Delayed Diagnosis of Recurrent Prostate Cancer Leads to Bony Metastasis

This case involves a 55-year-old male patient who was diagnosed with Stage II prostate cancer. The initial pathology reports revealed an adenocarcinoma throughout the prostate, with Gleason scores of 8 in all regions. A bone scan at the time revealed no evidence of metastatic disease and surgery was not recommended by his oncologist, but rather external beam radiation (IMRT) and androgen deprivation therapy were offered. The patient elected for IMRT therapy alone, without the androgen deprivation. The patient tolerated the treatment well with the exception of frequent nocturia and a constant feeling of incomplete emptying. He took several medications to deal with these issues, including Flomax. In the years that followed, several follow-up PSAs were obtained, however, no form of surveillance imaging was ordered by his radiation oncologist. A random PSA was done was taken by the patients PCP and it spiked to a value of 75, which finally prompted further investigation. At this time, the radiation oncologist ordered a full workup, including a bone scan and a CT of the abdomen and pelvis. The bone scan showed widespread metastatic disease to the spine, ribs, shoulders and pelvis.

Question(s) For Expert Witness

1. Does the standard of care require surveillance imaging as part of the follow-up protocol for a patient with this profile?

Expert Witness Response E-000027

Stand alone imaging is not standard of care for following prostate cancer in remission. PSA would be the best way to follow a patient initially. Current guidelines call for PSA to be done every 6 to 12 months for 5 years after the original insult. A PSA rise of 2 over the lowest recorded level would trigger the need for further imaging.