Robotic vs. Standard Surgery kzbin.info/www/bejne/kJLcgpZ-mNmfpZI Staging Prostate Cancer - MRI, PIRADS, & PSMA | Are Biopsies Still Needed? kzbin.info/www/bejne/p5-reYmibMpqiaM Diagnosing Prostate Cancer: Moving Beyond PSAs, Gleason Scores and Biopsies Through Advanced Imaging kzbin.info/www/bejne/rajXi4uhm7qSrdE

[@thailandbuddy4451]

Can I get a PSMA PET scan before getting a biopsy on a lesion in my prostate to see if I have cancer? A lesion was found by MRI. I now have DVT from it and on blood thinners.

[@cancerbetter]

Yes you can but insurance usually won’t cover it and it’s not a standard of care at this point. Studies are being done to find out

[@tonyczsg1]

Much appreciated and highly educational video. I wonder if pre-surgery bone and CT scan are negative for metastasis, and post robotic-assisted radical laparoscopic prostatectomy PSA (2months out) is negative (0.02) for a Gleason 4+3, grade 3 prostate cancer (pT3a N0) with genomic confirmation (DECIPHER SCORE =0.75) of high risk grade cancer (with intraductal features, cribiform pattern 4 identified, lymphovasular invasion identified, focal extraprostatic extension identified, microscopic bladder neck invasion identified, margins of resection are positive for tumor but seminal vesicles are negative for tumor), how accurate is it to conclude there is in fact no metastasis? Thanks for considering to offer your expert input :)

[@cancerbetter]

Please watch the video on PSMA PET scan. That would be the optimal test to evaluate for metastasis. That being said with a post op PSA as low as 0.02 the risk of metastatic prostate cancer is extremely low.

[@scoot77777]

Wow! Very impressive! Extremely educational! My PSA just came back at 5.7 my Doctor Immediately wanted to do a transrectal biopsy! I said NO! Finally after 6 months he agreed to a standard MRI with dye. Going to ask for the PSMA PET scan now! I am a disabled Air Force Veteran I find the VA very frustrating! To deal with 6 months just to get an initial appointment. Can you offer any additional advice? It would be most appreciated 🙏🇺🇸✅🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸

[@cancerbetter]

It’s one thing to get the MRI but the next step is your urologist should how to do an MRI targeted biopsy. I’d see if your urologist feels comfortable with the MRI targeting. While the PSMA PET scans are valuable they are usually not used for prostate cancer diagnosis so they might not order it unless cancer is diagnosed.

[@scoot77777]

@@cancerbetter Thank you Doctor 🙏😊🇺🇸👍🏻

[@n.c.b.8832]

Hi Doc, thank you for superb video and information, please keep them coming. Psma pet scans do seem to be the best thing we have at present time, I would love to have one to show exactly what is going on in my body, I just wish my backwards thinking NHS Oncologist at the local cancer hospital was as enlightened , they do have a Psma pet scan on site but not for me,, Gleason 9 with bone metz, so if not for me then who ?

[@carlchappell6383]

Sorry a bit late to the party, yes don't see why you are not an ideal patient? I'm also gleason 9 are you on adt?

[@philwinnard9189]

Yes, had one round of Chemo ( x6) now on hormone therapy, so far so good PSA 0.01. diagnosed Easter 22, How you doing ?

[@carlchappell6383]

​@philwinnard9189 Hi I was diagnosed sept 22, 39 radiotherapy, locally advanced lymph nodes and seminal vesicle involvement, finish adt Feb 24 it's taken its toll but hopefully done the job, I'll probably have a better picture in the next year or two god willing, psa was 12 now 0.03, thanks for replying

[@philwinnard9189]

@@carlchappell6383 what country you in Carl

[@cancerbetter]

@carlchappell6383 love to see that PSA so low! Hope it stays there and you start enjoying life off ADT!

[@Gary65437]

It seems like the first step with a high PSA 4.18 is a trip to the MRI machine. Is that screen accurate if you use a 1.5T or 2.0 or 3.0 machine. I got a PIRAD 5 using the 1.5T machine, lesion size 1.6x5.0 cm on both sides of the back of the prostate. What might be the next step. Been eating lycopene and diet change and now PSA came down 23% to a 3.20.

