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PSMA scan and surgery Trial

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User
Posted 05 Apr 2018 at 21:12

4 centres throughout the UK are enrolling men who meet the entry criteria for a PSMA scan and surgery.  Might be of interest to some but one of the requirements is that no previous treatment has been given including HT. http://www.isrctn.com/ISRCTN56584901

 

Barry
User
Posted 09 Aug 2018 at 22:59

The PSMA scan has been used earlier and to a greater extent in some other countries where it has also been found that it does not work for about 8 or so % of men (like Chris) who do not express sufficiently for the ligand to bind to cause a detectable result. Heidelberg DKFZ and University Hospital, who introduced the scan suggested as a guide men with a PSA of 0.7 as a suitable start point for it. As would be expected, it is increasingly more likely to show cancer where PSA is higher.

We know that a number of UK Hospitals want to be able to provide this scan because it can greatly influence or change the way quite a sizable number of men are treated. Maybe the fairly small study covering men in 3 kinds of situations now being done is to check the comparative advantage and perhaps longer term effects of this nuclear based scan. The UK often requires more confirmation than others on efficacy before widely adopting new innovations.

My first appointment for the PSMA scan was aborted because the machine that generates the tracer broke down just before the event. I was told that all the London Hospitals that provide the scan use tracer from this one supplier so would have been affected. It needs to be produced fairly close to the Hospitals involved due to it's short half life.

Edited by member 09 Aug 2018 at 23:01  | Reason: Not specified

Barry
User
Posted 11 Aug 2018 at 00:46

John,

Maybe because there seems to be a monopoly situation in the supply of the tracer, the cost of the PSMA scan seems to be going up rather than down in the UK. In Australia, as correctly forecast by the Professor in this video, there has been a considerable increase in the availability of the PSMA test there and they have kept costs down. The Professor said that they only used the Choline scan for about six months before going over to the much superior 68 Gallium PSMA one. This is a far ranging video, not only about this scan but how it can help change treatment plans and it also covers other aspects of PCa in the presentation and the Q&A session that followed. It's quite long and I have previously posted the link but recommend it for those who have not seen it. https://www.youtube.com/watch?v=0H-g047os6c

I did consider having my PSMA scan and a short holiday in OZ for the price of the scan in the UK but had to reject the idea for family reasons.

Incidentally, my treating hospital for HIFU, UCLH, believed that the uptake of Choline in an iliac lymph node indicated it was affected by cancer and recommended I start HT. They would not give me the PSMA scan on the NHS. However, other Hospitals I sent the Choline scan to for an opinion were not convinced. I therefore had a PSMA scan done privately and there was no indication of cancer in the suspect node or anywhere else outside the Prostate, so further focal treatment is now being considered without the need for HT, at least if/until the cancer spreads.

 

Edited by member 11 Aug 2018 at 00:50  | Reason: Not specified

Barry
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User
Posted 05 Apr 2018 at 22:49

And must be high risk but with no mets, and about to have RP with lymph node removal ... it’s a good job they are only looking for 60 participants!

I find it interesting that they feel the need to run a trial to see whether PSMA is reliable for lymph nodes.

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 05 Apr 2018 at 23:47
Originally Posted by: Online Community Member

And must be high risk but with no mets, and about to have RP with lymph node removal ... it’s a good job they are only looking for 60 participants!

I find it interesting that they feel the need to run a trial to see whether PSMA is reliable for lymph nodes.

Why is it interesting Lynn??

User
Posted 06 Apr 2018 at 00:17

Because papers in 2016 stated that PSMA was producing better results than all other tracers including choline 11 / choline 18 in all areas and the researchers went on to say that it was proving particularly effective at identifying biochemical recurrence in lymph nodes. So a decision to trial it now for lymph nodes at diagnostic stage rather than at the point of recurrence sounds to me like an attempt to prove value for money for wider application. In other words, the hoop jumping politics of NHS funding.

I will be happy when they get round to publishing the results of the FACBC trials as we know we will be able to get that in Leeds if / when John needs it, and Mr B tells us that it is picking up tiny traces.

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 09 Aug 2018 at 19:53
You might be right on the proving value for money point LynEyre.

