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Elevated PSA immediately after RP

Concerned daughters
Posts: 8
Joined: Oct 2012

My dad is 74 years old and recently underwent a RP ( 8 wks ago). His PSA pre-surgery was 9.2 and Gleason was 7. Post-surgery Pathology showed Gleason 10 with no disease outside the prostate. Also, he had a bone scan and CT scan pre-surgery that were both negative for disease. He just had his first PSA test approx 10 days ago and it came back at 3.8. Doctor ordered another PSA test a few days ago to confirm and it came back 3.94. We are of course not very optimistic. Doctor scheduled him for a prostacint scan next week so that he can determine where the cancer is to decide next course of action. Everything I have been reading suggests that radiation therapy will most likely not be effective with such high PSA levels. Anyone have any input on this issue? My mom passed away from ovarian cancer in 2010 so this is quite a blow. We go to dr appts with him and want to ask so many more questions about life expectancy, prognosis, quality of life with treatment, etc. but don't because we feel he may not want to know and it's not our place to ask. We (3daughters) would all rather know exactly what we are facing regardless of how bad. We would appreciate any feedback from this group. Please do not worry about upsetting us.....we would like it straight up. Thank you.

hunter49
Posts: 200
Joined: Oct 2011

Sorry to hear about his diagnosis. AS you know a G 10 is very aggressive and presents the best chance for being metastatic. I would get a second opinion on the final pathology form sloan or hopkins to confirm his diagnosis. Also, did your dad have Perinueral invasion or vascular invision cited on his biopsy? these would be of significance in a G10. There is no time frame you can define acurately. The PSA could also be from prostate tissue left behind. There are many drugs out there and you need to look into every possible one. Keep strong and never quit the fight.

Concerned daughters
Posts: 8
Joined: Oct 2012

Thank you for the advice. Had not thought of having the pathology report read by someone else. I don't believe there was any perineural or vascular invasion. I do know that the same pathologist read both the biopsy report and the post-surgical report.

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

Dear Concerned,

I'm so sorry to read about your father's situation. Evidently the biopsy failed to show the worst of the cancer within the prostate and only came in with a Gleason 7. This is really nobody's fault because a biopsy can only sample about 1% of the prostate volume and they draw samples from areas that have a high (but not certain) probability of finding cancer. The post surgical grade of Gleason 10 is not good news as you realize.

Many urologists will not do an RP for men over 70. Did your father get second opinions before proceeding with this treatment. With very high Gleason scores many, if not most, urologists consider that surgery is not an appropriate treatment because of the probability that the cancer has already left the prostate and removing it does nothing at all to curb the cancer growing elsewhere in his body. Of course, a Gleason 7 is not necessarily a high risk diagnosis and I wonder if your father had his slides read by a pathologist that specializes in prostate cancer? Gleason grading is highly subjective and while it is not unusual to see a post surgical change by a whole number, this is the first time I have heard of a Gleason score going from 7 to 10.

Prostate cancer with a very high Gleason score is almost certain to have spread beyond the prostate. The most likely place it goes to first is the tissue area immediately surrounding the prostate which is sometimes referred to as the "prostate bed" but if untreated it will travel via the blood stream and lymphatic system to other organs and lymph nodes. The bones is a frequent place where prostate cancer likes to grow.

Following RP the PSA should be very close to zero. Two PSA tests a few months after surgery that are nearly at the 4.0 level can only mean that this PSA is being produced by prostate cancer somewhere else in your father's body. A prostacint scan has mixed reviews on its ability to pinpoint where the cancer may be. It may not show anything then again, it could highlight some areas where the prostate cancer is but not all areas.

Your father may be reluctant to discuss the side effects of his surgery with you three daughters. While each man reacts to surgery differently, common side effects for a man your father's age are incontinence (this may improve over time) and erectile dysfunction. I suggest you three sit down with him and gently discuss how he is recovering from his surgery and see if there is anything you can do to help.

If the scans are negative, I suspect your father's doctor will recommend radiation treatment to the prostate bed area and hormone therapy. While the radiation is unlikely to cause additional side effects the hormone therapy will certainly affect him in many ways such as weight gain, possible breast enlargement, hot flashes, loss of libido, depression, and other side effects. Essentially, HT, is chemical castration and his testosterone levels will likely go to zero or near zero while he is on the medication. (Prostate cancer needs testosterone to grow) You should also understand that hormone therapy is not a cure for prostate cancer. It slows the growth of prostate cancer but eventually the cancer becomes resistant to HT drugs. When HT no longer works, there are other medications that can be used but they too are not curative. And they all have side effects.

None of us have an expiration sticker tattooed anywhere on our bodies and it is too early to make any educated guesses about how long your father will live with this prostate cancer. Many men (some are posting on this forum and you will probably hear from them) live several years. Others not so long. A lot depends on your father's general health and other issues that may affect his longevity.

One thing to keep in mind for you daughters. Breast cancer and prostate cancer are brother/sister diseases. There is mounting research into the genetic links between mothers with breast cancer and sons with prostate cancer and vice versa. All of you will want to make sure you do regular checkups with your medical team as early detection is critical in successfully treating cancer.

