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Rising PSA after Radical Prostatectomy - Doubling time

CarlosAlberto2
Posts: 17
Joined: Sep 2013

I just received the PSA result 6 months after cirurgy, and =0.05. The previous value , 3 months after cirurgy was 0.03 (same lab). In general, these are values still considered undetectable (below 0.1), but I´ve reading some information that indicates independently from the low values, the Doubling time faster than 10 months may indicate biochemical recurrence and early treatement. My Doctor does not consider this information as proven and so is just considering that the trigger for treatment is only when there is an absolute value and confirmed of PSA=0.2. I´m considering to have a second opinion from other Doctor.

Someone has already experienced this situation and has some information that can share.

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

Carlos

Welcome to the board.

After surgery, without any prostate in place the PSA should not exist. But the urethra also produces tinny fractions of the serum and such low value will always be detected in ultra sensitive assays. These are termed remission levels by the doctors and usually not significant. These low levels can also differ due to the tolerances in laboratory assays, the day and hour we draw blood (the biorhythm of a person) and be different among patients. My uru used a PSA< 0.06 ng/ml as his threshold indicative of surgery success. After the first PSA (two to three weeks post op) the level should be kept low without many variations. Many doctors use still lower values at 0.03.
In such a scenario the AUA usually follow a common level of 0.2 to declare recurrence.

In any case, The AUA also recommends earlier intervention (salvage therapy) once recurrence becomes apparent, but there is no practical definition for the meaning of “earlier”, when should it be in fact the timing to treat. I am not aware of the use of PSADT to define “earlier” but aggressivity.

The ultra sensitive tests can indicate recurrence in lower that usual PSA levels, however, at such tinny PSA fractions there is no rule indicating that a patient will do better in terms of survival with a salvage done when the PSA is 0.05 than when it reaches 0.07. I believe that we patients should be the ones to decide when the intervention should occur, when we feel it better and when we became comfortable and confident with the decision.
I would say that the different result in your two tests of 0.02 is not yet enough to consider your case as “recurred”. Probably you could wait for more tests to verify a constant increase and then make your final decision. Meanwhile you could take the time to research about salvage treatments, their risks and the side effects.

PSA Anxiety typically occurs when at your situation.

Can you share more details about your case? What is the Gleason rate and score? What was your clinical stage?

Best wishes for continuous remission.

VGama  Wink

lewvino's picture
lewvino
Posts: 1004
Joined: May 2009

Some men swear by the ultra sensitive PSA tests and others do not. My urologist does not like the Ultra Sensitive since he says it causes two much anxiety in his patients.

I Agree with him since I'm a 4 year survivor. My Psa had been at 0 up till my 3rd year post surgery and then .2.  It took it another 8 monts to go to .3 and I just started IMRT Radiation this week to knock out the beast for good. Today will be my 3rd IMRT Treatment.

 

The value of .2 is considered to be the recurrance point.

Lewvino

ob66
Posts: 214
Joined: Apr 2010

Whatever, lewvino. But when you get results back on an ultrasensitive and they are undetectable----less than 0.01, you have to admit it is a damn good feeling....Were I to get it back on the regular PSA test, it would not be quite as meaningful, were it good....

CarlosAlberto2
Posts: 17
Joined: Sep 2013

Iewino, I hope everything goes OK with you during IMRT treatment. Can you please tell us how you feel during and after, and side effects.

SeattleJ
Posts: 32
Joined: Mar 2011

My oncologist uses the ultra sensitive arrays but urges a lot of caution. He says that there are no conclusive studies that show PSA doubling time is meaningful or predictive when the results are under .1. He still does not really recommend salvage radiation or other treatments prior to the .1 stage.

I hate the anxiety that these tiny numbers bring!

John

CarlosAlberto2
Posts: 17
Joined: Sep 2013

I agree with you SeattleJ. Tiny numbers are terrible. But I´m worried with the rising speed. I hope your doctor are wright and Doubling time , on these low figures are not meaningful. You know, with this speed in 6 weeks I would be at 0.1. I´ve read that the speed depends if healthy prostatic material was left behind (more common on nerve-sparing and laparoscopy) or cancer cells on "fossa" or worst if there was already some micro-methastisis spread. I´m praying to be the first situation and that the PSA starts to stabilize below 0.1

REgards

CarlosAlberto2
Posts: 17
Joined: Sep 2013

Thanks guys for your comments.

I´m a bit anxious and fustrated. I was up to the last moment considering brachyterapie, but 1 week before decided for RP, just to avoid the psicological problems I could imagine by following the slow reduction of PSA with "bounces". I wanted to be free of that , to be possible to dedicate 100% to my job.

