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first PSA after surgery 0.51 any advice??

bn20
Posts: 7
Joined: Sep 2011

hi everybody,
my dad had his prostate removed 3 months ago, original psa was 13 and pathology report showed:

Poorly differentiated Adenocarcinoma of the prostate Gleason score 8 (3+5) is present in both hemispheres (left and right side) of the gland.
Tumour has invaded both left and right seminal vesicles to a small extent.
The prostate capsule has positive margins on both the left and right hemispheres of the gland.
There is perineural invasion present.
There is no evidence of lymph node involvement
stage PT3c N0Mx

so he had the first PSA test whitch came back as 0.51, his doctor didn`t suggest futher treatment and said that it s fine with this reading, and to come back to see him in 3 weeks,

any advice guys?, thank you

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

BN20

The pathologist report indicates an advanced case, and your dad’s diagnosis is highly risky for recurrence (Gs8, positive SV, positive margins, etc.). You may wait to confirm the PSA with another test, but the high PSA of 0.51 after surgery (3-month mark) with extracapsular extension is enough confirmation of treatment failure. By norm a PSA higher than 0.4 after op is indicative that the cancer still exists in the form of metastases. Your dad should be looking for an adjuvant therapy or salvage treatment.

His doctor’s comment is optimistic so that your dad do not enter into panic, but I would advice you to research about salvage treatments, (the most typical are Radiation and Hormonal based therapies), and that you prepare an extensive List of Questions for your next meeting (in 3-weeks) with his doctor. Surely there is hope that he gets cure or control on the cancer for many many many many years.
He needs to tackle the bandit the soonest, but there is enough time to educate oneself on the present status to get the best outcome. Be confident.

You haven’t indicated the age and any other health problem of your dad which may influence in the decision of your next step. Nevertheless I recommend you to particularly investigate on the risks and side effects of each treatment. You can google this sentence to get details; “salvage treatment after radical prostatectomy of prostate cancer”.

I believe that your dad got image studies (bone scan, CT, MRI) done before surgery because of his pre-op PSA of 13 and the pathological stage of pT3cN0MX. They may have been negative which could mean that your dad’s case is considered localized. This is a good indication that such metastases may exist as micrometastasis at the prostate fossa or at the lymph nodes at the iliac (too far to be dissected at surgery). The treatment of choice in such cases has been a combination of radiation (IMRT) plus hormonal (ADT), which have proven results of success (from long cohorts of studies).
However, many factors will influence the treatment and all aspects together with his present health conditions, family situation (leaving alone, etc), financial, and own desires (living permanently with some side effects that he would or would not accept), etc., are all important matters to be considered in advance.

You can find a list of questions by googleing this sentence; “questions to ask your doctor about prostate cancer”. In a separate thread I have posted this list which may help you in finalizing your own list;

1. How aggressive can we consider his case taking into account his age and other health complications and symptoms?
2. How far advanced is it?
3. Should I get a second opinion for all choices?
4. What are all options?
5. Should I consider do nothing and just monitor any advance?
6. What treatments are best for my father?
7. Can such treatment lead to other problems or interact with other medications?
8. What can be done to cope with the side effects?
9. Will my father have to stay in the hospital for treatment? How long?
10. Will the treatment keep him from doing certain things?
11. How often will he be checked after treatment?
12. Can he go back to normal daily activities after treatment?
13. What experiences have other patients had with similar treatment regimens?
14. Is there any new type of treatment or trials that might be beneficial?
15. What has been your experience with prostate cancer patients similar to his case?
16. Can you recommend any patient support groups in my area?
17. Are there materials I can read about his case?

You could leave the list with the doctor and call his office later to request any specific information on a question or answer on which you have doubts or could not understand when on consultation.
In this forum you will find many guys that will try to help you in understanding your dad's case along his journey.

Wishing you and your dad peace of mind.

VGama

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

Sorry, but I think Vasco is correct in his cogent assessment of your father's post surgical PSA reading. Without knowing his pathology before having his prostate removed it is impossible to judge his prospects but a PSA reading of 0.51 so soon after surgery strongly suggests that your father's cancer has moved beyond the prostate gland even though it may still be undetectable with scans. I would join Vasco in urging your father to seek second opinions on possible courses of further treatment.

Best to you.

K

bn20
Posts: 7
Joined: Sep 2011

thank vasco for all the information, i am really in a dilema, his doctor was very satisfied with result and told him from 13 to 0.51 is good, my mum asked him will he need radiation, he said NO,
after his visit with the doctor he meet his friend who had surgery with the same doctor and he told him that this doctor recommended him radiation when his psa reached 0.21
i don`t understand the doctor decision about noi futher treatment.

schould he see another doctor??
can he wait for another psa test?
, my dad has no knowledge about PCa and i am trying to help.
Vasco he is 57 with no health problem
please help

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

It's probably too early to make a decision about changing doctors but you do need a second opinion. Your father has an an advanced form of prostate cancer as indicated by the Gleason 8. I think that the standard steps at this point would be follow on radiation probably in conjunction with hormone therapy. Your father needs to educate himself quickly.