[@cancerbetter]

Diet change can lower PSA but if cancer is present it won’t make it go away. Sounds like a biopsy is a good idea. With regards to the MRI machine you want to get a scan on a 3 Tesla magnet for the best resolution.

[@Gary65437]

Thanks Dr. the biopsy seems like the next step, but at 68 I'm kind of avoiding the random 12 core standard here in jerkwater W Virginia and no 3 Tesla machines in town. My urologist doesn't have much faith in the MRI I got and wants to check my PSA in another 3 mo or so. Even my medicare advantage doesn't want to pay for screens so I may be doomed.

[@cancerbetter]

@Gary65437 you could potentially go to DC. Lots of excellent people there with experience with MRI. It’s fair to make an assessment of risks and benefits and then decide against the 12 core biopsies. Just want to make sure you are informed. I recommend you look at my video about your prostate biopsy can be wrong before your make that choice.

[@Gary65437]

Thanks doc. I think I recall the 12 core being 49% accurate at finding the cancer and hope no infection ensues. My father died at 84 after getting a C-dif infection in the hospital after his biopsy. Cancer had already spread to his bones so it was pretty much too late to try and start treatments at his age. His PSA was rising at age 72 and he let it ride.

[@cancerbetter]

@Gary65437 you may ask about a transperineal prostate biopsy as they have much lower infection rates

[@seascape35]

Great presentation.

[@cancerbetter]

Thank you!

[@smithkhabri]

My father's recent medical situation has left us feeling uncertain about the next steps. After his PSA level reached 13.5, an MRI showed PIRADS V, but a PET-guided biopsy came back negative. His PSA level has now decreased to 2.09, but we have received conflicting advice from doctors regarding monitoring the PSA or repeating the biopsy. We would greatly appreciate your guidance on the best way forward. Your expertise would be invaluable in helping us make an informed decision.

[@christianhermannengesser9817]

How many biopsy cores have been taken?

[@allanc9472]

Did he have treatment? How did the psa go from 13.5 to 2.09? Something he is taking or certain foods? Sound like he has no cancer as the PET-guided biopsy is negative and the rise in PSA maybe due to something else like BPH, UTI, Prostatitis? Just curious. Thanks

[@cancerbetter]

It’s very unusual to see a psa go from 13 to 2 but this can occur in certain situations. Things other than cancer can raise psa, ranging from infections of the prostate to a digital rectal exam prior to a blood draw. Even ejaculation prior to a prostate biopsy will often transiently increase psa levels

[@shahidasghar8350]

Very useful information !!

[@cancerbetter]

What else would be helpful to know?

[@F8Tributo]

​​@@cancerbetterDr, can a PSMA PET scan be used, "instead of" a biopsy?

[@cancerbetter]

@F8Tributo great question. Short answer is no because the PSMA PET does have occasional false positives. Most providers would not want to subject someone to prostate cancer treatment without first confirming cancer is actually there. Moreover there are low risk prostate cancers which could cause a PSMA PET scan to be positive that we don’t usually treat.

[@F8Tributo]

@@cancerbetter Thank you, doctor.

[@cancerbetter]

not reliably@@F8Tributo

[@stephenpisani1730]

Hi I'm 65yrs young and for the last 14 months my PSA has been 12.4. My Urologist sent me for an MRI scan and the results came back as inflammation and enlarged prostrate. Urologist told me i have Prostatitis the reason why my psa is high. I did mention about a biopsy but the Urologist was against the idea as their is no target with the biopsy needle as the mri scan is showing nothing suspicious. Im a little nervous as both my Dad and Grandad both passed away with prostrate cancer. Im even contemplating paying private to have my prostrate removed as its causing anxiety. How accurate is an MRI scan? I had another psa blood test yesterday 2 months after my last one so hoping the psa levels have come down. Results next week 🙏🙏

[@patriciareynolds2729]

ED here, hang in there buddy. i've been thru it all & still kicking. please believe in JESUS CHRIST as that is our only hope anyway!

[@cancerbetter]

If you have an MRI that finds no target and an elevated PSA data shows if these people undergo a biopsy 10% will be found to have prostate cancer.

