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increase in psa 7 years after seeds

GMGM
Posts: 6
Joined: Jan 2011

Seeds for prostate cancer 7 years ago. Last year PSA in January was 0.36, in June 0.35 and now 0.4. Should I worry?
Had PSA done every 6 months, is there a need to have it done more often?

VascodaGama's picture
VascodaGama
Posts: 1592
Joined: Nov 2010

Hi GM
Normally, PSA tests are required to be taken in shorter than 6 months periods (8 weeks or 3-months) when diagnosing any possible recurrence. This serves to determine the PSADT (doubling time) which is used to correlate with other data in the judgment.
However, your last PSA result of 0.4 could mean 0.3?, if that was not done in a sensitive assay of two decimal places (0.XX ng/ml). Say, it has been rounded up.

The chronology of your PSAs after RT (seed implants) is also relevant to determine if you really are on a recurrence. I would suggest you to verify which type of assay was used in your last test and take another PSA (two decimal sensitive assay) in one month time.

Do your Investigations but do not worry.
VGama

Kongo's picture
Kongo
Posts: 1167
Joined: Mar 2010

GM, welcome to the forum. In my opinion, the PSA scores you posted should not be a cause for concern. Following radiation treatment (including brachytherapy) as a primary therapy, PSA scores are expected to drop and most men see a PSA nadir of less than 1.0 ng/ml at a mean time of 12 months post treatment. Once a nadir is reached the PSA scores will vary for all the usual reasons such as sex before the blood draw, over-the-counter medications such as Advil, strenuous exercise, a hard stool, a urinary infection, prostatitis and so forth. While determining recurrence after radiation is somewhat controversial as there are several definitions, most radiologists consider that three consecutive rising PSA scores above 2.0 ng/ml could be indicative of a recurrence in the absence of some other explanation (like a urinary tract infection). Your readings aren’t anywhere near that profile.

Men who still have prostates, such as yourself, will continue to generate a small amount of PSA following radiation treatment. It will never go to zero or be "undetectable." My opinion is slightly different than Vasco’s regarding the interval of your PSA testing. Since you are seven years out from your treatment and have apparently reached nadir, PSA tests every six months seems reasonable to me but I would double-check with a radiologist, not a general practitioner. Of course, as cancer survivors, we will need to monitor our PSA scores for the rest of our lives but the data you posted does not seem to indicate anything abnormal. The small difference between 0.35 and 0.4 could well be within the standard deviation of the laboratory testing procedure being used, and you may want to inquire as to what the standard deviation numbers are for the assay that the laboratory uses.

If you are worried, I would suggest you discuss your concerns with a radiologist the specializes in the type of treatment you received rather than your family doctor or GP who is not trained in this specialty. Frequently GPs are not well informed about the nuances of prostate cancer and the importance (or lack of importance) for routine PSA tests after treatment.

As Vasco suggests, the trend in your PSA readings is more important than any single reading. At this point you probably have several years of PSA readings from which you can calculate your PSA velocity, PSA doubling time, and PSA density. There are nomograms on the web where you can plug your scores in and it calculates these metrics automatically. The Sloan-Kettering website has some good ones.

Best of luck to you.

K

GMGM
Posts: 6
Joined: Jan 2011

I had my PSA done every 3 months for the first few years, during the "rebound" effect. Since my last PSA had been 0.68 in 6/2009, 0.58 in 1/2010, 0.35 in 6/2010, I had them done every 6 months. The last one now is 0.4.
What would be my next step in treatment?

Swingshiftworker
Posts: 656
Joined: Mar 2010

I agree w/Kongo. Your PSA history to date does not seem to raise any cause for concern.

If you are currently scheduled for PSA tests every 6 months, I'd just wait to take the next test to see where you are then. I you are really concerned, you could schedule an appointment to meet w/your radiation oncologist, who I'm sure will just say the same thing, but if you need the reassurance, go ahead an talk w/him or her, and, if you're really worried, just ask to get another PSA test done in 3 months instead.