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

It's probably too early to make a decision about changing doctors but you do need a second opinion. Your father has an an advanced form of prostate cancer as indicated by the Gleason 8. I think that the standard steps at this point would be follow on radiation probably in conjunction with hormone therapy. Your father needs to educate himself quickly.

tarhoosier
Posts: 188
Joined: Aug 2006

BN
Without more details of the surgery and the pathologist report (VERY important) it is not possible to provide detailed instructions. If the report about the doctor and his advice is true (were you there and heard this personally?) I cannot understand what the doctor is trying to do. Your father is too young to be sheltered from the results of unpleasant pathology. At 75, perhaps I could understand in selected cases, but not at age 57. He needs the truth. If a reasonable time has passed from surgery and if a psa of 0.5 or more is recorded, and if this is confirmed with another psa result from the same lab, then there are issues about further treatment that must be addressed. What those issues are really depend on the pathology report which your father MUST obtain and have in his possession in order to read and understand. From the patient point of view, a post surgery psa of 0.51 is a bad result. If the doctor said the opposite, he is representing another view. This is also a bad sign.
Although it may be difficult, recall that your father is the patient and the client, and not you. He must make the call, understand the issues, discuss with his doctor(s). Any advice to you is to assist him with this.

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

BN20

You got already three responses from educated survivors. There is no dough that the PSA of 0.51 is a “bad“ result and it should be dealt with caution.
Your father’s friend case cannot be taken as a judgement even if the same doctor recommended radiation to him with a lower PSA. Other parameters are taken into consideration to decide on the treatment. (We may be similar but not equal)

The indicators of the pathologist report may be suggesting the presence of micrometastasis which is probably the classification your dad’s doctor is thinking of his case. Micrometastasis is a condition to which doctors have no definite protocol to follow. I was diagnosed with the same status ten years ago and was recommended to Watchful Waiting (do nothing). They say that radiation is not recommended because there are no definite targets; therefore the procedure would be like throwing arrows in the dark.

There are other “elements” in your dad’s diagnosis that is considered negative for a successful radiation. Guys with pT3c, Gleason score of 8 to 10 and considered with distant mets are also usually not recommended by doctors for the therapy. In my case I had a Gleason score of 2+3=5 (the lowest aggressive), pT3a, negative SV and negative lymph nodes, but positive margins and I had a voluminous cancer occupying a large portion of the prostate.

Here is the comment in an article at the Prostate Cancer Foundation;
It says;
“……the procedure is not for everyone. If there are obvious sites of disease outside of the immediate local area, if any tumor cells have been found in your lymph nodes, or if your Gleason score was 8-10, post-surgery radiation therapy may not be right for you. In this high risk situation, additional therapy may be warranted such as hormonal therapies or clinical trials.”
(http://www.pcf.org/site/c.leJRIROrEpH/b.5839311/k.13F6/Radiation_Therapy_Following_Prostatectomy.htm)

However, times have changed. Studies have been done and a different way of analysing these cases has surge with many doctors recommending earlier “attack” on the cancer with radiation or in a combination of radiotherapy and hormone treatment. NCCN also recommends this treatment in their practice guidelines.
Moreover, your dad is young therefore his life expectancy is over 15 years which classifies him as a candidate for aggressive attack on the cancer.

The conclusion of studies where it has been confirm that the soonest the radiation is applied (adjuvant) the better the results, is evident even to T3 cases. Here are excerpts of statements from the studies;

“….randomized trials have shown adjuvant radiation therapy provides benefit, whereas salvage radiation therapy evidence is lacking…..”

“……Immediate adjuvant radiotherapy for high risk patients, pT3, proven to be beneficial: The European Organization for Research and Treatment of Cancer (EORTC) 22911 showed a biochemical progression free survival, 74% vs. 52.6%, improved clinical progression free survival, and a significantly lowered rate of cumulative loco regional failure….”

The combination of IMRT + ADT is set as a protocol where radiation follows established isodose planning in the prostate fossa with additional radiation directional to the closed lymph nodes. The hormonal therapy (ADT) will treat any systemic cancer while at the same time is expected to help in the successful “killing” of the cancer under radiation.
Results have shown better outcomes with this combi than a simple salvage radio therapy, done at a later date.

You can read details of the procedure and results in these sites;
http://csn.cancer.org/node/215211

http://www.hisprostatecancer.com/salvage-radiation.html

I am not a doctor but I would recommend your dad to get another PSA tests done at the one month mark from the previous PSA (do not wait another three months). The result will be conclusive for a decision. As many here commented, I would recommend you to get a second opinion from another oncologist as well as from a radiologist. You will need a copy of the pathologist report, your dad’s chronology of PSA tests before RRT and after.
I read your post in another forum and know that you are in UK. The health system is different there and your dad may confront some restrictions in getting second opinions, but I would try to convince his doctor in getting a referral, and then just look for a different doctor he would be comforted with. His future treatment will be related to radiologists not surgeons.

