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PSA recurrence after surgery

sbj
Posts: 24
Joined: Jan 2011

May 2003 at age 67: surgical removal of cancerous prostate. Gleason 4-7. Lymph node check was ok.
PSA before surgery: 5.5
PSA after surgery: 0.003
2004 0.003
2005 0.02
2006 0.07
2008 0.11
2010 Feb 0.13
June 0.15
Sept 0.17
2011 Jan 0.20

Have just signed up for salvage radiation. Prostate bed only. Doc says 35 sessions. I asked lots of questions before taking decision, but missed these:

How soon after the salvage radiation can a PSA test be done?
What do you think of my decision. Could it have been better/worse?

Thanks in advance for your advice.
sbj

VascodaGama's picture
VascodaGama
Posts: 1515
Joined: Nov 2010

Hi SBJ
PSA after radiation has an erratic behaviour. It goes down as well as up before settling and declining to its nadir (lowest level). This can take years to be accomplished. Usually, PSA after radiation is taken every 3-months but some guys do take it on 2-months or 6-months periods. I did take one just at the end of RT for curiosity.
Your choice for RT is the traditional protocol but PSA is not the only factor taken to determine it application. Age and other health conditions are also seriously considered.
I wish you the best in this bumpy road.
VGama

sbj
Posts: 24
Joined: Jan 2011

Hi VascodaGama, thank you for your follow-up in answer to my questions. As you say, PSA will be erratic after salvage rad and so according to my understanding, some time must elapse before reading reaches nadir, which in my case, if malignant cells are totally contained in prostate bed, should be close to zero at that time.

Radiation choices offered were: (1) salvage of prostate bed only, (2) ditto, + pelvic lymph nodes, (3) (1) + HT, (4) (2) + HT. I chose (1) to hit what is thought to be the most likely site of malignant cells considering pathology report and advice of radiation doctor. Of course, only time will tell whether this decision was correct.

mrspjd
Posts: 688
Joined: Apr 2010

sbj,
Don't know if you've started RT or are asking which choice might be best, but if it's the later, more info is needed to make an informed decision. For instance, on the HT addition options, what is the HT protocol, such as which drug(s), what length of time/term on the drug(s), short or long term or intermittent, is being recommended; re the options without the addition of HT, is there a difference in the total amount of gy used and # of sessions between the tx to prostate bed alone than to prostate bed with local nodes; how many nodes would be treated if the RT included the nodes, local or extended nodes? I agree with Tarhoosier's previous post--even with the info recently provided about post RP pathology, the Gleason # is still unclear. Just a few things to question and consider.

Which ever option you choose, hope you obtain the desired results and best possible outcome.
Good luck,
mrs pjd

sbj
Posts: 24
Joined: Jan 2011

mrspjd,
Am at the stage of waiting for the first session. Have committed to prostate bed only radiation. Decisions was not taken lightly. But I now wish I had signed up when PSA was around 0.1, instead of dithering over the hope the rise was due to leftover benign tissue etc, etc.
In consideration of HT I did not ask or analyze the drugs used, since I have little knowledge of their different degrees of effectiveness, and from what I have read, there is still so much argument over those numbers. I just felt I could not stomach the addition of HT's peculiar side effects. As regards local nodes, then the radiation doctor said that side effects are generally worse the wider the range of salvage. Even with Tomo.

Right now I am highly frustrated and anxious over the delay that is occurring between when I had all the scans/tests for salvage rad and the start of the sessions. Today is the 8th business day since the set-up session and I can only wonder why it takes so long - the cancer of course not waiting, but continuing its deadly spread. I've called the doctors office and am told that I might get the call next Monday. Again, I ask why so long? Why not 24-36 hours? What do you and others think of this amount of wait time?