I´m portuguese and 59 years old. My diagnosis was last October 2012, PSA 5.5, Gleason score 3+3. I was submited to manual laparoscopy RP on February 2013 at British Hospital , Lisbon. The histological result rised Gleason score to 3+4, T2C, but negative margins.

The RP cirurgy was fine, and I´m 100% continent. I was very sexual active before RP, and now just works with injections. Doctor refers that takes time, to be prepared at least to 1 year.

My first PSA pos RP (3 months after) was 0.03 and second (6 months after) 0.05 on same lab. I just got the information from the lab that the the method used was Siemens - ADVIA Centaur PSA Assay, and the minimum sensitivity is 0,01. I´ve checked on equipment data sheet that is required a calibration period of 28 days, which was confirmed by the lab assuring evrything is being strictly followed.

Vasco, I will follow your sugestion and have some more tests before any decision. In 2 weeks I have an appointement with my Urologist and check what he think on repeat test before other 3 months period in other lab or not.

Regards and joy for all of you

 

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

Carlos

I am Portuguese and live in the Algarve. I have been a PCa survivor in the past 13 years with two failed attempts at cure; RP in 2000 Japan plus RT in 2006 Portugal, and now I am on IADT (intermittent androgen deprivation therapy) since November 2010. My uro-oncologist sees me at the HSP Lisbon. Now I hope to be followed by a medical oncologist at Coimbra University Hospital. I do not mind to share my experiences with you if you are interested in knowing details.

Regarding the PSA tests, I do not think that you need to repeat the test just now. I would wait for the periodical result in three month. You may change laboratories if you are not confident in the one of the previous tests.
As I commented in my above post, your PSA is very low so that you should wait to ascertain of recurrence (constant increase). Surely you do not need to wait until the “magical” number of 0.2 ng/ml is reached but your body should heal well before committing to salvage RT. Remember that the side effects will superimpose to the ones you already got from RP.

The Gleason grade of 4 is for an aggressive type but the score of 7 (3+4) is classified as intermediate. I wonder what the pathologist report describes on findings. What was the volume of cancer and if they have analysed some localized lymph nodes. Have you any image study?
Can you tell about any positive DRE found before surgery?

Do not let PSA anxiety to take over your case. Read about salvage treatments and get second opinions from other physicians (oncologist radiologists) once recurrence is confirmed.
Regarding ED (erection dysfunction) you should be active using the pump to avoid atrophy and to help in oxygenating the penis cavernous areas for faster healing.
I had an open radical prostatectomy and never experienced incontinence (urine and stool) and the “lovely nights” returned after three months but it never returned to the same “levels” as before, pointing now, at the best attempt, to the 3-4 o’clock direction.  Laughing

Best wishes for complete recovery.

VGama  Wink

CarlosAlberto2
Posts: 17
Joined: Sep 2013

Vasco

I appreciate your offer and I will ask for your experience on radioterapy , if I will need it (I hope not!! at least not so soon)

Before my decision to proceed with cirurgy I went to 3 Urologists and all them got negative DRE . Only PSA, biopsy and also magnetic ressonance confirmed. The histological report does not refers lymph nodes results. I assume (needs to confirm) that during RP, the Doctor did not look for, because was considering a low risk adenocarcinoma (3+3) in only 1 side of prostate, 2 positive cores on 12 and MRI (2 in different hospitals) showing a very small and localized . (I am far from my house where I have the reports. When I have the possibility I will put here the details).

About ED, I have been using the pump and Cialis 5 mg per day, just to keep the blood running, because does not work to get a minimum acceptable erection. The only way is by injections Caverjet 20 ug. But has been very painful. Erections of more than 6 hours ,with strong pain after 2 hours. I´ve been reducing the dosis to 1/4 , but even so, the time and pain still remains (a bit less painful).I will try next the Caverjet 10 ug and 1/4 of the dosis.

My next visit to the doctor it will be at September 19. I wiil post what will come out from this visit.

 

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

Carlos

You can e-mail me with any question or discuss the RT matter here on the board.

Regarding the Alprostadil injections (Caverjet) I would recommend you to use them very seldom. There have been reports of penile permanent damage (fibrosis) when it is used constantly. I have no experience myself but from what I read I would suggest that you take the smallest at 5 micrograms, starting with the ¼ dose you commented and then increasing as you go along and feel it better. It seems that you can avoid the pain with shorter erections (lesser blood “flowing” into the penis).