[@stephenpisani1730]

@cancerbetter Thank you for your reply and information. I had a psa blood test 2wks ago and now thankfully the psa levels are now down to 7.2 ...

[@kellyclover5953]

I am suffering from a group of symptoms that could either be from a bad case of enlarged prostate or even from prostate cancer. I have heard that some forms of prostate cancer do not affect PSA levels. The last PSA test had me at 1.6 ng/mL. which is a very good number. How confident can I be that my bothersome symptoms are not from prostate cancer?

[@cancerbetter]

PSA non producing prostate cancers are very rare and represent about 1% of prostate cancers. Your odds are very low.

[@michaelweyhrauch7833]

Thanks!

[@Giovan_Nino]

Very helpful 👍

[@cancerbetter]

Thank you. So happy to help

[@patriciareynolds2729]

ED here, my journey continues. been thru surgery, radiation, and some lupron. now my PSA # is easing off 0 again, like .36 for 1 year. next app. is Jan 15. Do i need PSMA scan and is PSA of 2.0 or above the beat time to do the scan. THANKS

[@cancerbetter]

Limited value of PSMA PET with a PSA

[@peterlewellyn2389]

How often should or could you have a PSMA test?

[@cancerbetter]

Usually these are done when a persons PSA starts rising after prostate cancer treatment. Ideally the scan would help you find an area of recurrence which you would treat with radiation or surgery, then you would go back to checking PSA levels until the PSA rose again.

[@glennoc8585]

My father recently passed and he had ADH treatment for 15 year aswell as radiotherapy with seeds after 10 years. He should've been given the option for chemo and radiotherapy earlier on we believe as his gleeson was 8 early on. He had the pet scan which detected metastasis and his psa levels were rising rapidly just using the hormone implant. His oncologist prescribed zytiga and cortisone but he found that put huge weight gain onto him and risked bone thinning and other issues. Another issue was age as many doctor's are reluctant to consider many options once you cross over 75. Thernostics therapy was a very real option but again unless you present as upstanding in movement and cognition you will find it hard to get referrals.

[@cancerbetter]

Sorry to hear about his passing.

[@JB-be8co]

Under MRI results show as PIRADS -2 & 3. Is here Biopsy test required?

[@cancerbetter]

depends on other factors like PSA density, age, prior biopsy status

[@kirkgossett4391]

I had a radical prostatectomy performed 28 months ago, nodes taken during surgery were negative however some cancer in seminal vesicles and had very high Gleasons pre-surgery. Post surgery, PSA levels were nearly undetectable until last week my PSA was .17. Just left urologist who is having another PSA test done and recommending a bone CT scan. BCBS apparently doesn’t cover PSMA PET scans but I am willing to pay the out of pocket costs to have it done. If PSA test results come back at .17 or lower on second test, would a PSMA Pet Scan be the course of action? Lots of confusion regarding radiation and ADT. I am only 60m years old.

[@cancerbetter]

I see. With a PSA that low PSMA PET, bone scan, and CT are all unlikely to show any area of cancer as a PSA that low reflects a very small volume of potential disease. Of these three tests however PSMA is far and away the most likely to show disease. If your PSA is rising on subsequent check your doctor is likely to recommend radiation to the prostate bed and the lymph nodes in that area. That is very likely to result in a elimination of your cancer as a threat. The total radiation dose of radiation after surgery is lower than the dose given for primary treatment which will result in a slightly lower side effect risk.

[@kirkgossett4391]

Wow, thank you so much for your response. I got my second PSA results this morning and it was .15. As I left my Urologist yesterday he said he was going to try to get BCBS to approve the PSMA PET. I like to be proactive so I called a couple of hospitals to see what would cost out of pocket and prices were $6-8K plus professional fee, nobody could pin down a grand total. Based on what you are recommending, it might be better to wait another 3 months and have another PSA test? I think I have read that .20 is the threshold but some recommend a “Doubling Factor?” Thankfully, money is not a primary concern, I am not opposed to being more aggressive but I am confused that my Dr wants to PSMA scan when I have had a .17 and now .15 PSA result? Again, thank you for responding so quickly. My brother is a Dr. And we were discussing how patients now get test results before the Dr. In many instances. I found out I had prostate cancer sitting on the couch with my wife when got an email and then I found out my PSA was going up after two years near zero via an email. Where do you practice? I find your video’s very informative and comforting and would be willing to travel and pay out of pocket for you to review all my test/post op/PSA results. I have been to Cleveland Clinic, Henry Ford and Corewell Health for opinions when my urologist was recommending I try a post-op clinical trial. @@cancerbetter

[@kirkgossett4391]

Ahh, I see you are at Cedars Sinai, my company built the Pathology Grossing Stations for your hospital and most pathology labs in the US.

