Patient Case 2: A 77-Year-Old Man With Prostate Cancer


Moving on to the second patient case of prostate cancer, Brian Helfand, MD, PhD, shares context for negative imaging results in this setting.


Brian Helfand, MD, PhD: In this case, this is a gentleman who is a 77-year-old man who was previously diagnosed with clinical T2 N1 M0 prostate cancer. Conventional imaging [results showed] 1 positive pelvic lymph node. Subsequently, after a discussion with the patient and his family he was started on external beam radiation therapy in addition to leuprolide and instructions to follow-up and check PSA [prostate-specific antigen] levels every 3 months. His subsequent clinical course and monitoring demonstrated that his PSA remained and nadired at 0.2 ng/mL and stayed there through 9 months of follow-up. Unfortunately, at that time, his PSA began to increase to 2.6 ng/mL at his 12-month follow-up appointment. His PSA levels were again checked 3 months later and jumped from 2.6 ng/mL to 5.7 ng/mL, again demonstrating a relatively high PSA doubling time.

The patient subsequently underwent imaging. He had a Gallium-68 PSMA [prostate-specific membrane antigen]—11 PET [positron emission tomography]/CT scan because the suspicion for recurrence was there. The results were negative. Again, this was somewhat disappointing because when we do these we say we should have positive result. The question in this is, what do we do from here? We have a lot of patients who we obtain next-generation imaging for and [their results] are negative. In some regards, I think the clinician and/or patient feel like we failed, we have the greatest technology and it didn’t pick up anything. Is this a false negative result? Is it somewhere? Did we use the right modality, etc., to obtain the PET/CT? I think these are all great questions.

As I explain to my patients, a negative scan is usually a good result meaning it demonstrates that there is usually not any kind of widespread metastasis, because [patients with that condition] are usually going to be positive. However, when we are saying we have these scans, and we are going to make a treatment plan that is really specific for you and then it comes back negative we are forced at hand to revert to conventional salvage therapies. I don’t think that that’s bad. I think before [we] had these next-generation imaging modalities, many times our standard therapies did work. They certainly were able to extend patients’ lives and they certainly helped, treated, and even obtained cure in a lot of patients. On the other hand, when you have a patient like this who had radiation hormones, you release the hormone therapy, and all of sudden the patient has recurrence and we can’t find that on imaging. We do feel like a failure. We say maybe you should talk to our medical oncology [team] and maybe we should consider more extended hormone therapy to keep this under control.

Transcript edited for clarity.

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