New PSMA trial in London with 3 different patient groups has come online this week:: https://clinicaltrials.gov/ct2/show/NCT03617588?lupd_s=07%2F10%2F2018&lupd_d=30 may be of interest to those who have not been able to get the scan

User
Posted 09 Aug 2018 at 20:25
Just wanted to add that my PET scans were in Oxford then London. When I was last at my local Southampton General they had a mobile PET scan lorry in the car park and I enquired about it. They are taking PSMA much more seriously. It is so accurate but can fail in 8% of patients to find anything. This may be the case with me as I am known N1 with rapidly rising psa yet it’s not found anything in me. Ulsterman had a ridiculously low psa and it picked up something !! I’m still not sure I’m trusting of the tracer reliability re the production and transportation and half-life , having had only 2 scans out of 6 attempts. I wonder if other areas have access to this scanner or is it the tracer production areas that are the problem ?
User
Posted 09 Aug 2018 at 21:17

Good find, Berks.

Here is the link on active for others

https://clinicaltrials.gov/ct2/show/NCT03617588?lupd_s=07%2F10%2F2018&lupd_d=30

 

Edited by member 09 Aug 2018 at 21:21  | Reason: Not specified

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 09 Aug 2018 at 22:59

The PSMA scan has been used earlier and to a greater extent in some other countries where it has also been found that it does not work for about 8 or so % of men (like Chris) who do not express sufficiently for the ligand to bind to cause a detectable result. Heidelberg DKFZ and University Hospital, who introduced the scan suggested as a guide men with a PSA of 0.7 as a suitable start point for it. As would be expected, it is increasingly more likely to show cancer where PSA is higher.

We know that a number of UK Hospitals want to be able to provide this scan because it can greatly influence or change the way quite a sizable number of men are treated. Maybe the fairly small study covering men in 3 kinds of situations now being done is to check the comparative advantage and perhaps longer term effects of this nuclear based scan. The UK often requires more confirmation than others on efficacy before widely adopting new innovations.

My first appointment for the PSMA scan was aborted because the machine that generates the tracer broke down just before the event. I was told that all the London Hospitals that provide the scan use tracer from this one supplier so would have been affected. It needs to be produced fairly close to the Hospitals involved due to it's short half life.

Edited by member 09 Aug 2018 at 23:01  | Reason: Not specified

Barry
User
Posted 10 Aug 2018 at 05:14

I enquired at the Paul Strickland Centre about a Gallium PSMA scan, and they said it cost £2600. It is not available on the NHS, but on occasion the NHS does pay for the cheaper choline scan at around £1100.

And then I read in Australia they are available for AUD $800!

https://www.huffingtonpost.com/larry-diller/fly-to-australia-for-to-s_b_12807018.html

And I have just found in India you can have one for £236 - don’t think that’s the Gallium one though. I’ll see what my oncologist says - he’s Indian.

Edited by member 10 Aug 2018 at 05:31  | Reason: Not specified

User
Posted 11 Aug 2018 at 00:46

John,

Maybe because there seems to be a monopoly situation in the supply of the tracer, the cost of the PSMA scan seems to be going up rather than down in the UK. In Australia, as correctly forecast by the Professor in this video, there has been a considerable increase in the availability of the PSMA test there and they have kept costs down. The Professor said that they only used the Choline scan for about six months before going over to the much superior 68 Gallium PSMA one. This is a far ranging video, not only about this scan but how it can help change treatment plans and it also covers other aspects of PCa in the presentation and the Q&A session that followed. It's quite long and I have previously posted the link but recommend it for those who have not seen it. https://www.youtube.com/watch?v=0H-g047os6c

I did consider having my PSMA scan and a short holiday in OZ for the price of the scan in the UK but had to reject the idea for family reasons.

Incidentally, my treating hospital for HIFU, UCLH, believed that the uptake of Choline in an iliac lymph node indicated it was affected by cancer and recommended I start HT. They would not give me the PSMA scan on the NHS. However, other Hospitals I sent the Choline scan to for an opinion were not convinced. I therefore had a PSMA scan done privately and there was no indication of cancer in the suspect node or anywhere else outside the Prostate, so further focal treatment is now being considered without the need for HT, at least if/until the cancer spreads.

 

Edited by member 11 Aug 2018 at 00:50  | Reason: Not specified

Barry
User
Posted 24 Oct 2018 at 10:12
Having had two different private consultants independently recommend that I get a PSMA PET scan, I was more than somewhat disappointed when my insurer declined to pay for it, saying I “didn’t fit the criteria”. I was told by the admin at the centre where an appointment had been made for me that the cost was £1800. I did not get the scan (yet). I was also told that this centre can only do this scan on Mondays & Fridays because of the need to pre-order the isotope. I’m T2 Gleason 7 with a surgery date set for 3rd Nov. One consultant said to me that the PSMA PET scan has shown the bone scan to be “useless”, but I haven’t had one of those either. He also said my insurers are only interested in saving money whereas he is interested in saving lives. Still charges over £100 for a telephone call lasting less than 15 mins though! Not that I expect him to work for free, just struck me as ironic.