[@cancerbetter]

@kirkgossett4391 I currently am part of the academic team at Cedars Sinai. Search Michael Ahdoot MD and you’ll fine me. Happy to see you but in your case it sounds like a good radiation oncologist may be a wise person to consult as well.

[@pinegd1]

Biopsy may actually spread cancer cells before therapy even begins. Why else do most patients have recurring tumors years after radiation or prostatectomy.

[@jamesbreiling3427]

What is the variance or standard error of the SYVs?

[@jamesbreiling3427]

How is a PSMA “hit” validated (biopsy) when the PSMA is the most sensitive & specific test available?

[@cancerbetter]

Often times your provider will trust the scan if all signs point towards cancer in the area detected. If there is any doubt they will usually recommend biopsy.

[@gtrgenie]

Recently Dx PSA 49.5 Gleason 4+4 and 4+5 PSMA-PYL done today awaiting results Are you still at Cedars?

[@cancerbetter]

Yes I am

[@gtrgenie]

Thanks. I heard of a newly Dx patient getting Lutetium-177 as first treatment before anything else. Is this possible?

[@cancerbetter]

@gtrgenie yes as part of a clinical trial.

[@gtrgenie]

Ahhh, Thank you Dr. Ahdoot🙏🏽

[@glennoc8585]

​@gtrgenie that's interesting as usually lutenium is seen as a last resort for metastatic prostate cancer

[@PythonLee]

I have a psa of 21 and a Gleason score of 4+3 and the doctor told me I am not eligible for one of these.

[@cancerbetter]

That is likely inaccurate

[@cancerbetter]

I’d recommend a second opinion

[@rayp7135]

100% untrue at least in NJ and should be covered by Horizon BCBS as well.

[@Biochemechanic]

Can this test diagnose a cancer in the prostate at an early stage as a noninvasive alternative to a biopsy? Is 3T MRI a better test?

[@cancerbetter]

As of now the MRI is the best test for diagnosis but trials are being done to assess PSMA PET.

[@Biochemechanic]

@@cancerbetter Thanks, having an MRI soon. Standard biopsy is a non-starter. From the papers I have read a negative on the MRI is pretty conclusive. My first rodeo.

[@cancerbetter]

@bruceharkness4497 about 10-15% of people with a normal MRI but with an elevated PSA will be found to have prostate cancer. This is a situation where using PSA Density to assess risk is valuable to help make the decision about whether or not to biopsy

[@Biochemechanic]

@@cancerbetter The other advantage to a parametric MRI is if it is a negative result, it’s been confirmed through studies that it is a conclusive result. With a biopsy it’s not as conclusive. I am hoping for a negative result. The MRI is well worth the cost and it’s painless and zero risk.

[@Biochemechanic]

@@cancerbetter Here is what I found in a PSAD trial notes: “It is worth to mention that today there are additional commercially available blood tests to help diagnose clinically significant prostate cancer better than PSA such as 4Kscore and prostate health index (PHI) 18 as well as urine-based tests including PCA-3 19 and SelectMDx 20.” Thanks, I know more now.

[@hitechrr]

My VA doctor refused to set up a psma scan.

[@cancerbetter]

Very frustrating. For Gleason 8 or higher prostate cancer I really feel this is just antiquated care not to offer it. For Gleason 7 you could make a cost savings argument. You could get a scan outside potentially or just go forward with treatment and see if the PSA goes to zero. Be selective about who you let operate on you.

[@hitechrr]

I had a Gleason 3+4=7. They did 26 rounds of radiation. My PSA 4 years later is around 1.74. It was below 1 a year after treatment.