Do not be anxious. Your father will deal a “blow” to the bandit too. Just try to get him involved in the research process and act on the matter. Knowing what was happening to me in advance, it has helped me a lot along my eleven years of fighting and surviving the disease.

A good book I recommend you to get (Amazon sells copies) is;
“Beating Prostate Cancer: Hormonal Therapy & Diet” by Dr. Charles “Snuffy” Myers; which informs on diagnosis and treatments for systemic cases. This famous oncologist specialized on PCa is himself a survivor of a challenging case on his 12 year of survival, where he battled the bandit with IMRT and ADT.

Wishing your dad and all of the family the best.

VGama

bn20
Posts: 7
Joined: Sep 2011

vasco
i read in some website that radiation is not successful for cases like my dad`s, so i think this what his doctor decided, no radiation, because the doctor himself is a radiologist, he has a clinique where he does surgery, radiation, biopsies...
but why no futher treatment? is it normal to wait for a rise in psa before starting hormone therapy?

my dad had surgery on 15/5/2011 so this psa reading is on 1/9 almost 15weeks after surgery

i hope you can send me you email, this is mine clock87@hotmail.co.uk

thanks for all your help.

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

BN20

Does your dad’s Doctor repair Shoes too?

Your comment in regards to your fathers’ doctor surprised me. Surely he may be excellent in his job with his tools but I never heard of a doctor for all “Seasons”.
If in fact it is true that he is that good, he for sure has missed to order a PSA test done at three to five weeks post-surgery as it is recommended by the European Association of Urology (EAU)
Nevertheless, your dad’s case is very indicative of recurrence and the same EAU practice guidelines (which the doctor seems not to follow), recommends starting a treatment which could be ADT to his case.

As I commented above, many factors influence decisions in treatments. We could say that “one fits all” do not exist in prostate cancer affairs. Oncologists also have different threshold values in PSA to trigger hormonal treatment. Your father can inquire in his next visit to the doctor, which value or symptom or (????), he uses to start the treatment.
(add the question to the list)

Usually doctors take into account past histological behaviour of PSA trends such as PSADT (doubling time) and vPSA (velocity), and volume of cancer, etc., and plot those parameters in their “private” diagnostic Tables to define the value of a “trigger”.
In Gs 8 guys (high risk patients) the time to treatment is short. Maybe your doctor uses PSA=1.0 to start the hormonal therapy.

I would not recommend my example to your dad because we have different Gleason grades, apart that the thresholds used ten years ago are not reliable in present times. Medicine has evolved in the past decade and there are now many studies done in real cases indicating “the Good the Bad and the Ugly” of the “old” thresholds. The value used for Gs 5 guys in 2000, was 3 to 4.

I surely recommend your dad to not wait until the cancer speads and shows symptoms.

Best regards.
VGama

(my e-mail; nanbangin@gmail.com)

2ndBase's picture
2ndBase
Posts: 220
Joined: Mar 2004

I had a Gleason of 9 and psa of 24 at age 52. I took radiation treatment which killed all the cancer in the prostate but it had already spread. I have been in hospice care for one year I still work as a tutor at Ivy Tech College. Let your dad chose the path he likes. I took the quality of life, nostress, and have outlived many predictions. It sounds like there would be no cure for your dad at this time and he will need a lot of support and hope to survive.

mrspjd
Posts: 693
Joined: Apr 2010

Re: “Smitts” etc.

Good post, Kongo. Active CSN members on this PCa forum are familiar with trolls, who seem to come and go over time. Unfortunately most public discussion boards and blogs are easy targets for both obvious and disguised trolls, such as marketeers phishing for biz and seeking to push their wares and advance their products or txs, especially those peddlers who blatantly embed links into their posts. BTW, probably not a good idea to click on those embedded links, which usually show up in the post as a different font color.

In addition to the PCa forum, “Smitts” has similar posts on some of the other CSN forums and has lurked here before. These bottom feeders often time their hacks after website admin hours, on the weekend, or just before holidays, when webmaster or site admin personnel may be “off.” So it may take some add’l time before CSN admin removes the posts.

Flagging these individual posts is important and an option we have as logged in members but, with multiple posts, it’s not always possible to flag them all. Instead, click on the “CSN Feedback” option (this option is available to both members and non-members alike) located in the red box on the upper left side of the page under CSN, and report inappropriate posts to CSN admin. Any posts deemed to be “inappropriate” will be removed by CSN. This can take time, but know that admin is working on it. Also, any posts “attached” to the “inappropriate” posts are usually removed along with it, even if that post was “appropriate.”

If you have no idea what this post is about, then most likely the flagged posts have been taken down/removed from the forum by CSN admin.

In addition to marketeering and snake oil sales, the primary intent of these “get a life” trolls is to provoke readers into an emotional response or to disrupt normal online discussion topics.

Do Not Feed The Trolls or "DNFTT" (and marketeers) is often recommended.

Many thanks to the CSN admin staff for a great job of keeping the forums free from advertisements and solicitors.

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