I'm not sure of the exact post surgery Gleason number, other than what I have said - Gleason 4 with a touch of 7. The surgeon did tell me the cancer was totally contained within the prostate shell with no spread to local node sample.

mrspjd
Posts: 688
Joined: Apr 2010

I "hear" you loud and clear, but know that a few days or weeks may not make much difference, but the anxiety is still there. In PJD's case, he absolutely wanted the local pelvic nodes treated along with the prostate (he did not elect surgery). His tx was completed in Oct 2010, and he is doing fine with no side effects from the IMRT. Please read Vasco's newest post today carefully, as it, along with the link he posted, explains the thinking about why including the tx of the local lymph nodes may be an important consideration. Also, if the protocol for the addition of HT is a short term course (6 mos), it might also be worthwhile to give that a 2nd look. If the side effects were causing issues, then you could discontinue the usage and expect the side effects to resolve.
Best,
mrs pjd

sbj
Posts: 24
Joined: Jan 2011

A few days or weeks do not make any difference, other than if during that very timespan malignant cells metastasize! There is no way of knowing when this deadly event will occur, other than the certainty, that the longer amount of time you give it, the more likely is such bad outcome. This factor is the major cause of my anxiety.

sbj

mrspjd
Posts: 688
Joined: Apr 2010

It's a tough situation and anxiety/stress can be debilitating. Fear, anxiety, stress are all related. Putting things in perspective, you or I could be walking down the street tomorrow and a car could lose control and kill one or both of us. We just don't know, do we? No way to change the past, predict the future, or know what tomorrow will bring. Best to try not to dwell on what we cannot change or what we have no control over. However, we can work on thinking positively today, living in, and enjoying, this moment right now because in reality, this is all we have for sure. It's a gift and that's why they call it the "present." This philosophy, along with a practice of deep breathing, is fundamental to "Mindfulness Based Stress Reduction Through Meditation," which can be done in as little as one minute during the day. There are books available on this thinking/practice and if you'd like a recommendation, LMK, and I will post the info.

sbj
Posts: 24
Joined: Jan 2011

mrspjd,
Absolutely right. I agree with your perspective. The way I look at it is this: I'm 73 years old and along the way, along my lifeline if you will, others, some dear loved ones, close friends, have dropped by the wayside. So I count myself lucky to still be around. Right now, I feel comfortable with my decision and the possibilities of there being different outcomes. We all know that nobody gets out of life alive. As you say, live the moment - enjoy now.

sbj

sbj
Posts: 24
Joined: Jan 2011
Kongo's picture
Kongo
Posts: 1167
Joined: Mar 2010

sbj,

Welcome to the forum and I'm sorry that your PSA history seems to indicate a recurrence of PCa.

The PSA rise you experienced seems to follow the classic recurrence curve associated with a return of prostate cancer. Most urologists consider that a rising PSA above 0.2 ng/ml is evidence of recurrence and you seem to be there. You may wish to go to one of the PCa nomograms (visit the Sloan-Kettering site) and plug your PSA scores into the free calculator and determine your PSA doubling time and PSA velocity. Without knowing the exact day/month your PSA reading were taken, it looks to me that your PSA DT is fairly long (probably greater than three years) which is usually indicative that an early salvage treatment will be very successful.

It sounds like the IMRT treatment your doctors are scheduling is standard protocol for a case like yours. The only question you may wish to pursue at this point is what type of machine and delivery method is being used. Some newer types of IMRT can be delivered with a higher degree of accuracy than older models which will help reduce radiation to uninvolved organs and tissue and result in fewer and milder side effects. You may wish to look at some of the various new methods that include the Varian models, Calypso, and so forth over traditional IMRT delievery systems. I would also want to discuss with your doctors what lymph nodes (if any) they intend to address and why.

Because of the inflammation to the remaining prostate tissue in your prostate bed, they generally wait three months before looking at PSA scores again.

Studies have shown that salvage IMRT in conjunction with hormone treatment has a higher overall success rate than IMRT alone but there are side effects associated with HT. You ought to discuss the pros and cons of this option with your medical team.

As always, I would seek a second opinion before going forward but it my non professional opinion, you seem to be taking a prudent and appropriate course of action.

Best of luck to you and please keep us in the loop as you go forward.

K

Beau2
Posts: 228
Joined: Sep 2010

Kongo,

I am reading on another forum af "trials" using Avodart for rising PSA after RP. Apparently, benign tissue left behind after a RP can raise PSA. It appears that .2 cc's of tissue can cause a PSA rise of 0.2.

Apparently some men have gone 2+ years without further PSA rise after starting on Avodart.

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Kongo
Posts: 1167
Joined: Mar 2010

Hi, Beau

I too have read some of those trials that show Avodart can curb the rise of PSA and agree with you that prostate tissue left behind after RP can cause some small amount of PSA. Avodart suppresses the DHT (dihydrotestosterone) in the blood which will cause the prostate (and presumably the remaining prostate tissue after an RP) to shrink. I belive though, that you have to use some caution with interpreting PSA levels with this and other testosterone blocking drugs as they tend to "mask" the true PSA reading and the result you get after starting the drug is not really as low as the readings might indicate, but I would leave it to someone more knowledgable about the affect on our body chemistry by these drugs to explain that.