Good luck!

VascodaGama's picture
VascodaGama
Posts: 1592
Joined: Nov 2010

GM,
According to the PSA chronology you describe above, you may have not reached yet the nadir PSA (lowest post treatment). Seven years with a constant downfall (including bouncy period) of PSA it is extraordinary. Instead of being worried with “next treatments” or having consultations with your doctors, you should go out and celebrate.

Just as informative, once you reach nadir, the third rise above it would be used to qualify your case in biochemical failure. These three rises should be taken not shorten than 8 weeks apart. From there the pattern of the PSA curve would then be used to evaluate your recurrence as Kongo explains above. After such confirmation, the trigger to start a “next treatment” is reserved to your care giver. Kongo refers to a PSA >2.0, but my doctor used PSA=1.0 for my case.

But, sincerely, you look to be far from seeing yet any recurrence.

Congratulations
VGama

GMGM
Posts: 6
Joined: Jan 2011

Just to clarify, during the first maybe 4 years (the bouncy years took a longer time for me) my PSA went up and down but in the last 3 years my PSA has gone down except for this time when it went up from 0.35 to 0.4.
Thanks for your support

VascodaGama's picture
VascodaGama
Posts: 1592
Joined: Nov 2010

Yes, GM, after RT an erratic PSA (down/stable/up/etc)is quite common. Your case is just a typical result of a successful treatment. Only now (7 years later) you are closer to nadir.
As I commented in my first post above, your 4.0 may very well be a result of the assay your laboratory used. Just confirm if it was a sensitive assay of two decimal places (0.XX).
Take care.
VGama

GMGM
Posts: 6
Joined: Jan 2011

I would think they use two decimal places since in the past my PSA was 0.35 or 0.58.
You could be quite right, my pSA has been erratic for quite some time and lately, in the last 2-3 years it has gone down consistently (0.68 to 0.58 to 0.35).
Much appreciated your comments

GMGM
Posts: 6
Joined: Jan 2011

Once the PSA nadir is reached at 0.35 (after seed implant) it means that this is the lowest level. Does this mean that from now on it has to always be 0.35? It seems scientifically imposible since there is always a margin of error. So if it goes up to 0.4 is it normal or recurrence?
What to do next?

GMGM
Posts: 6
Joined: Jan 2011

What are other treatments after recurrence if seeds were done first?

Swingshiftworker
Posts: 656
Joined: Mar 2010

You're no where near worrying about this BUT . . .

if BT fails, the general approach would be to use hormonal therapy and IMRT or EBRT. See: http://theoncologist.alphamedpress.org/cgi/content/full/10/10/799

This approach should work if the cancer is still confined to the region of the prostate/bladder, but chemotherapy would have to be used if the cancer has spread to other parts of the body.

Surgery may also be an option but is not generally recommended because of tissue damage caused by radiation treatment and because follow-up hormone/radiation treatment is likely to be equally effective w/o the trauma of surgery.

Kongo's picture
Kongo
Posts: 1167
Joined: Mar 2010

There is always going to be slight PSA variations once nadir is reached. For brachytherapy, nadir can take several years to reach the low point but since you are seven years out from treatment, I would assume that you're most likely there. Since men that are treated with brachytherapy or other forms of radiation as an initial treat still retain their prostate, low levels of PSA will continue to be generated. It helps make the fluid in ejaculate, for instance, and PSA can flucuate based on how soon after sex you have your blood drawn (PSA half life after ejaculation is 48 hours), and some OTC medications such as Advil can cause PSA to increase. Even after nadir, PSA will continue to gradually increase with age just like in a man who doesn't have prostate cancer, and if the prostate enlarges with age (a common occurence) the PSA readings will increase as well.

Most of the anxiety about PSA scores are from men who have had their prostate removed. In those cases, any rise in PSA after surgical recovery is most likely caused by a PCa recurrence. For those of us who still have prostates, it is a completely different situation.

