Best pet scan for lower PSA levels

A choline PET scan won't find anything with a PSA that low - PSA needs to be about 2, not 0.2.

There are much better PET scans available now. The best one so far is DCFPyL PET and if it is available in Toronto, it would be through Glenn Bauman at the Lawson Health Research Institute in London, Ontario
Contact: Glenn Bauman, MD 519-685-8650 [email protected]

Waiting to treat decreases the probability that treatment will be successful. He is better off assuming that there are no distant metastases and treating right away.

I think that's good advice if you can get one of the newer (not choline) PET scans right away. I don't think it's good advice if you have to wait for a higher PSA -- it will become a self-fulfilling prophecy if you wait.

I was afraid of that. DCFPyL is a PSMA scan. All of the PSMA scans are experimental at this point, so you can only get it on a clinical trial. The one he meant is the Ga-68-PSMA-11 PET. That one detects cancer in 11-31% of patients with PSA below 0.2 - so not really likely to find anything in your father. The only place in Canada I've seen it is in Montreal at Sir Mortimer B. Davis - Jewish General Hospital. Call to see if they've started recruiting yet - it should be soon - and they do take men who are recurrent after surgery with a PSA>0.1. The contact there is: Stephan Probst, MD 5143408222 ext 5374 [email protected]

The next best scan would be the Axumin PET scan. It is FDA approved in the US- I don't know about Canada. But it is not nearly as good at low PSA, so it is highly unlikely to detect anything.

I don't think you should delay salvage radiation any longer - the odds of cure get much worse as PSA increases.

It depends on his goal. If he wants to cure the disease, he should go for SRT. If he wants to manage the disease, he can go for HT. At age 63, I would think he is more interested in cure, but if he has significant comorbidities and an expected lifespan of ten years or less, he might do fine with just managing it.

There is seldom an exact target for SRT. Even when they can find a tumor big enough to see on a PET scan, they still irradiate the entire prostate bed. They have to treat what they can't see as well as what they can see. I was just told that the minimum detectable tumor size on our best PSMA PET/MRI is about 90,000 cancer cells. But what about all the masses of fewer cells? The purpose of the PET scan is not to find tumors in the pelvic area - that would all be irradiated anyway - it is to find tumors outside of the pelvic area. If tumors are found outside, then irradiating the pelvic tumors is futile. So the PET scan is done to rule SRT out, rather than to rule it in. With your father's low PSA, there's a good chance that his cancer is still in the pelvis and therefore curable.

If you want to calculate the odds that SRT will cure him, you can use this nomogram:
/pcnrv.blogspot.com/2016/08/probability-of-remaining-recurrence.html

As for his urinary difficulties, you are right that the SRT is likely to make matters worse. If the leakage is severe, he might want to have an artificial urinary sphincter installed. Put "AMS 800" in the search bar to read about patient experience with it.