If your father didn't get second opinions the first time he had treatment, I certainly suggest you get additional opinions at this point. I would recommend you start off with an oncologist. Oncologists are trained to used drugs such as hormone therapy and chemotherapy to treat cancer. You will also want to visit a radiation oncologist to discuss options in this area as well.

It's great that the three of you are so strongly supporting your father. He needs that support now.

Best of luck to all of you.

K

Concerned daughters
Posts: 8
Joined: Oct 2012

Thank you so much for the response. We had two opinions with regards to surgery or no surgery. I should have mentioned in my original post that my dad had a very large prostate that was causing him other problems. Both doctors felt that a RP could take care of both problems. Also, due to the fact that my mom's cancer was found too late, my dad was all for getting it out of there. He has been open about what he's experiencing after surgery. He is still suffering from incontinence but has seen slight signs of improvements. He is undergoing pelvic floor stimulation and is on 4th visit out of 6. Nurse does see signs of improvement as well. All of us are checked frequently due to my moms ovarian cancer and now we will advise the doctors of this as well. I have read a lot online about the prostascint scan and don't really know what to think about it. It seems very controversial. We will research radiation and HR side effects in depth. Thanks again for your response and suggestions.

Concerned daughters
Posts: 8
Joined: Oct 2012

Sorry I don't know how to delete this post.

jmchugh's picture
jmchugh
Posts: 15
Joined: Feb 2010

http://theprostatedecision.wordpress.com/2012/10/13/emr-killed-the-blogging-star-and-gleasons-10-and-prostate-cancer/

I hope this will be of help to you. JM

VascodaGama's picture
VascodaGama
Posts: 1526
Joined: Nov 2010

Concerned D

3.94 ng/ml after surgery is high and indicates treatment failure. Gleason grades of 4 and 5 (your dad is 5+5=10) are of poorly differentiated cancer cells which tend to be of the type producing less serum PSA and very aggressive for spread.
Your dad should get a LHRH agonist shot (similar to Lupron) the soonest, even if he has no definite treatment set yet.

It is common in surgery failures to try and locate the cancer so that one may get a target to radiate. Unfortunately there are no perfect testing that can 100% assure positives outputs, and we fall in despair. Prostascint used to be very unreliable due to poor contrast. It still misses detecting or gives false positives but much improvement has been done along the past 12 years of my researches.
Here is a link;
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1472938/

In any case, image studies are very limited and judgement is done based on past experiences. Radiation of the prostate bed and abdomen areas (including the lymph nodes and iliac) is typical as a salvage treatment. Typical protocols exist and you should get second opinions from two specialists.
In my case (IMRT of 68Gy in 37 fractions) the treatment managed to kill the cancer on the targets (PSA was down from 3.8 to a nadir of 0.05 in 13 months), but leaved spots causing me a second recurrence. No image study ever caught the cancer (MRIs, CT, PET) along my 12 years of survival. I am now on intermittent HT.

All treatments got side effects attached and they tend to superimpose to the ones from previous therapies. Radiation may damage the colon, urethra and bladder. It all depends on the isodose planning done for your dad’s case. If the radiologist considers the quality of life then he may avoid high radiation to certain areas. That could be a good hit and cure your father or it could become as palliative as hormonal therapy, giving control on cancer advance.
You need to research the net about the side effects. Just google “prostate cancer SRT and HT side effects”.

I hope your dad finds a satisfying way to treat his cancer.

Hope for the best.
VGama

Concerned daughters
Posts: 8
Joined: Oct 2012

I will definitely relay this information to my dad. We have a lot to think about and decisions to be made. I really appreciate the input.

Concerned daughters
Posts: 8
Joined: Oct 2012

I have spent a lot of time on this website already. It's a great resource. Thank you.

laserlight's picture
laserlight
Posts: 165
Joined: May 2012

Will you Dad allow you to visit with the doctor during his checkups. These checkups are the time to ask questions. With mine I spend a lot of time asking questions and looking for answers. My doctor said that he welcomes this and has indicated that he wish more men would ask questions.

Keep in mind that the doctor will discuss ED issues and bladder control and leaking during these visits. One of the reasons with ED is that there is a current thinking out there that blood flow and increasing blood flow helps in healing and nerve regeneration After surgery. Some doctors prescribe levitra or the other drugs to help in this area.

My doctor took a lot of time explaining the above to me and was verified by my GP.

At this point in time information is very important the more the better.

Hunter made some good points, it might be good to have the Pathology report reviewed by another source.

A second opinion would be helpful, this might clear up questions.

By the way I have 5 daughters. Hang in there and keep working with your Dad.

Kurt

keden7
Posts: 2
Joined: Jun 2013

My Dad has agressive prostate cancer too. He is recovering from surgery today and his birthday was yesterday. He is only 66 years old and a Viet Nam vet.  We have no history of cancer anywhere in the family so we assume it was from Agent Orange as well.  We are going to find out if it has spread tomorrow and then he will decide what he wants to do. My question is, how did you prove it was from Viet Nam?  We know it must be but would like to find out how to trace it. 

