June 2023 Introduction of PSMAPETCT scan as a onestop staging scan for very high risk localised prostate cancer The Bristol MDT Pilot Overview Background Proposal Results Discussion Background ID: 1041896
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1. Tom BirdConsultant Clinical OncologistJune 2023Introduction of PSMA-PET-CT scan as a one-stop staging scan for very high risk localised prostate cancerThe Bristol MDT Pilot
2. OverviewBackgroundProposalResultsDiscussion
3. BackgroundMore ‘accurate’ (proPSMA)Potential to improve outcomesImpact on outcomes currently unknown - ?could be worseEquivocal findings – resource implication & uncertaintyPathway effects?GuidelinesClinical trial recruitmentPostcode lotteryPatient queries
4. BackgroundMore ‘accurate’ (proPSMA)Potential to improve outcomesImpact on outcomes currently unknown - ?could be worseEquivocal findings – resource implication & uncertaintyPathway effects?GuidelinesClinical trial recruitmentPostcode lotteryPatient queries
5. Proposal6 month PilotGo Live MDT: 02 November 2022Approximately 30 patientsChoose a cohort of men with potentially highest chance of PSMA-PET positivityProspective patient listRetrospective data collectionModification of STAMPEDE criteria for ‘very high risk’N1 disease on MRI prostate ORGleason 9OR2 of: T3b/T4 on MRIGleason 8PSA>40MDT Criteria
6. Proposal (2)
7. Evaluation PointsCan a PSMA-PET-CT be requested, performed and reported in a timely manner (similar to current CT/bone scan timelines) so that the patient’s cancer diagnostic pathway is not delayedAre the correct patients having a PSMA-PET-CT requested by the urology MDT (as per locally set eligibility criteria)Do equivocal PSMA-PET-CT results cause uncertainty for the MDT in its treatment recommendationsDo equivocal PSMA-PET-CT scans lead to further imaging requests (e.g. MRI scans) for clarificationWhat treatments did these men receive?
8. Results2/11/22 – 31/5/23 inclusive31 MDTs37 PSMA-PET-CT
9. Results: Cohort CharacteristicsNumberPercentageAgeAge (50-79; median: 68)<60719%60-701643%70-801438%CT ± Bone scan1027%PSA<10719%10-201130%20-30411%30-40411%40-100719%>100411%
10. Results: Cohort CharacteristicsNumberPercentGleason 9 OR N12467%Gleason 9 + N126%Gleason 9 only1644%N1 only617%2 of: T3b/4, Gleason 8, PSA>401233%All 313%T3b/T4 + Gleason 8514%T3b/T4 + PSA>40514%Gleason 8 + PSA>4013%
11. Results: TimelinesMDT – PET: Median 9 days, <10 days: 57%; <16 days: 78%PET – Report: Median: 4 days, <7 days: 100%MDT – Report: Median 16 days, <21 days: 86%MDT – MDT: Median: 21 days
12. Results: Equivocal results1 x non-PSMA avid disease – referred for bone scan1 x indeterminate adrenal lesion – referred for CT adrenal1 x ?sarcoid – referred for CT chest1 x ?T8 metastasis (& pre sacral nodes) – for MRI T-spine
13. Results: Staging resultsN1 Mx on MRIN0 Mx on MRI
14. Results: Staging results (2)10 patients having conventional & PSMA-PET-CT staging
15. Results: Staging & TreatmentsStaging PSMA-PET
16. Results: Staging & TreatmentsRALP (7)H+RT (9)Staging PSMA-PETN0M017
17. Results: Staging & TreatmentsRALP (7)H+RT (9)Staging PSMA-PETN0M017pT3b pN1 pT3a pN1pT3a pN0pT3a pN0pT2 pN0X2 TBC
18. Results: Staging & TreatmentsRALP (7)H+RT (9)Staging PSMA-PETN0M0N1M0RALP (1)H+RT (7)178pT3b pN1 pT3a pN1pT3a pN0pT3a pN0pT2 pN0X2 TBC
19. Results: Staging & TreatmentsRALP (7)H+RT (9)Staging PSMA-PETN0M0N1M0M1Systemic Therapy alone (2)RALP (1)H+RT (7)Systemic Therapy + RT (10)17812pT3b pN1 pT3a pN1pT3a pN0pT3a pN0pT2 pN0X2 TBC
20. Conclusions / Discussion PointsPSMA-PET-CT can be incorporated in to staging pathway86% Reported within21 daysPSMA-PET-CT can be incorporated in to staging pathway86% Reported within21 days
21. Conclusions / Discussion PointsPSMA-PET-CT can be incorporated in to staging pathwayEquivocal PET-CT results not a major issue86% Reported within21 daysPET Radiologist MDT presence?PSMA-PET-CT can be incorporated in to staging pathwayEquivocal PET-CT results not a major issue86% Reported within21 daysPET Radiologist MDT presence?
22. Conclusions / Discussion PointsPSMA-PET-CT can be incorporated in to staging pathwayEquivocal PET-CT results not a major issuePSMA-PET ↑ sensitivity for N1 compared to MRI86% Reported within21 daysPET Radiologist MDT presence?20% N1M0PSMA-PET-CT can be incorporated in to staging pathwayEquivocal PET-CT results not a major issuePSMA-PET ↑ sensitivity for N1 compared to MRI86% Reported within21 daysPET Radiologist MDT presence?20% N1M0
23. Conclusions / Discussion PointsPSMA-PET-CT can be incorporated in to staging pathwayEquivocal PET-CT results not a major issuePSMA-PET ↑ sensitivity for N1 compared to MRIPSMA- PET ↑ sensitivity for M1 compared to CT/BS86% Reported within21 daysPET Radiologist MDT presence?20% N1M040% M1PSMA-PET-CT can be incorporated in to staging pathwayEquivocal PET-CT results not a major issuePSMA-PET ↑ sensitivity for N1 compared to MRIPSMA- PET ↑ sensitivity for M1 compared to CT/BS86% Reported within21 daysPET Radiologist MDT presence?20% N1M040% M1
24. Conclusions / Discussion PointsPSMA-PET-CT can be incorporated in to staging pathwayEquivocal PET-CT results not a major issuePSMA-PET ↑ sensitivity for N1 compared to MRIPSMA- PET ↑ sensitivity for M1 compared to CT/BS86% Reported within21 daysPET Radiologist MDT presence?20% N1M040% M1PSMA-PET-CT can be incorporated in to staging pathwayEquivocal PET-CT results not a major issuePSMA-PET ↑ sensitivity for N1 compared to MRIPSMA- PET ↑ sensitivity for M1 compared to CT/BSLittle evidence for ‘under-treatment’86% Reported within21 daysPET Radiologist MDT presence?20% N1M040% M195% eligible for Surgery or RT to Prostate
25. Conclusions / Discussion Points (2)Review of MDT criteria?Need to review PET at MDT?Ways to avoid additional CT & Bone Scan?Need to only request PET at MDT?
26. Thank YouRory Halley-HoggAmy HadleyJon AningLaquiesha Watts Kelly FogwillAlliance MedicalNBT CNS teamJulian KabalaRandeep KulshresthaIsabel LaurencePaul McCoubriePelvic Surgical TeamProstate MDT Julian KabalaRandeep KulshresthaIsabel LaurencePaul McCoubriePelvic Surgical TeamProstate MDT