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psa rise

alinur
Posts: 12
Joined: Dec 2011

plse advice! i had robotic prostatectomy in january 2011. my first post psa(3&6 mons)were
both <.04. The last 9 mons psa is .07.I use the same lab.pathology:pT3b,margins negative,gleason 3+4=7 (85%,15%).Is this worrisome!
thanks to everyone.

tboy
Posts: 2
Joined: Dec 2011

The increase rate over time is what you need to watch. Are you on any follow therapy, casodex, lupron etc. It is too early to worry, but something to watch for on your next psa test. This is a time to keep positive and enjoy the season.what is your age. Was there any infiltration of margins.

VascodaGama's picture
VascodaGama
Posts: 1467
Joined: Nov 2010

Alinur

The increase of 0.03 points in 3 months is significant (0.04 to 0.07). However, these are values still far from the threshold of 0.20 which is the PSA level used by doctors to indicate recurrence.
As Tboy comments above, the rate of increase over time is the point to watch. Wait for the next Test to ascertain your present status.

Can you share more info about your case? What was your clinical stage before surgery? Is there any image study results?

Hope for the best.
VGama

alinur
Posts: 12
Joined: Dec 2011

Clinical stage was T2b with psa=13.5 and gleason7 .Didn't use any therapy after surgery.All scans negative. age 57.
Blessings,

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

Alinur,

Welcome to the forum and sorry that you're experiencing anxiety about the rise in your post surgical PSA scores. As your doctors may have explained to you, a T2b stage meant that the cancer was palpable (it could be felt during the DRE) and that prostate cancer was evident in more than half of one side of the prostate gland.

While your PSA scores today are still very low, keep in mind that prostate cancer can begin metastasizing when tumors get to the size of 2 mm, which was probably the case of the palpable tumor felt on your DRE. You may wish to refer back to your post surgical pathology report to get a better idea regarding the size of your tumor. The negative scans does not mean the cancer has not spread beyond the prostate, it only means it couldn't be seen in the imaging. Mets always start at the microscopic level and go from there.

The negative margins you describe is obviously a positive sign but was there any mention in your post surgery report about involvement in the seminal vesicles or lymph nodes?

You may wish to ask your medical team about other tests that can be taken that could identify metastasis by looking at circulating prostate cancer cells in the blood stream or tests to determine PCa in the bone marrow through various aspiration techniques.

While your PSA thresholds are presently very low and apparently detectable only through the ultra-sensistive PSA test, if the trend continues upward on your next PSA test you can probably assume there is some distant micro metastasis occurring. Several studies have shown that early hormone treatment--sometimes used in combination with radiation--can significantly help the long term management of this disease and you may wish to begin researching these options now.

Best of luck to you.

K

alinur
Posts: 12
Joined: Dec 2011

Thank you Kongo.
I mentioned before that my post surgery stage was pT3b, which means seminal involvement.That is what worries me!
My doctor says wait & watch yet, but I still consider eariy adjuvant radiotherapy is a better approach in my case.that is why I need your expertise.
all the best.

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

Alinur,

Sorry that I misread your earlier post. With involvement of the seminal vesicles I too would be worried as that seems to be a strong indicator of recurrence.

You may wish to read an illuminating paper on this at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1476128/ While there is some quibbling about the definite of SVI it basically says that if the muscular wall is involved then you're going to see a recurrence. The authors include Jonathan Epstein and Alan Partin from Johns Hopkins...two pretty heavy hitters in the analysis of what this pathology really means.

The paper also suggests that EBRT may not be effective. Now, there have been some significant advances in the state of the art of radiology since 2000 so you will want to discuss the effect of newer forms of radiation such as IMRT and SBRT on this metastasis.

Your doctor seems cautious and conservative but given the clear implications of the impact of SVI, I really don't get what he's waiting for except to see if there is a problem with the chemistry or laboratory technique of the PSA test. I would be talking to other doctors to balance opinion.

K

VascodaGama's picture
VascodaGama
Posts: 1467
Joined: Nov 2010

Alinur

With your present status there is lots of logic to wait for the next PSA test. Doubling and velocity of rise will give you important stats in your case. Seminal invasion (pT3b) go in both directions; extra prostatic extension or confined.
Your doctor’s “conservative” approach is not a bad judgement and even if recurrence is found to exist at the 12-months mark, an earlier salvage treatment of two months wouldn’t alter the long term free survival rates. PSA values in your case are very low indeed. And you have at hand negative image studies and negative margins which results are weighing in the doctor’s considerations.