PSA by itself is not a bad thing. It's just one of several indicators that could indicate the presence of PCa when it is present at higher than normal levels. Also, a single PSA reading is just a single data point. It's not a significant number unless it is taken within the context of several readings over a long period of time so that a trend can be established. Trends that urologists examine with prostate cancer include PSA velocity (how fast the PSA is increasing), PSA Doubling Time (the predicted time it will take for the PSA score to double), and PSA density (the ratio of PSA to prostate volume). You can calculate these scores yourself if you use one of the nomograms available on the web. See: http://www.mskcc.org/mskcc/html/10088.cfm for information on how to calculate your numbers and what they might mean. Generally, a low PSA velocity, a long doubling time, and low PSA density are indicative of indolent cancer and not something you need to worry about.

Most urologists consider that recurrence has occurred for men who have been treated with readiation when they see their PSA levels rise above 2.0 ng/ml and continue to rise for three or more consecutive tests. At 0.4 you are a long, long way from that. But you should be aware that there are many differing opinions in the field of radiology as to what actually constitutes a recurrence so you may want to research that subject on your own or discuss it with your medical team.

If you should experience a suspected recurrence, the doctors will most likely want to do a biopsy to confirm it, as well as bone scans or other imaging techniques to locate and identify where it is. Your treatment options at this point are many. If the cancer has a very low velocity and long doubling time, for example, you may just want to make some lifestyle changes and pursue Active Surveillance. As Swingshift mentioned, hormone therapy is also an option as is orchiectomy (removal of the testes). Surgery to remove the prostate could be considered as well but because there has been some scarring from the radiation, you run a higher risk of urinary incontinence and ED following such a procedure. There are a number of surgeons who specialize in this form of salvage treatment. Chemotherapy is another drug used to curb a recurring cancer but you probably are aware of the many side effects from chemo. Additional radiation is also an option but requires careful planning by your radiology team. Other options include cyrotherapy where the prostate is frozen and thawed several times (also side effects) and HIFU (high frequency ultrasound) treatment) but HIFU is not yet approved by the FDA for use in the USA so it is an out-of-pocket expense in another country.

As you can see, GM, there a plenty of further options should you ever experience a recurrence but I think you're working yourself up over this without good reason. You should schedule an appointment with your original radiologist or another one who specializes in brachytherapy and discuss it with them.

You may wish to scroll back through a couple of pages of posts and read previous discussion about the impact of diet, particularly red meat and dairy products, on prostate cancer. In my own case, eliminating dairy significantly dropped my pre-treatment PSA in about six weeks. Taking a baby aspirin each day can also lower the risk of recurrence as well as a regular exercise program. Statins (drugs like Crestor) have also been shown to lower the risk of recurrence in prostate cancer patients.

Best of luck to you.

K

VascodaGama's picture
VascodaGama
Posts: 1592
Joined: Nov 2010

GM,
You are right about differences in PSA, not just by possible errors but by differences in the type of assays, as well due to other factors (lovely nights) as Kongo explains above. That is why one simple PSA result shall not be used to judge an occurrence.

There are a series of salvage treatments once seeds-RT fail. Cryosurgery is typical. However it all depends on the status of the patient (eg; age, other health problems, physical fitness, and private choices). Quality of life was important to me since my diagnosis in 2000.
A very important parameter to consider in any decision for a salvage treatment is the side effects of treatment. Along the years of PCa management, many see themselves treating more the side effects of therapies than the cancer itself.

Watchful Waiting is a good choice for guys with minimum fluctuations in PSA (slow progression of cancer activity). Active Surveillance is recommended as an initial therapy but you could follow one of its protocols, because you still got your prostate.
Hormonal therapy is a palliative treatment excellent to keep the cancer “at bay”, but HT in a case as yours, would influence the PSA readings which is an important marker for judgments of progress.

Do some investigations but do not become anxious for a single reading of PSA.
Take care
VGama

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