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Is This Normal - PSA test not done until 3 months after radiation

dhrocks
Posts: 20
Joined: Aug 2011

It has been quite a while since I posted on this site but had a question regarding my husband's PSA tests. Just a little background: My husband (82 years old) is going through his radiation treatments (44) and is half way through with no side effects so far. I just found out today that they are not going to check his PSA until 3 months after the radiation treatments end. Is this normal? I do not like the odds on waiting to see if the radiation actually worked or not since he is a Gleason 9 with T3 results.

It just doesn't seem normal to have to wait. The radiologist said after the treatments the radiation is still 'working' for another 3 months.

Should I ask to have a PSA test done earlier?

Thank you.

janekirstine
Posts: 24
Joined: Nov 2010

Hi dhrocks,

Yes, it is normal to wait about three months.

http://www.prostate-cancer-radiotherapy.org.uk/psa_bounce.htm

The measurement of PSA levels after treatment is an important indicator of the outcome of treatment. In the case of surgical removal of the prostate (prostatectomy) in which all the prostate tissue is removed and where no prostate cells have metastasised to remote sites, the PSA should fall to an undetectable level in two or three months after the operation.

For radiotherapy, the behaviour is more complex even without any hormone use. The radiation does not of itself kill cells. Radiation works by damaging the DNA molecule in a cell. Generally, this is repairable but sometimes it produces fatal damage so that when the cell comes to divide into two cells (mitosis), these offspring cells have fatally flawed genetic information and so they are not viable cells. They either die at mitosis or peter out after a few generations. The time scale for prostate cells to reproduce is significant and may range from a few months up to periods of the order of a year or so - as evidenced by PSA doubling times. Now, the cells with fatally damaged DNA still continue to produce PSA and this only ceases when they die. As a result, PSA declines quite slowly after radiotherapy.

Best of luck to you and your husband! J

dhrocks
Posts: 20
Joined: Aug 2011

Thank you...not what I had hoped for but a clearer understanding of what is going on right now.

Thank you for your quick and detailed response (and also the link to the website).

rch
Posts: 79
Joined: Nov 2011

Good explanation !!
But just wondering however,why there is a PSA bump after a year or two following Brachy , but not so much following other forms of External Radiation.

Swingshiftworker
Posts: 658
Joined: Mar 2010

There's a possibility of a PSA bounce w/BT and all other forms of RT, CK included, but it apparently occurs more w/BT than other RT methods.

There is apparently no single explanation for why it happens but (whether it occurs or not) the bounce is apparently not statistically significant in determining your prospects for survival or recurrence.

See: http://www.psa-rising.com/med/ebr/psabounce1004.htm

Old-timer's picture
Old-timer
Posts: 133
Joined: Apr 2011

My oncologist waited three months before checking my PSA after radiation treatments. That was in 2005.

I wish successful results for your husband and you.

Jerry

dhrocks
Posts: 20
Joined: Aug 2011

Looks like this is the norm then. However, I'm sure it was a long wait for all of you too but I feel as though we are wasting time if this treatment didn't work. Since he is on hormone therapy and radiation I guess we are doing everything we can for now.

I now know if we were to get a PSA test now it would be kind of meaningless.

Thank you all for your wishes and personal knowledge.

Tsantos
Posts: 2
Joined: Dec 2011

My dad was diagnosed with 2tb prostate cancer in July. Gleason score 7 , and PSA pre treatment was 7.7 . He completed 42 rounds of IMRT radiation, and just got his 1st PSA (6 weeks after his last tmt). It came back as 14, which is horrifying for me, but doc does not seem too concerned. He wants to re test in April. Given that the PSA doubled in just 3 months while undergoing RT, should I be concerned? Or is it possible it was too early to retest? Please help. My dad is my best friend and my hero.

VascodaGama's picture
VascodaGama
Posts: 1598
Joined: Nov 2010

Santos

Welcome to the board.

There is lots of “guessing” when taking into consideration the levels of PSA just after radiation, to judge success. The standard schedule for the test is three months counting from the date of end of the treatment but still many doctors recommend a period of six months to allow healing of the areas irradiated.
Radiation causes inflammation at the areas of the treatment which will cause prostatic cells (benign and cancerous) to produce elevated amounts of PSA serum. This happening is more pronounced in protocols that involve wider areas for radiation (prostate gland, lymph nodes at the iliac, and areas adjacent in the pelvic). Our body also takes time to clean all those dead cells circulating in the blood.