I hope your Dad is doing well. This is a very scary and sad thing for all involved.

Regards,

Kim

MichaelF1002
Posts: 54
Joined: Mar 2013

Kim,

Sorry to hear about your Dad's cancer.  There is no requirement to prove that Agent Orange caused his prostate cancer.  The VA presumes it did and he is eligible for disability benefits if he set foot in Vietnam during his time in service.  I have filed and am awaiting a decision.  Be aware that the VA is very backlogged (up to 2 years I've read) so the whole process may take some time.  Therefore, he should file as soon as possible.  It is my understanding that upon death, the disability benefits continue to the surviving spouse or dependent children. You can go to the web page below for further information. If you'd like additional info (i.e., where and how to file, the paperwork needed, etc..), send me a message through CSN giving me your email address and I will forward you all the details.   

http://www.publichealth.va.gov/exposures/agentorange/diseases.asp

Michael

p.s. I see you're new here; if you send a message to me make sure you send it through the CSN Email system; do not put your email address here in the public forum.

keden7
Posts: 2
Joined: Jun 2013

See above.

Rakendra's picture
Rakendra
Posts: 74
Joined: Apr 2013

I, too, am very sorry  to hear of your father's case.  There is going to be nothing easy about Pca, but you are on the right course tuning in here.  You have already heard from some of the best advisers that there are, and this information is not easy to come by. It is also difficult to be able to anticipate anything about the future.  So much depends on treatment results, side effects, your father's health and mental atitude, and your support.  It is pretty much a moment to moment process.  Any treatment may have unpleasant side effects and can affect quality of life.  Worry about the future will also harm that quality of life.  Understand that you have already had your father for 70 years, and will have him for some time in the future, but no one can tell how much time that may be.  Celebrate your past time with him, and make every second of your life and his count now.  Use this experience not as a disaster, but thankfullness that you still have time left.  If he had been taken by a heart attack, you would not have the advantage of this time now.  While the future prospects may not be what you would wish, you still can make the most of each moment.  

Love, swami rakendra

starr15
Posts: 31
Joined: Oct 2011

An FDG PET scan may be better than Prostascint in high grade gleason cancers.

Also, a C11 acetate PET scan might be useful, but only a few places do it, and insurance often wont pay for it.

mrspjd
Posts: 688
Joined: Apr 2010
Recently there have been some discussions on this forum about different contrast agents used with imaging modalities to detect PCa mets in advanced/recurrent cases.  I thought some add'l info might be helpful about a few agents, including F-18 sodium (NaF) and F-18 fluorodeoxyglucose (FDG). 
 
F-18 sodium (aka sodium fluoride F-18 or NaF)
is a contrast agent used in conjunction with PET/CT fused imaging to detect PCa BONE mets. PET/CT using NaF is described as similar to the common nuclear medicine test known as a bone scan, but the main difference is the use of a PET/CT scanner. The fused PET/CT provides images of both anatomy (CT) and function (PET) taken at the same time. An NaF PET/CT scan shows the differences between healthy and diseased bone and is therefore helpful for detecting BONE mets, especially in PCa. 
 
F-18 fluorodeoxyglucose (FDG) is also a contrast agent used with PET/CT. It is combined with sugar (glucose) and often used to evaluate some neurological and cardiac disorders, as well as to diagnose, stage and monitor the treatment of a variety of different cancers. 
 
Newer contrast agents and combinations are currently under investigation in clinical trials. One prospective pilot study involved the efficacy of combining both NaF & FDG together using PET/CT imaging:
"Prospective evaluation of (99m)Tc MDP scintigraphy, (18)F NaF PET/CT, and (18)F FDG PET/CT for detection of skeletal [bone] metastases." "CONCLUSION: Our prospective pilot-phase trial demonstrates superior image quality and evaluation of skeletal disease extent with (18)F NaF PET/CT over (99m)Tc MDP scintigraphy and (18)F FDG PET/CT. At the same time, (18)F FDG PET detects extraskeletal disease that can significantly change disease management. As such, a combination of (18)F FDG PET/CT and (18)F NaF PET/CT may be necessary for cancer detection. Additional evaluation with larger cohorts is required to confirm these preliminary findings." A related clinical trial is underway in the USA, Portugal, and elsewhere:
 
Re C-11 Choline: currently the C-11 Choline contrast agent used for imaging tissue is only manufactured & available at one prestigious institution in the USA: Mayo Clinic in MN. However, C-11 acetate is available at several locations. Which contrast agent--C11 Choline vs C11 acetate--is best for diagnostic imaging in high risk & recurrent PCa cases?  That depends on which peer reviewed studies you read and how the clinical findings are interpreted!
 
New contrast agents are now in the nuclear medicine pipeline. Along with advances in imaging technology, it is hoped that the efficacy and safety of those newer agents will enable medical specialists to detect, stage & treat high risk & recurrent PCa cases more effectively and with curative intent.
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