Seminal vesicular invasion is paired with extra-prostatic extension, when considering a salvage treatment. However the logic is to wait for apparent recurrence, investigate possible locations and then decide on a protocol for a salvage therapy. The option with the most successful outcomes in such cases diagnosed as “Localized” is a combination of RT plus HT.

As indicated in Kongo’s post, salvage radiotherapy alone in SVI cases where not considered beneficial if the protocol of radiation would not include the areas of pelvic lymph nodes and at the iliac. In any event, modern approaches in pT3b recurrences include the wider planning of irradiation of the whole pelvic. Patients in such status with ulcerative colitis are more at risk of problematic side effects.

I understand your anxiety but in your shoes I would wait for the next PSA test. Mean while I recommend you to educate yourself (do some researches) into newer ways of image tests to look for any possible metastasis, if needed. Micro mets are still “invisible” to the traditional types of scans, but you could use this time in waiting to add some tests to your post op care portfolio. PSA, PAP (prostatic acid phosphatise), cytokeratin, and bone density scan (DEXA), etc., will be important indicators in your journey with or without apparent recurrence.

Both RT and HT got their own risks and side effects to which you should be aware of.
Two good books you could consult on your case are;
A “Guide to Surviving Prostate Cancer” by Dr. Patrick Walsh (second edition June 2007); and
“A Primer on Prostate Cancer, The Empowered Patient’s Guide” by Dr. Stephen Strum and Donna Pogliano; which explains well the whole process of diagnosis (and recurrence).

I have no medical enrolment. I have a keen interest and enthusiasm in anything related to prostate cancer, which took me into researching and studying the matter since 2000 when I become a survivor and continuing patient.

Wishing you find an answer to your quest.

VGama

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

Alinur,

Vasco makes many good points and I do agree that you should examine bone marrow aspiration testing to look for PAP and cytokeratins which (depending on the values) which are indicative of prostate cancer in the bone marrow. All in all, however, if I were in your shoes i would not be waiting to see if the PSA continues to rise before seeking hormone treatment. What are we waiting for, spontaneous remission or a miracle? Not that these events don't occur, they do. It's just that if it were me I would take a more specific approach over hope and a prayer.

The T3b diagnosis with involvement in your seminal vesicles is evidence enough of metastasis in my lay opinion. Prostate cancer is not one of those cancers that only slowly burrows out of your prostate into surrounding tissues. While it does do that it also travels to distant sites via the blood stream and lymph system. The negative margins were a positive sign but the SVI is proof positive that your cancer was not contained within the prostate capsule.

Frankly, given the spread to your seminal vesicles I do not understand why your medical team did not immediately recommend hormone treatment. As Vasco points out there are certainly side effects involved here but many men tolerate it well and there are drug cocktails that can be fashioned to minimize some of the effects.

Of course, no two of these cancers is the same and besides the lay opinions you get for free here in this excellent forum vary all over the map as well. Even paid professionals have widely divergent views on treatment depending upon their training and experience. I don't think you lose anything by consulting with another doctor on your situation.

K

alinur
Posts: 12
Joined: Dec 2011

Hi everyone.
thanks to Kongo and Vasco for the precious advices. I rechecked my psa 6 weeks after the last .07 one, and it came back .09. I think this is a good indication that something is happening inside me.I now feel that i have to prepare for a tough fight.
all my best wishes.

VascodaGama's picture
VascodaGama
Posts: 1467
Joined: Nov 2010

Alinur

This is enough information and, in my opinion, the growth seems to indicate recurrence.
In my calculations doubling is at 4.5 months much lower than the 14 months midterm. Nevertheless, a PSA of 0.09 is low and you do have time to analyse your situation properly. Do the things coordinately.

You got above some opinions on treatments. I would get a second opinion on the diagnosis and explore protocols for a salvage with a combination treatment. You can research on them (risks and side effects included) to find the one most satisfying to you. You can also check for available trials for similar treatments. They are safe and include newer drugs which have proven results. Here is one that includes HT plus RT now recruiting;
(http://clinicaltrials.gov/ct2/show/NCT01023061?term=abiraterone+acetate&rank=17)

I recommend you to prepare a long list of questions for your visits, even if they seem awkward to you.
Do not be anxious because there are many ways of knocking down the “bandit” again.