The surgeon says the PSMA scan would be helpful with staging, but didn’t seem overly bothered that I wouldn’t have had one before the surgery when I last saw him. So it’s not just the NHS which is unconvinced about cost effectiveness yet. I only set off down the private route after my NHS MRI appointment got cancelled ‘cos the machine broke down.

So I’m very confused as to the importance of this scan for someone in my position. It sounds like it is destined to become standard at some point in the future, but we aren’t there yet.

User
Posted 24 Oct 2018 at 10:22
PSMA scans are approved for men with biochemical recurrence after primary treatment has failed, or where there are reasons to suspect oligometastases. Since you are down to have surgery, I can see why you don’t meet the criteria. I think you have been befuddled or misled into believing a PSMA scan would be good in your case.

The bone scan is another matter. That is a postcode lottery; in some CCGs all men get a bone scan once prostate cancer has been diagnosed while in others the bone scan is only done if the Gleason or PSA are high.

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 24 Oct 2018 at 19:11

If you had a PET scan and it found something your operation might be cancelled.  Personally I'd rather have the op first as, just a personal belief, taking away the big one takes away the main feeder.  Medics seem to believe the op isn't worth it if it's spread too much although radiotherapy could be an option in some cases.

User
Posted 25 Oct 2018 at 01:18
To cover the point raised by PsP, you could ascertain before having a PSMA if it showed more distant spread whether the op would still go ahead. If it only showed some close by lymph nodes affected, it could also assist the surgeon when looking at what to remove, perhaps more easily done with open Prostatectomy , so something else to ask before deciding on the scan. Little seems to be straightforward when making decisions because so often there are pros and cons to so many options.
Barry
User
Posted 25 Oct 2018 at 08:44
Thanks all for the responses. My surgeon did say - more than once - that it would be helpful in determining if there were any “large lymph nodes in the pelvis” that needed removing. Lyn, you’re not wrong on the befuddlement, two different consultants made the same recommendation and each was unaware of the others recommendation, so what is a civilian to think? But then once it was declined apparently it wasn’t that important...
User
Posted 25 Oct 2018 at 09:27

PSMA is a new toy so perhaps (it is the cynic in me) both consultants are keen to play with it if they have a patient whose insurer might pay? But if you read up on it you will see that PSMA is not used in diagnosis so much; what is exciting the oncology world is its ability to spot micromets in biochemical recurrence.

Was it definitely PSMA and not one of the other PET scan tracers .... there are so many now.

Edited by member 25 Oct 2018 at 09:28  | Reason: Not specified

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 25 Oct 2018 at 10:54

Actually there are no formal regulatory approvals for the PSMA scan as yet - but this is true for choline scans in the UK also.  Its use is on a named patient/compassionate basis.

As noted by Lyn, BCR is certainly the use which seems to be gaining the most interest in the academic literature and the use which appears to offer the best results for change in management based on the scan. 

If due to have surgery the PSMA scan may detect spread beyond the prostate which in the UK could result in not being eligible for surgery

User
Posted 26 Oct 2018 at 09:22

Hi Lyn,

The same thought had crossed my mind about the “new toy“ aspect. Yes, definitely PSMA, I was given a “shopping list” with most preferred option first, basically get one of the following:

PSMA PET/CT

Choline PET/CT

Bone Scan.

So far I’ve had none of them!

The whole Catch 22 situation regarding mets and eligibility for a scan that can detect them seems slightly illogical. But the argument seems to be that the 3T mpMRI didn’t show anything outside the prostate, so it hasn’t spread, even though the area covered by that scan is relatively limited. The counter to that being a relatively high PSA density, with a relatively small tumour shown on the scan.

User
Posted 26 Oct 2018 at 10:23
A bone scan should be routine in a case like yours, even on the NHS.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 26 Oct 2018 at 12:30
The PSMA scan may be regarded as 'The new Kid on the block' but it is much more than a 'toy'. In due course it may well replace the bone scan because tests have shown it to superior in this respect. https://www.ncbi.nlm.nih.gov/pubmed/30120038

'CONCLUSION:

68Ga-PSMA PET/CT is superior to and can potentially replace bone scan in the evaluation for skeletal metastases in the clinical and trial setting because of its ability to detect lytic and bone marrow metastases.'

Barry
 
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