Some guys have indicated that they get better with different types of injections moving from one to the other (Caverject to Trimix, to Bimix, to etc). In the last couple of years there has been news about the “newer” TriMix gel, that seems to be friendlier to the patient and it promises to accomplish better the purposes. The absorption rate is not that powerful which may became the proper dose for you. Innocent

Here are links to the drugs;
http://www.ereleases.com/pr/increased-dosage-needlefree-erectile-dysfunction-medication-trimixgel-krs-global-biotechnology-141403

http://www.pharmacydiscountmeds.com/increase-penis-size/caverject-versus-trimix.html

http://forums.webmd.com/3/prostate-cancer-exchange/forum/108

Link to Q&A on injections;
http://www.ustoo.org/PDFs/Injection.pdf

Patient experiences on the drugs;
http://www.healingwell.com/community/default.aspx?f=35&m=2785409

In fact, the injections are just an alternative to Cialis, Viagra, etc (PDE5 Inhibitors) tablets which in your case should do the job. Remember that you want “the system” to return to natural functions permanently. The lesser artificial ways are used the better.  Cool

 

Best wishes for complete recovery.

VGama   Wink

 

 

 

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

I hope this is not off-topic.  I have used a lot of these products.  The best for me was Kamagra, which is liquid Viagra made in India.  However, here in the Phills, they sell a Chinese Herbal product called Robust.  The guys I know prefer this as it is at least as effective and has no side effects.  The downside is that you must take it two hours before the event.  In any case, good luck.  love, Rakendra

CarlosAlberto2
Posts: 17
Joined: Sep 2013

Thanks Rakendra . The tips of products are fine, specially Robust if it works. I don´t know if I can find it in Portugal. Alternative is buying on the net.

Wish your full recovery.

Carlos

 

CarlosAlberto2
Posts: 17
Joined: Sep 2013

Vasco,

Here are the results of the reports before RP (biopsie) and after RP

Before RT:

Adenocarcinome Gleason 6 (3+3) envolving 40% of extension of right apex core (1 out 0f 6). Not found perineual invasion neither extra-prostatic extension.

Prostate with 37cc.

After RP:

Prostate with 36gr 5x4x3,5 cm

Adenocarcinome Gleason 7 (3+4). Tomour envolving peripheric zone of apex and medium third (terço médio) envolving both sides but predominant at left side. Not associated with extraprostatic extension neither envolving seminal vesicules. Estimated value of 3.1cc

pT2c N0 R0

As I´ve referd there is no reference to lymph nodes.

By this report I was not expecting , with a experient surgeon, to have the first PSA (3 months) with 0.03 and 3 months after with 0.05. It will be this an evidence of cirurgy failure?? I remind that it was a manual laparoscopic cirurgy, and I´ve read that experience is even more important on this kind of intervention. I had some good information about the surgeon, but I never had the right number of interventions done before (just more than 100).

 

 

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

Carlos

As commented above you should wait for the next results to have a better understanding of your case. The tinny increase of 0.02 ng/ml could be a cause from many things including tolerances of the assays or even from a benign small piece of the prostate left behind. Neither biochemical failure nor “clinical failure” can be declared yet.

At this moment you cannot blame the surgeon for anything. Supposedly he did his job well so that you are “alive” and still better, you are continent. A good PCa surgeon is the one that manages to cut off the prostate leaving no “scars” behind. They cannot assure cure neither assure that no metastases are existent. The micro tumours cannot be seen by the open eye, so that the surgeon hopes to get the whole cancerous tissue by dissecting the whole gland in one piece.   Laughing

A bad job of a surgeon would be to have the prostate dissected into smaller pieces, cutting probably through the cancerous portion which would raise the probability of leaving some cancer tissue behind.   Yell
Another not so common practice is that some doctors cut less when dissecting at the bladder sphincter to avoid damage of the muscles controlling the flow of urine. The urethra sphincter is not severed so that heeling is faster too, but it should be done only if cancer is none existent at the transitional zone close to the base of the prostate. This practice is done after proper testing (biopsy or high resolution MRI images) to have an assurance that cancer is not existent at the tissues left uncut.

From the data you shared here, the biopsy of 6 needles is not the typical standard. Nowadays the norm is for 12 needles. The MRI is a good tool if done with high resolution equipment (3-tesla) but even these machines got limitations when the PSA is low. Yours was 5.5 so I believe that something was seen as you commented. In any case, the biopsy should include a directional needle to the transitional zone to gather more evidences.
The cancer was found at the peripheral zone (apex) and, I suppose, at the central zone but the seminal vesicles were dissected together and found clean, so that no “escape” of cancer at the ejaculatory duct (a possible metastases route).