[@cancerbetter]

@hitechrr you seem like a reasonable person for a PSMA PET from what little you described here. The can would show where there might be active cancer. There are times where this test would also not be ordered. For example if a person has a less than 5 year life expectancy it might not be worth addressing as the risk of death from the cancer may be low in that time period. Generally if a persons PSA is rising on 3 consecutive PSA measurements after radiation we consider this person a likely radiation failure.

[@alanwittenberg4833]

Do you have any opinion about IsoPSA test developed at Cleveland Clinic? My urologist had me take the test (immediately following a DRE) a couple days after a lab PSA which showed my PSA slightly elevated. The IsoPSA showed my PSA significantly higher only after 2 days compared to the lab PSA. My urologist wants me to re-take it in 30 days. Many thanks.

[@cancerbetter]

It’s a good test. ascopubs.org/doi/abs/10.1200/JCO.2023.41.6_suppl.325#:~:text=The%20sensitivity%20of%20IsoPSA%20to,9.6%20(p%3D0.007).

[@alanwittenberg4833]

Very appreciate your prompt response. I’m having my 2nd IsoPSA soon. I’m not sure if you’re seeing new patients; but I’ll likely want a 2nd opinion soon. I very much trust my urologist who’s vey skilled; but I think it’s a good idea to have another opinion. Thanks again for your assistance.

[@cancerbetter]

I’m happy to provide second opinions. You can call cedars urology at 310-423-4700 to make an appointment. My typical wait is about 2 months to be seen but I’m constantly trying to reduce that.

[@gvet47]

So my PSA was 5000 so CT and bone scan was then done and cancer was in all my lymph nodes and all very enlarged. Told there was little to be done. So I lsy here waiting to die. Cannot even eat or drink! At least a palliative nurse helos me with pain meds.

[@patriciareynolds2729]

ED, a patient also. please pray to JESUS CHRIST and may we meet in heaven!

[@F8Tributo]

Sooner or later, one way or another, we all must make peace with ourselves and God. Whatever stage we are at, we need to direct our prayers to heaven, and seek heart and mind coherence.

[@cancerbetter]

This is not true. You can get on Lupron and enzalutamide. This will usually stop the cancer for several years at least.

[@federico1974]

Very informative video why this test is better for cancer prostate spread, Thank you . My PSA=5 , DRE negative, 3T MRI PI-RADS 2 = LOW , TRUS biopsy found 2 cores positive Gleason 3+4 low volume , Gleason 4 was 15 % total tumor volume posterior RIGHT SIDE of Prostate. On the other hand the PSMA-PET GA-68 says localized prostate cancer N0 M0 , Mild focal uptake in the LEFT SIDE of Prostate peipheral zone may well represent the site of the primary prostate cancer. The BIOPSY and the PSMA-PET do not agree on where the tumor is located, Could useful to have a Transperineal Prostate Biopsy before deciding on treatment to clear confusion? I have watched all your videos with advantages and disadvantages of different treatments and need to make a decision. I have been told I have time to decide on treatment. Thank you very much for all the videos they are excellent .

[@cancerbetter]

It’s possible the biopsy cores were mislabeled. Believe it or not this can happen. If you are considering focal therapy you might want to consider a repeat biopsy to clear up the discrepancy between the imaging and the biopsy locations. Transperineal biopsy is my preferred biopsy technique for lower infection rates but in terms of cancer diagnosis the two methods are pretty even in most studies.

[@federico1974]

Thank you for the information, yes that is a very good point it really matters only if I have focal therapy . Thank you very much

[@thomaslehmann5981]

​@@federico1974I would tell them to cook the whole gland myself.

[@sduke39]

My PSA test 4 months post my radical prostatectomy is 0.2 and my urologist said it should be 0.02 at this point in time. Now I'm terrified the cancer spread before I could get the surgery. My urologist has not mentioned a PSMA PET scan, Should I seek a second opinion from another urologist and does Medicare even cover this test?

[@cancerbetter]

Yes Medicare covers it. Often with a psa that low a PSMA PET will not find the area of residual prostate tissue. Your doctor is likely to recommend radiation therapy which can treat any remaining disease

[@patriciareynolds2729]

ED here, been thru all the above and my PSA off 0 for 9 mo. now!!

