0:00

So moving on to part four

0:02

and we're going to start talking about

0:05

clinical assessment here.

0:06

And this is what, um, our doctors,

0:08

and sometimes it's technologists

0:10

or nurses, um, usually we'll go

0:11

and have a quick chat with the patient

0:13

before the scan is undertaken.

0:15

And that's to get, um, to get an idea of the

0:18

relevant clinical history which is going

0:19

to aid in the interpretation of the scan.

0:23

So in this short interview, what do we cover?

0:25

So we talk about the prostate cancer history.

0:27

We talk about whether the patient has come with any new

0:30

or concerning symptoms that may be related

0:32

to their prostate cancer diagnosis

0:33

or a complication of their treatment.

0:35

Um, whether there's other clinically

0:37

relevant medical history,

0:38

which can be quite important since we are doing whole body

0:41

imaging and whether they have had prior investigations,

0:44

particularly imaging and where they have had it.

0:46

So we have availability of that comparison imaging

0:49

to aid in our interpretation.

0:52

So with the prostate cancer history,

0:53

there's a lot that we need to cover.

0:54

And what we talk about is really dependent on

0:57

where the patient is in their journey.

0:59

So, but the first thing we think about is

1:01

what is the clinical question?

1:02

Why has the referrers sent the patient

1:04

to us today for imaging?

1:05

What question do they want answered?

1:07

What are they worried about? You know,

1:09

how do they want us to help?

1:10

So that's the way we start. I wanna know

1:13

the time of diagnosis.

1:14

Were they diagnosed last week or 10 years ago?

1:17

And if it is a new diagnosis, particularly

1:18

what the Gleason score is,

1:20

'cause that gives me an idea about my clinical index

1:22

of sufficient and what to expect.

1:25

Um, we might wanna ask whether it's first line therapy, um,

1:28

or if they're on longer term therapy.

1:30

Um, and any relevant biochemistry results.

1:32

We mentioned that we wanna have a look at the PSA

1:34

'cause that can give us some information.

1:36

We also wanna think about prior

1:37

and current treatments and dates.

1:39

Um, are they on current therapy?

1:41

Did they have radiotherapy 12 months ago, 24 months ago?

1:44

And what surgery they've had and whether

1:47

or not they have a prostate actually is really important.

1:49

'cause not all of our patients do.

1:51

They may have had a

1:52

prostatectomy as their first line therapy.

1:54

And so if they have had a prostate out, it actually changes

1:57

how we protocol their scan.

1:59

Um, and whether or not we decide

2:01

to do an additional dynamic phase,

2:02

which we'll see in the upcoming section, I'd like

2:05

to know if they're on hormone therapy or if they've had

2:07

other systemic treatments.

2:09

And also get a sense of what the current therapy goals are.

2:12

And that kind of to me, thinks about whether we're aiming

2:15

for cure or if we're looking at palliative management,

2:18

thinking about symptoms and concerns.

2:20

We don't wanna have an hour consult about everything

2:23

that the patient has gone through and, you know, we,

2:25

we love talking to our patients.

2:26

We definitely do. Um, but we wanna try

2:28

and take a targeted history

2:29

and limit it to relevant issues if we can.

2:32

Um, so just trying to screen if the patient has new symptoms

2:36

that has prompted the evaluation, for example,

2:38

back pain or neuropathy.

2:40

Um, particularly if we're worried about a bone met,

2:42

impacting on nerves

2:43

or spine, um, whether they have new back pain or bony pain

2:47

or if they're new lower urinary tract symptoms.

2:50

In terms of other clinically significant medical issues,

2:53

which is again that kind of screening test, um,

2:55

we wanna see if there's any conditions

2:57

that are going to change how

2:58

We perhaps interpret the study.

3:00

So could that be major trauma

3:02

and they've had multiple fractures

3:03

or surgery, you know, what organs are still there,

3:06

what organs have been impacted by surgery, whether

3:08

or whether or not they have any, um, diagnoses such

3:11

as current current malignancy or, um, infection

3:14

or inflammation, um,

3:15

inflammatory conditions which could change

3:18

the pattern of uptake.

3:19

And so the more information we have about this is going

3:21

to allow our reports to be more accurate

3:23

and be more clinically useful.

3:25

We wanna give something that's useful.

3:26

We don't wanna send referrals on a wild goose chase

3:29

for a lung lesion when they already have a known diagnosis

3:32

of lung cancer, for example.

3:33

So that all helps. A couple of other things

3:36

to think about is whether

3:37

or not the patient has had recent vaccination,

3:39

because if you're vaccinated in the left arm,

3:41

then you can have reactive lymphadenopathy on that side.

3:44

Really relevant on FDG pets.

3:46

So our conventional pet, those nodes can be really hot,

3:48

particularly after covid vaccines,

3:50

but also we will get some inflammatory

3:51

uptake with A-P-S-M-A pet.

3:53

So it's useful to screen for this.

3:55

Um, and we also wanna think about renal disease,

3:57

particularly if we're thinking about giving intravenous

3:59

contrast for delineation of the urinary tract.

4:02

For our prior imaging.

4:03

We think about, um, other PET CT studies, we want

4:06

to get the comparison imaging into our system

4:08

and look at them side by side if available.

4:11

Um, so we always ask what practice, when were they done

4:13

and then try and get those studies.

4:15

Um, in Sydney, that's not too bad.

4:17

We can usually get contact with the private practices

4:19

and the public system is all linked up.

4:20

Whether they've had an MRI.

4:22

MRIs are really important, particularly for initial staging,

4:25

um, to try and localize whether the lesion

4:27

of concern on MRI is indeed PSMA expressing, um,

4:31

whether there's been any diagnostic CT imaging.

4:34

Um, and then as we said, make sure you know which practice

4:36

that imaging was done at.

4:38

And then we bring all of that together when we do our

4:40

reports and hopefully we can be more accurate,

4:42

more sensitive, and more clinically useful.

4:45

The last thing we wanted to ask the patient is do they have

4:48

any questions or concerns?

4:49

Because of course we are there to answer questions,

4:51

we're there to educate, we are there to work

4:54

with our patients to ensure

4:55

that they have the highest quality care.

4:57

And the last thing we do is confirm informed consent.

5:01

And that is both for the intravenous contrast if we're

5:03

administering it, but also for the PET scan themselves.