Potential side effects of Avodart are loss of libido and impotence but I understand that these side effects are much less a factor than with an earlier DHT inhibitor like Dutasteride. One unrelated positive side effect of Avodart is that it apparently reverse male pattern baldness so perhaps you can get a twofer here.

These would be good options for SBJ to discuss with his medical team and perhaps there might be benefit to him if he joined the ongoing trial.

K

Beau2
Posts: 228
Joined: Sep 2010

Do you know how a person could determine if a PSA rise was due to a recurrence of PCa or due to benign prostate tissue being left after th RP? Maybe the rise from benign tissue stablilizes (reaches a nadir or plateau)... kind of like radiation therapy ... but in reverse.

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Kongo
Posts: 1167
Joined: Mar 2010

Beau,

I believe a recurrence would be characterized by a steady rise in PSA over several readings such as the case indicated by SBJ in his first post on this thread. PSA caused by benign tissue would tend to be very, very low (depending upon how much tissue was left behind) and while it might vary up and down it would remain relatively steady over a long period of time and show a very long PSA doubling time and low PSA velocity. Depending on the sensitivity of the PSA test, benign PSA would tend to be referred to as "undectable" or "zero." Ultra sensitive PSA tests might show fluctuations at the second or third decimal point and cause mostly anxiety in the patient, not an indication of anything to worry about.

I don't think it's like a post-radiation nadir, per se, its just a very low level that should be proportional to the amount of tissue left behind. Men with very large prostates tend to have more left behind after surgery than men with smaller prostates. Surgical skill is also a factor in how much tissue is left behind. They're never going to get all the prostate tissue out at RP.

sbj
Posts: 24
Joined: Jan 2011

hank you Kongo for your follow-up in answer to my questions. Doubling time: 12-months worst case; 18-months best. There was some distortion in earlier readings due using different labs. Same lab, readings became more consistent. I did consider salvage of prostate bed + HT, but was turned off by reports of bad side effects from the hormone treatment. For the same reason, I also decided against having a wider salvaging beam to radiate the pelvic lymph nodes. A sampling of pelvic lymph nodes taken during surgery did not show any cancer there at that time.

The radiation technique is known as TomoTherapy, and I quote: "a treatment system that combines intensity-modulated radiation with the image precision of a CT scan to guide radiation exactly to the tumor areas." I have no knowledge of the radiation generator itself. Tomo is supposed to be highly accurate. Is this what you were referring to?

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Kongo
Posts: 1167
Joined: Mar 2010

sbj,

Tomotherapy is a very highly accurate form of delivering IMRT type radiation to the affected area and has the ability account and adjuist for organ movement through it's CT scan process. I have a close friend who is going thorugh treatment with this system now and is very satisfied with the procedure and apparent accuracy of the system. He chose tomography as his primary source of treatment along with a 12-month Lupron protocol.

Best of luck to you as you go forward.

k

tarhoosier
Posts: 181
Joined: Aug 2006

J:
More information from your pathology report could be helpful here in understanding your case. Nonetheless, your doubling time is slow, something on the order of 15-18 months using the most current figures with year and month available. The longer before a detectable psa appears, the more likely the recurrence is local to the prostate region. This is good news in your case. At your current age of ~75 years, even with only the treatments we have available today, you are unlikely to die of prostate cancer. Therefore, your treatment decisions could not have been better. Radiation can be quite successful in eliminating small amounts of disease residual in the prostate area. Even if it just slows the growth of your tumor this means you would have even more time allowed.
Assuming you have normal functioning of bladder, urethra and colon today, then radiation is reasonable. Any weak function in this area can be affected by the radiation. A colonoscopy, if not done within the last 5 years or so, might be a good idea before starting your course.
In successful radiation it takes time to determine success, sometimes years. Failure is usually apparent sooner. Your current schedule of every 3-4 months seems reasonable for future psa.
I do not understand your Gleason of 4-7. Can you be more specific?