Regarding the dissection of the lymph nodes, we know that the procedure is difficult to be achieved in “robotic” type of RP (manual laparoscopic surgery included). In some cases, doctors stop the robot arm and introduce their hands through the small holes to reach and dissect closer nodes. In your case, probably no nodes were dissected so that the pathologist report does not describe any analyses results. What is confusing in your pathological stage of pT2c N0 R0 is the designation of “N0” which internationally means that the nodes were examined but found “clean”.
In cases of no dissection (no tissues for analyses) then the terminology should be “NX”.
I believe that your R0 stands for M0 (distant metastasis) which should also be designated as “MX”, because its findings could not be assessed with any means, such as image studies or bone scan.

In any case I think that you should give time a chance. Relax and accept what is set to be (your Fado). Enjoy and celebrate these moments of remission. No one knows but you may be cured.  Innocent

Best.

VGama  Wink

CarlosAlberto2
Posts: 17
Joined: Sep 2013

Today I´m going to celebrate the result of my third PSA test after RP.

It came back to 0.03!!! After the rise from 0.03 to 0.05 on the second test, now it came back to the nadir value, 9 months after RP. What a relief!Thanks guys from your wise advices.

Wish you the best

Carlos

SeattleJ
Posts: 32
Joined: Mar 2011

Carlos,

Congratulations! That's good news. My PSA has been bouncing around for some time--less than .03 (considered undetectible) for several tests, then .03, .04 and back to .03. This could go on forever or it could start rising. I think it best to stay in the moment and enjoy where we are and try not to worry about what it may do in the future.

John

CarlosAlberto2
Posts: 17
Joined: Sep 2013

That´s it John.Thanks

We need to appreciate all these moments. We never know when the bandit (as Vasco call it) shows on, so we need to gain forces to face it and win.

I dont´know if what I have been doing is helping or not, but at least gives me a sense of control.

I´ve changed my diet, avoidind dairy and red meat, and eating a lot of raw vegetables. One hour per day of moderate to vigorous exercise.

Supplements I´m taking, cayenne,green tea, pomegranate juice, Pomi-T pills and CoQ-10, beside the statins I was already taken before.

I lost 6 Kgs, and I am now at BMI 24.

With This I hope being helping my body to keep the bandit away.

Keep on low values. Wish you the best

 

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

These are great news from both of you; Zeros. I absolutely agree that the moment is for celebration and I want to be a member of your celebration. This is a chance to drink another glass of Esporao red.  Tongue OutSmileCool

I think that Carlos is doing it right with the physicals, diet and supplements. Your fitness may lead you to avoid the statins or take them intermittently (my way with Sinvastatine 20mg 2 month on/3 months off).

Parabens,

VG  Laughing

CarlosAlberto2
Posts: 17
Joined: Sep 2013

Thanks Vasco. About statins it is something that I was now evaluating. In fact my last analysis (past week) shows a total colesterol of 147 which is much better than the recommeded max of 170. And my "good" colesterol is 61, above requires 45. From the point of view of colesterol, I think that reduction of statins could be an option, and I can consult my family doctor. However I read some articles where a positive role of statins on prevention or slowing progression of PCa was refered. So, I am not sure how to proceed.

Wish you the best 

TonyT
Posts: 5
Joined: Dec 2013

I am a semi-retired analytical chemist.  I have worked in both the clinical chemistry and pharmaceutical chemistry fields.  No test is perfect.  A homgenous sample analyzed multiple times can give a range of results.  This is especially true of values down around the detection limit of the test.  So, the bouncing around of PSA results at low levels may not be statistically significant.  I think that some doctors take the results obtained as "gospel."  Decisions concerning prospective treatment should not be based on one test result.  My PSA results prior to my prostatectomy were routinely around 4.5, then one came back as 1.5, and the doctor didn't question this anomaly.  Believe me, labs make mistakes!

CarlosAlberto2
Posts: 17
Joined: Sep 2013

I just received PSA result one year after RP . And, thanks God, still at same value of 0.03 than previous test 3 months ago. We never know if the bandit is alive, but at least ,it not doing bad!

Best for you all

Carlos

 

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

Congratulations, Carlos.

Remission is so nice to have it. I am very happy for the news.

Another excuse for a glass of Esporao Red.

VG  LaughingCoolTongue Out

CarlosAlberto2
Posts: 17
Joined: Sep 2013

Just to update. PSA 15 months after RP continues on 0.03

My doctor passed me to 6 months monitoring due to stable values. It´s a good notice, but I will keep at least one more test at 3 months, before that. But of course I will celebrate with 2 glasses of Red Esporão (following V Gama preference), 1 by the result and the second for my 60 birthday.

Wish you the best

Carlos

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