Some protocols, particularly those involving hyperfractionation, are known to arrest the PSA down quicker, but that does not mean that the treatment is superior to other protocols delivering highly conformal lower dosages.
Typically the PSA after radiation lowers to a certain extent in the first year and then presents a bounce (plateau followed by an increase and then a decrease and again a plateau) before it starts to decrease to a nadir. The process may take two three years for accomplishment. This is valid in patients with the prostate gland in place. In patients without the gland (RP survivors) the bounce is not so relevant and the patient gets to nadir quicker. In my case as a RP survivor, after salvage IMRT the PSA declined to its nadir taking 13 months for the accomplishment.

Surely, if there is an error or the isodose planned protocol does not include the areas where the cancer is located, the PSA is not expected to decrease. Nevertheless, in your father’s case the increase of the PSA seems to be more likely due to inflammation. The doctor may be right in delaying the test to April.
For peace of mind, you can do a PSA earlier but the level will be erratic with no clinical significance.

You can search for details on the "bounce effect" of PSA after radiation typing the term in the net.

I wish continuous recovery to your father and successful results.

VGama

mrspjd
Posts: 693
Joined: Apr 2010

Tsantos,

The assumption is made that the RT your father received was a primary tx, not a post op RP neo adjuvant or salvage tx, and that there was no neo adjuvant hormone tx. You may wish to share more details about your father’s PCa journey since many facts and stats are missing. Without knowing his PCa history, including PSA history (in the mos/yrs prior to the 7.7), age, clinical biopsy pathology report(s), Gleason (3+4=7 or 4+3=7?), etc., it is difficult, and perhaps too early, to offer opinions as to whether his PSA reading of 14 is indicative of inflammation, tx success or failure. Nevertheless, I do understand your concern and worry. Your father is fortunate to have you on his team and assisting him with PCa research about his situation.

IMO, it’s important to know the total Gy dosing (the total amount of radiation applied) that your father received in the 42 txs and if the tx given was at a medical center/clinic with up to date, state of the art medical equipment. Older RT equipment may do more collateral damage to nearby tissue, increasing inflamation and/or potential tx side effects. It’s also helpful to understand the radiation tx field/area that was identified for tx and received radiation. As VascodaGama highlights so well, in addition to RT to the prostate tumor, more aggressive RT tx may also include the prostate bed and/or local lymph nodes, as was the case in my husband’s RT tx.

In the months following RT tx, PSA readings can be erratic and reflect inflammation as Vasco also points out. Some OTC anti-inflamatory or Rx meds may help reduce some inflammation (always check with your doctor first). Any PSA fluctuation should be within certain acceptable ranges following RT. You and your father may wish to ask his radiation oncologist and/or PCa oncologist what ranges s/he considers acceptable in your dad’s case. And you may also want to obtain a 2nd opinion.

With the limited info you’ve provided so far, and depending on his pre tx PSA history and so on, if this were my father, FWIW, I’d ask for a 2nd PSA test in another 45 to 60 days just to establish a PSA trend early on.

Welcome to the PCa forum and good luck to you both.

mrs pjd

Tsantos
Posts: 2
Joined: Dec 2011

All of your responses were indeed reassuring. After reading more of the thread- I am hoping the PSA may have in fact been done too early to tell anything just yet. I too am also realizing that I may be searching for a definative answer that may never be there. (does he have cancer- or does he not) I figured the post tx test would be more like a pregnancy test- eiter you are... or you arent. I can see now that this is a lifelong journey, and can only now begin to understand that bonding amongst cancer survivors and thier loved ones. Were all in it together- huh?

RT was his only TX plan (no HT or surgery). He is a very active -hockey playing- works FT-
69 yr old who loves to followhis grandsons to all thier sporting events . He received IMRT imaging (have totals written down at home) at a Coc approved/newer faclity.
Gleason was 3 + 4 = 7 and his PSA prior to biopsy was 4 in January 2011. (Then 7.7 in July now 14 in Nov- just 6 wks out of tmt) After pathology reports and digital imaging- he was diagnosed T2b- borderline C (Tumor over 90% in one lobe- but still encapsulated- no evidence of cancer in Lymph's, nearby organs or bones)

I am gratefull for this forumn to all of you for your thoughtfulness. I have encouraged my dad to register on this site and think he (and my mom) would find it helpful as well. I will plan to check back in periodically- and after his next tests.