[@lascelleswilson2259]

I often wonder about that

[@cancerbetter]

Happy I can help

[@Midnitexowboy]

So why won't a urologist use this scan before doing a biopsy especially if you had a clear MRI

[@cancerbetter]

It’s purely for cost savings. Everyone with a negative prostate biopsy and a Gleason six prostate cancer probably wouldn’t need the scan anyway so the insurance companies deny the scan approval until there is a biopsy that confirms cancer. I’ve tried repeatedly to get PSA pet scans for patients of mine before the biopsy, but have not been able to do it outside of clinical trials that I enroll some of my patients on.

[@rayp7135]

Does a negative PSMA PET scan that is revealed to be no longer accurate by a positive PSMA PET scan showing 2 lymph nodes with cancer approximate 6 months later mean the spread is recent (within the last 6 months) or does it mean the original PSMA PET scan was just wrong and the nodes were positive all along? Also, is it likely there’s even more spread not appearing on the most recent PSMA PET scan?

[@cancerbetter]

Can’t say for sure but the more likely scenario is that cancer had spread prior but was too small to be detected on the prior scan. Over time the cells multiplied to a size that allowed them to be seen.

[@rayp7135]

@@cancerbetter Thanks for the reply, is that likely the extent of the early spread at this point? Note: immediately after this turn of events it’s Orgyvyx, Abiraterone, and IMRT at a top center and “with intent to cure”. So the question is is it really very early ogliometastatic?

[@cancerbetter]

@rayp7135 hard for me to say without seeing your scans. Sounds like you have a good team and plan

[@rgriffsf]

Insurance companies are still rejecting PSMA PET scans even now.

[@cancerbetter]

Depends on the indication. In my practice to look for prostate cancer outside of the prostate or to assess for recurrence if there is a psa rise after prostatectomy they are getting approved

[@chicagomike]

@@cancerbetterdoes Medicare cover at least.

[@cancerbetter]

@@chicagomike yes it does. All major insurances in the US cover PSMA PET

[@pinegd1]

Biopsy may actually spread cancer cells before therapy even begins. Why else do most patients have recurring tumors years after radiation or prostatectomy.

[@chrislee633]

Is this proven? …..what evidence is there?

[@cancerbetter]

There is no convincing evidence to suggest biopsy results in the spread of cancer.

[@Toby-kn8tc]

@@cancerbetter 8:16

[@JoeSherrishow]

@cancerbetter Joe is newly diagnosed. PSMA Pet scan says no metastasis despite a PSA of 63.5 and Gleason 8,. He has a normal DRE, no symptoms, a low risk decipher score. Thought the PSMA pet would be defining factor on whether to treat with just brachytherapy or with adt and EBR, but it seems there is a 20% chance that metastasis has been missed according to this video. This will be a game changer for us and we will choose the add on treatments. Thank you.

[@F8Tributo]

@pinegd1 The relapse could just be from the same metabolic factors that precipitated the cancer in the 1st place, i.e., sugary diet, high carb diet, lack of exercise, etc

[@barneyclancy4312]

Is there anyone in colorado that would do this test

[@cancerbetter]

Sure yes. Many. Try a major university?

[@chitobalazo]

I’m just asking your opinion or do I need a 2nd opinion on my prostate cancer with a Gleason Score of 3+7 which is 7. However my PSA is 1.75 and MRI Cat shows I have cancer. However I did a PSMA Pet Scan it didn’t highlight the cancer. My Urologist said I have I different type prostate cancer that is not detected by Pet Scan or PSA. However the biopsy confirmed I got prostate cancer Gleason 7 (3+4) and was shown via MRI Scan showing lesions in my prostate. My Urologist gave me two options Radical Prostatectomy using Robot or Radiation Therapy. I chose Radical Prostatectomy. Do you think I made the right decision. I will do in March next year. I was only diagnosed prostate cancer 2 months ago.

[@cancerbetter]

It is a well-known fact that PSMA PET scans, do not detect, low-grade and many intermediate grade prostate cancers. This is a known shortcoming of the test and it’s quite common for people with 3+ for prostate cancer not to have a positive finding on PSMA PET. This is valuable, because you know that this scan will not be a good way to assess for cancer recurrence if that was ever something that you needed to do in the future.