Wishing you luck in your journey.

Have a good season.

VGama

alinur
Posts: 12
Joined: Dec 2011

I take PROZAC and I read contraversial articles about it,in connection with cancer.
Any insight about this topic ?
Wishing you well.

rch
Posts: 76
Joined: Nov 2011

Hi Alinur
Sorry to hear about your PSA rise . You're getting some great advice from other members on this forum. As to Prozac and prostate cancer, I'm not aware of any association nor could I find one in the PDR. Nonetheless, interestingly it has been used off-label to treat premature ejaculation by delaying climax which is actually an unwanted side effect of most SSRIs.I read some where that in some countries these drugs are sold on the street as 'endless climax' pills. But to answer your question,I'm not sure whether the drug has any impact on the PSAs. Also,you probably have been on the drug all along, and so cann't attribute the PSA rise to the drug.

alinur
Posts: 12
Joined: Dec 2011

Kongo,Vasco and all friends,

Very sad that my psa doubled in so short a time from last .09 to 0.18 in 2 months.With my high risk disease ,now recurrence is for sure.We ,here in Europe ,my surgeon and the hospital protocol recommends Salvage radiotherpy before the psa reachs 0.2 and If radiation fails, then ADT is started.I can have radiation only after atleast a month. With so fast rising psa ,I think it will hit >0.2 sooner. I really agreed with my surgeon before, because I believed that doing therapies one after another is worthwhile to avoid side effects ,but reading in this forum your highly documented advices and experiences , I need them again.
This is really The Dilemma: Hormone immediately or follow the protocol!

Friends in need,Wish you well.

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

Alinur,

Sorry to read that your PSA is moving in the wrong direction. It does appear that you have recurrence and that salvage radiation is in order. The only question is whether to do it in conjunction with HT or wait and see if the RT curbs the progress of the disease before starting it.

I am not familiar with what options and choices your health care system in Europe may require but here in the US, I would say it's time to move beyond your surgeon. His work is done and it wasn't successful. What you need at this point is a radiologist experienced in salvage therapies and an oncologist with a prostate cancer specialty who can advise you about hormone treatment.

There are several studies if you care to google them that indicate that salvage radiation and hormone therapy at the same time have a higher success rate than staggering the treatments. I can't imagine why your medical team would suggest otherwise unless there are protocols they must follow that are driven by cost. Radiation isn't cheap. Neither is hormone therapy. But the consequences of failure is much more expensive so it may be penny wise and pound foolish.

You are unlikely to experience any lasting side effects from the radiation. There may be some temporary urinary irritation but if it occurs it passes quickly. Hormone therapy side effects depend upon the patient and the drug combination but often include hot flashes, weight gain, loss of libido (your testosterone is blocked), breast enlargement, among others. These effects almost always pass after treatment is over but some men have lasting effects. The trade off here is going for a more effective approach with some side effects, or gambling and going for a less effective approach but in the end you might have to do the HT anyway.

It's a difficult choice and one that I think should be driven by your outlook on life and how much value you place on quality of life over efficacy of treatment.

Good luck and keep us posted on what you decide.

K

VascodaGama's picture
VascodaGama
Posts: 1467
Joined: Nov 2010

Alinur

I would be thinking that by now you have done some researches on recurrence and got an idea of what is happening and what must be done.
Being anxious is the worst thing you can now add to your case. Cancer thrives on the “new-blood” that your mental status will put into circulation. Reading about the problem may help you to relax.

You are on biochemical failure. The spike on PSA in two mounts cannot judge the cancer as very aggressive. Similarly to you, after RP I got a rising PSA leading my case to biochemical failure (0.26) at the 5th month. Two month later the PSA was 0.42 (seven months post op). Several doctors with “big” names declared me with Micrometastases, a common term for PCa status at those times, and I was put on Watchful Waiting (WW) for 5.5 years. Along the years the PSA never behaved linear, with rises and decreases and got me to periodical averages of PSADT between 14 and 18 months.
I started SRT when the PSA got to 3.80.