The American Cancer Society also launched another site for survivors that I plan to check out. If anyone is interested it's http://acs.whatnext.com/

My Heart,
Terri

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

Tsantos,

Welcome to the board and I hope you encourage your father to also join the forum so he can benefit directly from the wealth of knowledge and information available here from men who have had to deal with similar situations in dealing with their prostate cancer.

Like the others who have replied to your post, I believe six weeks is too early to be worried and wonder why your father even had a PSA test so soon after his treatment. Someone should have told him any results this soon after radiation are rather meaningless. Radiation causes significant inflammation to the prostate. This is why some men have feelings of urinary urgency following their radiation treatment that can last for a month or so after their last session. Frequently, well meaning family doctors order PSA tests shortly after prostate treatment without realizing the anxieties that this information could trigger for no valid reasons.

Unlike men who undergo surgery to remove their prostate and see a significant drop in PSA immediately after treatment, radiation takes much longer for the effects to manifest themselves as it does not kill the cancer cells directly but rather damages the cancer DNA making it impossible to undergo cell division (mitosis) and spread. With prostate cancer cells this can sometimes take two or three generations and remember that prostate cancer cells are very slow growing compared to other cancers. For this reason, men who undergo radiation treatment will see a gradual decline in their PSA levels to some low point referred to as a nadir. This can take as much as four years to reach. Men who have radiation will never see a zero PSA score since they still retain a prostate with cells that will continue to produce PSA.

Vasco referred to a PSA bounce. While I wouldn't use the word "typical" to describe the frequency of of this phenonema it is not uncommon and seems to occur in 25-35% of all men who have radiation with men who have brachytherapy seeing a slightly higher frequency of occurrence over men who receive external radiation treatment. The mean time for a PSA bounce is about 18 months but it can occur as early as 13 months and as late as three years after treatment. Some men have multiple PSA bounces. There are varying definitions of what a PSA bounce is and nobody really seems to know what causes it although many radiologists speculate is is associated with the death of cancer cells. In general a PSA bounce is characterized by a decline in PSA levels and then an increase (bounce) in PSA for one or two tests, then a return to declining values. It doesn't seem to make any difference in long term effects whether you have a PSA bounce or not and I've even read recently that some oncologists feel a PSA bounce is a good thing as it may presage a lower nadir which is strongly indicative of long term success.

A typical nadir following IMRT is in the order of < 0.5 ng/ml but there are really no hard and fast rules here. Everyone has a different nadir and some are higher than others. The important thing is the trend which should see declining PSA levels over a few years to some low point that remains fairly steady over time. An increase in PSA after reaching nadir may be an indication of recurrence so it is something your father will want to observe for the rest of his life.

In any event, it's much too early to be wondering about PSA bounces in the case of your father but something to keep in the back of your mind should you see a rise in PSA levels a year or so from now.

I think one of the reasons mrs pjd asked about whether or not your father was taking hormone therapy in conjunction with his radiation (not uncommon for a Gleason 7 patient) is that the HT tends to have a completely different affect on PSA levels above and beyond the radiation and the usual rules about testing and monitoring are different. As she suggested in her post, it would be helpful to know more about your father's history with prostate cancer such as his PSA history, DRE results, family history, and any other relevant medical data that affects his pathology and prognosis.

Speaking of family history, I hope you now realize that with your father's diagnosis you are at higher risk for developing prostate cancer. If you haven't done so already, you need to establish a PSA baseline at your first physical over the age of 40 and follow up every time you get a check up.

Best of luck to you and your father.

K

Swingshiftworker
Posts: 658
Joined: Mar 2010

A PSA 3 months after treatment and every 3 months after that is the normal diagnostic approach until the patient reaches the anticipated nadir of treatment (below 1 for RT) and maintains that level for at least a year.

After that, your husband can probably go to PSA testing only twice a year for a year and, if there's no increase further increase in that year, 1x a year after that.

