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Prostate Cancer: Recommendations After Negative Imaging Results


Expert perspective on next steps for physicians and patients following a negative imaging result when recurrent prostate cancer is suspected.


Brian Helfand, MD, PhD: When you have this, the question is also based on what was previously said in the first patient [case], which is, did we use the right modality? Was this gallium PSMA [prostate-specific membrane antigen] PET [positron emission tomography] the correct one that we should have used? It was easy. It was available. [But] was it wrong that we got it? It absolutely was not wrong. It just came back negative. The question is, should we obtain an additional imaging study? I think that really becomes a shared decision-making discussion that you have with the patient. I think you should be able to continue to follow this patient. I think you, in this type of scenario, have that discussion and say let’s follow your PSA [prostate-specific antigen]a little bit more. If that PSA increases, we can either ultimately repeat the same type of scan and/or we can really talk about obtaining a different type of PET imaging modality. Maybe it’s fluciclovine [scan]. Maybe it’s a different PSMA scan. I think that’s really the ongoing discussion and it also [depends on] what you have available to offer that patient.

I am fortunate in our institution that we have multiple—even PSMA imaging modalities, we have the fluciclovine, so we do regularly alternate or offer patients who have a negative scan whose PSA is continuing to rise. I don’t think that that’s wrong because we still don’t understand the true biology that is underlying most of these imaging modalities. I think that there is opportunity to offer patients, at the present time, repeat scans. The problem from our practical standpoint is barriers to insurance to obtaining multiple tests. Certainly, we haven’t had at our institution too much push back from [public] institutions like Medicare, etc. Some of the private insurance companies have certainly required peer-to-peer review. In the setting of a continued rise in PSA, most of those insurance companies have supported the use and understand why we have tried different modalities to help localize this. At the other end of this, if we could avoid a lot of these systemic therapies, which are very costly, then we are still saving money.

Transcript edited for clarity.

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