Dr. Parikh: Let us start with the beginning. If you have a patient with metastatic prostate cancer that is hormone-sensitive, how do you approach the situation? Obviously, they undergo a workup, biopsy, and then imaging studies. Nowadays, we perform PSMA and PET scans. In your practice, what has your experience been? Have there been any difficulties in obtaining PSMA and PET scans? How is the availability of nuclear medicine and radiologists for these scans, and how soon can they be done? Are there any challenges or experiences you can share?
Dr. Perkel: For new diagnoses, we all have different variations, but I generally use the NCCN or the AUA guidelines to determine whether it is unfavorable intermediate risk or higher, roughly Gleason 8 or PSA greater than 20. I then look at initial staging. For low-risk disease, we do not always stage. We then explore all localized treatment options. If there are signs of metastatic disease, we follow that pathway, which is more complicated now.
Dr. Parikh: Have you had any difficulty in obtaining PSMA and PET scans?
Dr. Perkel: We have some payers that do not cover it. There are a few private payers that will cover it, but they require conventional imaging first. Therefore, we need to obtain a bone scan and a CT or an MRI, and if those are equivocal, then they will cover the PET. Medicaid in the state of Georgia does not cover it universally, although most Medicare plans do. It is sometimes necessary to undergo step therapy or step imaging before obtaining approval from private payers.
Dr. Parikh: How about the availability of those scans? Can they be done in a timely fashion?
Dr. Perkel: Our PET scan center is definitely backed up. There is a prior authorization process for many of these Medicare replacement or managed care Medicare plans, which is slow. Once we obtain approval, there is a backlog. It is not horrible; our MRI centers are even more backed up. It might take between two and six weeks sometimes.
Dr. Parikh: It seems there are some challenges regarding imaging studies for these patients. Once you have a diagnosis, what is the next step? How do you collaborate with other specialties, particularly medical oncologists? Could you describe how your practice handles this?
Dr. Greenstein: I would break it down into two different types of patients. The first type is the patient who presents with a first-time visit to the urologist, with a PSA of 500, who has not seen a doctor in years and likely has full-blown metastatic disease. The second type is the patient who has had previous treatments such as surgery, radiation, or HIFU, and now their PSA is rising. They may not have received hormone treatments like Eligard, Camcevi, Orgovyx, and their PSA levels are increasing.
For the patients who are presenting for the first time with very high PSA levels, it is important to obtain a tissue diagnosis even though the situation is clear. Once we get a tissue diagnosis, we would start them on some form of ADT, such as Lupron, Eligard, Camcevi, Orgovyx, or Firmagon, depending on availability. After initiating ADT, we would proceed with imaging studies, including CAT scan, bone scan, and PSMA scan. Sometimes I go directly to PSMA scan based on payer requirements. If a patient can pay out of pocket, I may encourage them to do so.
Once all information is obtained, I collaborate with the medical oncologist to discuss the role of chemotherapy. For patients who have been through therapy and are seeing rising PSA levels, my understanding is that once the PSA hits 0.2, we have the opportunity to perform a PET scan or PSMA scan. Sometimes we may also need MRIs or bone scans depending on the individual case.
Dr. Parikh: Dr. Greenstein, you make an excellent point about the importance of tissue diagnosis. For patients with advanced metastatic prostate cancer, we may be able to diagnose based on radiographic findings and elevated PSA. However, in today’s practice, tissue diagnosis is important not only for diagnosis but also for molecular analysis. It is crucial to obtain tissue for molecular analysis, even if the diagnosis can be made otherwise. In our practice, we typically start ADT and then perform a prostate biopsy to obtain tissue for molecular analysis. This step is important for identifying potential targeted therapies.
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