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califvader
Posts: 108
Joined: Aug 2010

i have the same decision to make. salvation radiaton or hormonal therapy. i do not like what h/t does to you. the side effects suck. so i am thinking of the radiation only. my bladder, urethra, are in good condition. kongo mentioned the method of radiation and i will look into that. my psa has risen much more than sbj. it is now 5.8. i had a bone scan 4 months ago and it showed nothing. 7 years since my surgery so how do i know if the cancer has spread outside the prostate bed? i'm tired of thinking about cancer.

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Kongo
Posts: 1167
Joined: Mar 2010

Cal,

You may wish to investigate a relatively new method of detecting cancer outside the prostate bed known as the prostascint scan. It takes three days and involves the use of radioactive antibodies that attach themselves to cancer cells which can then be read using a special scan in conjunction with MRI and CT. Not all hospitals offer it but if you are in or near a larger metropolitan area you should be able to find it. Just enter "prostascint" in google and you'll find plenty of information.

K

califvader's picture
califvader
Posts: 108
Joined: Aug 2010

never heard of it but i have looked it up. i will definitely bring this up with my urologist. thank you Kongo.

mrspjd
Posts: 688
Joined: Apr 2010

Re: “Benign” tissue
Post RP, one might wonder whether it’s the “amount/size of (benign) prostate tissue” left behind OR the “amount of microscopic (undetectable) PCa cells” left behind in that tissue (no matter the size), that would be producing even small amts of PSA. Possibly a combination of both? Barring post RP path lab errors, might the same reasoning be used in a finding of “clear/negative” prostate bed margins, especially since PCa cells (if remaining) may be too minuscule to be picked up by current pathology lab analysis?

Re: Avodart
When taking drugs such as Avodart (dutasteride) or Proscar (Finasteride), the general rule of thumb is to double the PSA number in order to determine the “untreated” PSA number.

Re: Prostascint testing
All of the doctors we consulted during pre-tx decision PCa staging, were in agreement that the prostascint was not a reliable testing procedure due to accuracy issues. But I’m sure there is some disagreement on this subject in the PCa medical community (like almost everything else). The newer endorectal MRI w/spectroscopy (E-MRI/MRSI) with Tesla 3 technology, is the gold standard for determining if there is locally advanced PCa disease, such as to the seminal vesicles (SV) and/or the pelvic lymph nodes--pre RP or pre any tx, if medically indicated by biopsy results. I’m assuming that post RP, if SVs and/or nodes are remaining, then the E-MRI might still be a valuable recurrence diagnostic tool, given rising PSA results. Bone scan and pelvic CT are used to rule out distant mets, however, unless disease is very advanced, the bone scan & CT usually result in negative findings.

sbj
Posts: 24
Joined: Jan 2011

califvader,

If you've read my posts on this thread you'll knows that, like you, I've also suffered dreaded reoccurrence. While your PSA is higher than mine, I was led to believe by my rad doctor that the actual PSA number is not the only factor indicative of size of tumor. A lot depends, he said, on personal metabolism and location of malignant cells, in our case, the reoccurrence area. Unlike me, you might want to go for a more powerful treatment profile - prostrate bed for sure, but hit pelvic nodes too. While this can mean the possibility of more side affects, most of these affects, I'm told, lessen with time. Furthermore, side effects from HT for example - that you might want to consider too - lessens if not disappears completely a few months after end of treatment.

I understand that radiation can only be undertaken once. You can't go back and have lymph nodes done after a bed session. It's really all or not at all as far as our malignant cell targets are concerned. Me, being lower in PSA, have decided on just the bed. But I worry that if the malignancy is in the nodes, then my treatment will be an utter waste of time and effort. Hopefully of course, this will not be the case.

Today, I start the first of 35 sessions. Each one I hope to be mortal for those pesky maligs.

Good luck and best wishes whatever you decide.

sbj

sbj
Posts: 24
Joined: Jan 2011

Tarhoosier: thanks for the follow-up to my questions. I have been told that post-surgery Gleason was 4, with a "tiny bit of 7 in righthand top quadrant." Colonoscopy done about 6-months ago. Bladder normal.