At least that's what my RO told me. I'm still far from there and have been tested every 3 months since I was treated w/CK in Sept 2010.

dhrocks
Posts: 20
Joined: Aug 2011

Thank you Swingshiftworker....I just hope my husband doesn't get worse while we sit and wait. Of course he is still only half way through his radiation treatments now and I am probably worrying for nothing (well not nothing but maybe prematurely).

He is also getting hormone shots every month but I don't even know if that is helping.

Thanks again.

VascodaGama's picture
VascodaGama
Posts: 1598
Joined: Nov 2010

Hi dhrocks

It is nice to see you so engaged in the care of your husband, but try to control any anxiety particularly when in the proximities of him. Prostate cancer afflicts all members of the family and many even call it as a couple’s disease. However, we the patients like to feel the warms and care surrounding us but do not like to sense the worries.

You got above splendid opinions from educated survivors that you can trust. I am a layman in the subject but believe that your husband will get better once the treatment ends. Probably there will be a series of side effects but such is usually cared with medications. The nasty ones disappear typically two to three months post RT.
You have also to consider additional side effects from the hormonal treatment portion (HT).

The PSA after RT which you are taking as your guide to verify outcomes may be not the proper way for judging on the effect of the radiation yet. HT will influence and “mask” the PSA results and that means that you probably have to wait for the drugs to lose its effectiveness before getting a stable judgement (on the overall of the therapy).
Nevertheless, a continuous low PSA in the long run will be indicative of a successful treatment.

I do not know about the protocol your husband is taking or his diagnosis. The combi of RT plus HT is known to be very effective as a treatment in PCa. You just have to give time a chance for celebrating the Zeros. Meanwhile be positive and share your stories with other patients in the forum. We all would like to read more of your opinions and posts.

I wish your husband an eventless treatment and excellent outcomes.
The best to you both.

VGama

dhrocks
Posts: 20
Joined: Aug 2011

You are absolutely right about this being a "couple's disease" and I also agree that my husband deserves to have his surroundings as peaceful as possible. However, my husband's dementia seems to be getting worse and never remembers why he gets his hormone shots or when he is to get his radiation. Both are the standard treatment: 44 radiation treatments and Fermagon every month.

I will definitely try harder not to be so negative and look at the brighter side of this bump in the road.

At least he doesn't seem to be having too many side effects from the radiation...this is definitely a positive.

Thank you for all your advice.

All the best.
dhrocks

nwgeoff
Posts: 6
Joined: Sep 2011

I would like to offer a counterpoint on when to test PSA after radiation (If you are also on Lupron). The complete article is attached but this is the essence.

"To explain the findings from the re-analysis of data from these two trials with care, we need to explain two specific measures of PSA value:

The PSA end value is defined as a patient’s PSA level immediately following the completion of radiation therapy.
The PSA nadir value is defined as the lowest level that a patient’s PSA reaches at any time after the completion of radiation therapy (and is a value that many patients will be more familar with).

D’Amico et al. have shown that, based on their analysis, a PSA end value and/or a PSA nadir value of > 0.5 ng/ml in men treated with external beam radiation therapy + 6 months of neoadjuvant hormone therapy are surrogate markers for prostate cancer-specific mortality. In other words:

If the patient’s PSA end value and his PSA nadir value are both ≤ 0.5 ng/nl, then his cumulative risk for prostate cancer-specific mortality is very low (< 10 percent at 10 years of follow-up), and therefore the only future therapy he is likely to need might be intermittent hormone therapy to manage his PSA and avoid bone pain.
If either the patient’s PSA end value or his PSA nadir value are >0.5 ng/ml, then his risk for prostate cancer-specific mortality is significant (20 to 30 percent at 10 years of follow-up) and he should immediately be considered as a candidate for long-term ADT and for trials investigating the use of drugs that have been shown to extend survival in men with castration-resistant prostate cancer (CRPC)."

I had my PSA tested immediately after radiation (6 days). I had been on Lupron 4 months at the time. It was 1.1 which is not so great. But it tells me that the Lupron is not completely effective and perhaps I should evaluate additional treatment now instead of waiting 3 months. I am a high risk patient, gleason 8.

http://prostatecancerinfolink.net/2011/11/24/who-needs-aggressive-treatment-after-initial-radiation-and-who-does-not/

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