[@pinotwinelover]

Have you considered focal, therapies besides radiation and Ralp

[@jamesspadaro1996]

Show me the data, you did, thanks

[@cancerbetter]

Glad you appreciated it!

[@richardbutera1743]

You are much more credible when you shave!

[@cancerbetter]

Hahahaha love this comment!

[@garymitchell6056]

The information remains the same either way doesnt it?

[@barneyclancy4312]

PSMA is very expensive, how accurate is a PET CT scan finding Metastasis from prostate cancer,

[@cancerbetter]

All depends on the context and volume of disease. Usually PSMA pet will find areas of met of 5mm in size or larger if the cancer is expressing the PSMA receptor (which is the case in most high risk prostate cancers)

[@bobpatel5432]

I am regreting to get complete prostate surgery since it was on first stage i should have just take a rediation because now i dont have any sex filling nor it eject its driping pee all the time no spurm coming out it fill like i have no pinus or another word its only good for pee now nothing else

[@cancerbetter]

Speak with your urologist. There are numerous ways to regain erections.

[@kirkgossett4391]

Looking for more advice, my PSMA-PET Scan provided the following results,. Thank you for this video and response to my questions. I pushed my insurance to cover the scan. Background, 60 yr old, biopsy done with high Gleason scores, radical prostatectomy 2.5 yrs ago, great PSA follow up results, a month ago my PSA started to go up, scan had the following results. Shocked to hear cancer might now be in my ribs. Any suggestions? What would be the next step? My Urologist mentioned there was a trial for metastatic prostate cancer but waiting on the details, are we talking radiation and hormone treatments or are you aware of something else? Petrified in Michigan. Narrative PET-CT Illuccix Ga 68 Gozetotide PSMA Todorov PROVIDED HISTORY: * 60 years old Male * Malignant neoplasm of prostate, status post prostatectomy COMPARISON: No prior PET/CT scans at William Beaumont Hospital for comparison. CORRELATION: Bone scan dated 04/26/2021 PROCEDURE: The patient (weight 205 lbs; height 6 ft 1 in) was injected intravenously with 4.75 mCi of Ga 68 Gozetotide (Illuccix PSMA) assayed at 2:51 pm hrs. Injection site: Right antecubital IV. After waiting an approximately 60 minutes a series of bed positions were acquired to cover the skull base to mid thighs. The data was reconstructed into a three-dimensional volume rendered display. CT imaging was performed for anatomic correction and anatomic localization. Prior to imaging, the patient was prepped with 450 mL of oral contrast. This report represents interpretation of the PET-CT imaging by nuclear-medicine physician. FINDINGS: PELVIS AND ABDOMEN: Images in multiple projections demonstrate no definite focal intense tracer activity in the post prostatectomy region. There is no gozetotide avid adenopathy in the peri-prostatectomy, lower pelvic, retroperitoneal and abdominal areas. No focal intense tracer activity in the liver, pancreas and adrenal glands. CHEST AND NECK: There is no subdiaphragmatic lung parenchymal lesion bilaterally. No tracer avid adenopathy in the hilar, mediastinal, axilla, clavicular and neck regions. BONES: There is sclerotic lucency in the right posterior fifth rib with a maximum SUV of 4.3, metastatic disease cannot be excluded. Tiny focal activity in the left anterolateral fifth rib shows a maximum SUV of 3.8 IMPRESSION: Ga 68 Gozetotide PET/CT scan demonstrating sclerotic lucency in the right posterior fifth rib and focal activity in the left anterolateral fifth rib with a maximum SUV of 4.3, metastatic disease cannot be excluded. No scintigraphic evidence for gozetotide avid SOFT TISSUE disease.

[@cancerbetter]

Definitely recommend you speak with your doctor. Recent studies have demonstrated zapping the areas of metastasis if they are fewer than 6 results in improvements in cancer control. I’d ask about radiation to the area of cancer spread. Hope this helps you

[@kirkgossett4391]

Thank you so much@@cancerbetter

[@scoot77777]

Thanks!

[@cancerbetter]

Thank you for helping to support my efforts!