VascodaGama's picture
VascodaGama
Posts: 1515
Joined: Nov 2010

SBJ

I am glad that you have reached a conclusion to your salvage treatment. I also had SRT after a failed surgery, but I choose a plan that included the lymph nodes (inner iliac), because they are usually the places from where cancer metastasizes. I think that you have done research on the details of your decisions; however it would be wise to relook into this aspect of irradiation plan because a repeated radiation of the same area is restrictive and has lots of complications. Here is the comment of Dr Charles "Snuffy" Myers who is regarded as one of the most prominent oncologists on prostate cancer. He quotes;

“….If surgery was the initial treatment, radiation should also be considered. Here there is a major controversy. Do you radiate the prostate bed or extend the radiation to the pelvic lymph nodes? I am biased because I keep seeing men who had radiation to their prostate bed and now have recurred. When we look, we find the cancer in the pelvic lymph nodes only in many of these patients. Radiation to those pelvic nodes then serves to put the patient into complete remission. So, I am a strong advocate of radiation to the prostate bed and pelvic lymph nodes…”

For the full article look here; http://prostatecanceradvice.org/about/myers/androgen-deprivation-therapy-after-surgery-or-radiation/

In my surgery 9 lymph nodes were dissected and all were free of cancer. These nodes are the ones easily to be accessed for dissection but there are others that can be reached/treated only with radiation.

I hope that you discuss about the above with your doctor and get to a final conclusion and peace of mind.
VGama

sbj
Posts: 24
Joined: Jan 2011

VascodaGama, I looked long and hard at the two alternatives - prostate bed vs. bed+lymph nodes and concluded that based on pathology report and having discussed with the radiation doctor, concluded bed only was sufficient. Of course, only time will tell whether or not this decision was optimum. The key factor for me was a guy who had bed+lymph tomo-rad who told me he suffered mightily after various with bowel, bladder problems, and still does 2yrs after treatment. Furthermore, this unfortunate fellow now has cancer in his bladder, caused he strongly feels, by the radiation dose. Of course this single encounter does not preclude others who have had success with the higher treatment level. This discussion however did convince me that I could not endue the risk of such torment, and so decided on a narrower, more sharply focused treatment.

Thank you again for your valued comments. Each and everyone of us is different. Each decision a roll of the dice.

sbj

VascodaGama's picture
VascodaGama
Posts: 1515
Joined: Nov 2010

SBJ
The most important will be the confidence in the treatment choosen, and I believe yuo did that in the best way.
I hope you a continuous development of your case uneventeful with an excellent conclusion.
Wishing you the best
VG

paterjak
Posts: 4
Joined: Feb 2011

Hey guys. Thanks for the thread. I would like to recount briefly my history. Any and all comments would be most welcome. I underwent RRP in November of 1996 at age 51. A biopsy had found cancer a month earlier (Gleason 3 + 4). Path report following surgery was mostly good news: seminal vesicles and lymph nodes were clear, but cancer had escaped to the capsule--not beyond. I should note here that PSA just before surgery was 4.5, after having been 4.0 the year before. My prostate was enlarged and the urologist could palpate a spot that was harder than the rest of the organ. Anyway PSA after surgery was 0.1 or less until December of 2009, when it was 0.15. Last month (slightly over a year later) it was 0.22. I never believed I was out of the woods (I imagine few of us ever do) and, as much as I'd like to, I can't come up with an explanation for the numbers other than the obvious one. I have an appointment with a radiation oncologist to discuss next steps. I hope for the best for all of you (and, of course, for me).

sbj
Posts: 24
Joined: Jan 2011

paterjak,

Your post-surgery pathology, time interval since surgery (before recurrence), time to double etc., indicate to me you're on a path of good outcome. In fact so long is the length of time to reach 0.22 (15 years), you might want to consider not being radiated at all. However, if you do decide on a course of salvage, a critical question you will face is extent of radiation; prostate bed only or bed+pelvic lymph nodes - with or without hormone therapy. Generally, the wider the field of treatment the worse the prospect of side affects. In any event, you should make sure radiation technique offered is a type called TomoTherapy.

This personal account of my experience thus far may help you better envisage what lies ahead:

Personal observations on the first week of 7-week, 35-session prostate-bed TomoThreapy radiation course.

Each patient must be in full-bladder, empty rectum state prior to treatment. This means judging when and what you eat for dinner the previous evening. Approximately half hour before your appointment (1) empty bladder, (2) drink 16oz of water. The displacement of these two organs is scanned before the start of each session. A computer screen shows how optimized fill/emptiness effects their position relative to radiation beam - with bed+nodes they end up more in the way. An empty, or even partially filled bladder hangs like a deflated balloon over target area. So drink up!

The further out the way these organs are the less chance of collateral damage - hence lower side affects.