Surely one cannot compare his case with others’, but a PSA of 0.2 or 0.6 do not change the way on the treatment and the outcome would not be different. This PSA rise in your case is indicative that the timing for starting a salvage treatment is rightful. However, you should apply your thoughts into tests in preparation for a decision.
Being from a member state of EU, allows you to get treatment in another member country under the same terms of that of yours. The choice is wide open and you can look for specialists to get second opinions on your future treatment. (I live at the Algarve, Portugal)

Nowadays salvage treatments for localized cases involves a neoadjuvant HT (two to three months) followed with RT (wide isodose planning) plus adjuvant HT (6 months to 2 years). There are many reasons for this combination and it has shown better results in long term studies.
HT will sensitize the androgen receptors of cancer cells to the ionizing of the radiation, therefore helping in the “killing” process. I read in some MD articles that the timing of such sensitization seems to be better at the two to three month mark. This suggests that a long term neoadjuvant HT is not the best choice, if one adopts for the combi. On the other side, the adjuvant HT (administered after RT) seems to have no impact on the radiation but it may prevent the “weakened” cancerous cells from “rejuvenating” easily. It helps in keeping them on the canvas and die.
The pitfall of such treatment is that one cannot use the PSA post SRT as a “real” marker to judge outcomes. In this respect, many doctors prefer to get their patients on RT alone, check the outcome with PSA tests and then apply HT if it recurs again.

In my layman’s opinion you do not need to follow the 0.2 threshold imposed by your doctor. You better take the time (two months) to find out more details about your other health facts (rectum colitis, testosterone levels, bone health/DEXA scan, lipids, etc.) while researching for a decision. Get second opinions on the treatment and protocols from specialists, and once prepared then advance with your choice. (You would not lose anything by delaying it two to three months)

Kongo as usually posts the best advices. I would also check for the financial point of view in the treatment. RT may take you out of the job for two months because it is given every day except Sundays. You may have to drive far away from home or even have to stay close to the nuclear clinic.
You should give preferences to modern equipment/machines because the outcomes from radiation differ a lot if it is delivered by old EBRTs. Huge differences in risks and side effects.

Hope for the best.

VGama

alinur
Posts: 12
Joined: Dec 2011

thanks Kongo, thanks VGama,thanks all.

"The beginning of knowledge is the discovery of something you don't understand". I don't understand much about this disease ,but I am so lucky to have a place where I can light my candles.Thank you for all your advices.
I will travel soon to Germany for radiation. I have 2 options:
-Tomotherapy in the clinic where I had RRP.
-IMRT,IGRT in another clinic.
Both are in university hospitals (best in Germany). I also had IMRT-RapidArc option.
I need your proficiency about this types of radiotherapy.Which is better?

"BE ACTIVE,GIVE NO PLACE TO INDOLENCE,DON'T FRIEND THE BANDIT" VGama teachings.

Thank you and wish you well.

VascodaGama's picture
VascodaGama
Posts: 1467
Joined: Nov 2010

Alinur

I do not know which type or system delivers the best “shot” in a case like yours, but I would like to note that you are looking for a protocol that will radiate a wider area (around the bladder, lymph nodes at the iliac, urethra at the sphincter, etc.). Surely each of the places is considered focal but due to the variety of “barriers” (round-shaped bladder, urethra, colon, etc.) between the entrance of the rays and the tissue to be radiated, the treatment should be done by the equipment/system that presents a more flexibility approach in the delivery.
This is not as radiating one form with certain thickness (prostate gland) but thin tissue where precise modulation and dose aspects are serious.
In SRT there is a tendency of applying fixed isodose plans to which I would recommend you to discuss and get advice from a radiologist not an urologist. The Tomotherapy advertises live scans on the day of radiation which if possible in your case, could assure you lesser injury.

I hope you get better answers from the guys experienced with the latest in RT. I have done IMRT for my SRT. It did not cure me but it did not injure me either. Nevertheless, radiation is not a walk in the park. 5 years after I have found in two occasions blood in my stool which may be part of what is known as late side effects.
Will there be any more symptoms in the future? No one knows or can provide me with an answer.

I hope that you get the bandit down for good and that you recover with the lesser side-effects.

Wishing you the best.
VGama

jbsquare
Posts: 1
Joined: Apr 2012

prozac raised my psa to 11.5 and my crp to 5.1 within 2 weeks and both went down to normal as soon as I got off prozac.

VascodaGama's picture
VascodaGama
Posts: 1467
Joined: Nov 2010

JBS

Can you share more info on your findings?
Are you aware of any study regarding the effects and interaction of depressive disorder medications in PCa patients?

An increase in PSA due to Prozac is very significant in guys on HT. I weould like to know more about your findings.

Thanks.
VG

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