The first three sessions for me were like Nightmare on Elm Street II. I drank too much (20oz), too early. As a result, lying on the trestle, within the bowels of the machine, I suffered agonizing minutes of self-torture trying to stave off peeing all over the equipment. The reason for this, in part, is that the timing of when one starts treatment can vary by as much as an hour or more - depending on the time each patient takes ahead of you. This variable is greatly affected by the result of the pre-scan. For example, if the bladder is not full enough, or too full, or the rectum has an air pocket (gas bubble), the test is held up for the patient to walk around to try eliminate the condition. Of course after each walk around the set-up scan has to be repeated. If this goes on long enough, those waiting have to visit the bathroom, release their straining bladders and re-drink enough water to replenish. It was not until the 5th session that I was able to better judge amount and time ahead of session to avoid a repeat of this agony.

For me, radiation time is 13 1/2 minutes. To this must be added 5 minutes for set-up to accurately align body with laser-lit lines that cross dead center of the prostate bed marker and tiny tattoo dots placed either side of your lower abdomen, 5 mins for the pre-scan, 5-15 mins for the doctor to come view the screen to okay the test, and 2-3 mins at the end before you can hop off the trestle and rush to rest room - a total of a half hour or more, depending on how quick the doctor can get from his interviewing schedule to the pc.

The test itself is painless and not at all unpleasant - other than the issues described above! The sound reminded me of a laundry room on wash cycle. The key is to carefully judge bladder fill - even to visiting the restroom to 'leak' a few ounces and replenish same amount if you feel 'overfilled' or you're going to be delayed over and above the scheduled time.

sbj

paterjak
Posts: 4
Joined: Feb 2011

sbj,
Thanks for your thoughts. 15 years seems like a long time to me too and I realize I have been more fortunate than many. But, I'm curious about your observation that I might want to think about not being radiated. That sounds pretty risky to me. What's your thinking?

midmi636
Posts: 2
Joined: Apr 2011

Age 69, RP 11 years ago, Gleason was 6-7. Margins were well defined. Annual PSA test has always been ND at <0.1 detection limit. Today was advised PSA test of yesterday showed 0.1. I'm not eager for radiation, but if the 0.1 is real and increasing I'll take that route. What do you guys think? Is this a rising PSA? Should I re-test right away? Wait a month and re-test? Since one year after surgery have not consulted with an oncologist since there appeared to be no need. I have not yet met with an oncologist but likely will have a consult next week.

mrspjd
Posts: 688
Joined: Apr 2010

Welcome to the forum. Wondering if you might clarify your meaning of the term RRP, as it is used most often on the PCa discussion board to mean Robotic Radical Prostatectomy. However, it can also mean Radical Retropubic Prostatectomy, which I believe is your intention, assuming you had an "open" rather than a laparoscopic or robotic operation in 1996. Thanks.

paterjak
Posts: 4
Joined: Feb 2011

mrspjd,

Yes, radical retropubic is what I meant, which at the time distinguished it from radical perineal. I don't think much (if any) robotic was being done then. Time marches on.

mrspjd
Posts: 688
Joined: Apr 2010

I didn't think so either (that RRP, as in "Robotic," such as DaVinci was available for PCa in 1996). Although that said, someone is sure to pop up and indicate otherwise.

That is exactly why I posed the question. Thanks for the clarification.

VascodaGama's picture
VascodaGama
Posts: 1515
Joined: Nov 2010

Midmi636

Welcome to the board.
I wonder why you talk about a salvage radiation treatment. PSA=0.1 is very low and not yet considered as recurrence. The difference between <0.1 and 0.1 in terms of PSA in prostate cancer is considered as equal; meaning that it has not changed.
Some laboratories give results as (<0.1) with the meaning of “remission”.
If you are concerned for any other reason or because your doctor has alarmed you, than try having a test done in a laboratory that uses higher sensitive assays in the level of two decimal places (0.XX ng/ml). This is the standard nowadays.

The meeting with the oncologist will give you peace of mind.

Wishing you the best.
VGama

midmi636
Posts: 2
Joined: Apr 2011

I appreciate very much your input. I was thinking much along your line of comment, and certainly for repeat higher precision testing before undertaking treatment. My day job prior to retirement involved conducting chemical testing (nonmedical) and understand well the risks of relying on measurements reported at the detection level. I'll advise, and perhaps again search for guidance,following higher sensitivity testing.

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