Question about interpreting Nadir criteria

DougS

First I would like to offer some encouragement to those recent entries with Gleason 9 level prostate cancer. I am currently 58 and was diagnosed in March, 2008 with prostate cancer- PSA 29.7, Gleason 9 (4+5), with the biopsies on the left side of the prostate involving between 50% to 100% of tissue. After receiving eight weeks of IMRT radiation (73.8GY) and subsequent 3 years of hormone therapy (July,2008 to July,2011 - and still responding) my PSA came to it's lowest at 0.21 (April,2011). Since that time, I have been off hormones with my PSA rising back to 2.04 (July, 2012).

Life has been good - enjoying the family (still chasing the wife around), playing golf, some fishing with my boy, and yes - even enjoying work! Particularly enjoyable has been bringing into the world two new grandchildren. Hang in there...

My question I would like to ask everyone, though, is about interpreting nadir criteria. The standard rule of nadir being (+2.0) above minimum comes from radiologists. It is not based upon a combination of radiation in combination with hormonal therapy. My radiologist has suggested that correlating testosterone levels along with a rising PSA and establishing a PSA velocity and doubling time will be needed to verify what is happening. Should I be more preemtive or simply wait until my next scheduled appointment (November)??

Your thoughts/suggestions are appreciated.

Samsungtech1

Tests
Doug,
I had a urologist whom I didn't feel comfortable with. My GP gave me my biopsy results four days after. Urologist had me waiting a month. I went to another urologist gave him a copy of biopsy and he sent me for tests and scheduled RP. Urologist #1 when we met told me no worries he had seen it all before and he would schedule surgery in a couple months because it was nothing. Quit him. Surgery showed it was in the bladder, etc.
My point being when it is your life on the line you have to get it right.
Have you got an Oncologist? I would think that CT scans and an MRI would be a good start. This should clear the air, somewhat. If your PSA has risen that much in just over a year you should be concerned. I must be missing something because the two times I had radiation they sent me back to my Oncologist, and urologist. They were done. Why are you still seeing a radiologist?

Mike

DougS

Samsungtech1 said:

Tests
Doug,
I had a urologist whom I didn't feel comfortable with. My GP gave me my biopsy results four days after. Urologist had me waiting a month. I went to another urologist gave him a copy of biopsy and he sent me for tests and scheduled RP. Urologist #1 when we met told me no worries he had seen it all before and he would schedule surgery in a couple months because it was nothing. Quit him. Surgery showed it was in the bladder, etc.
My point being when it is your life on the line you have to get it right.
Have you got an Oncologist? I would think that CT scans and an MRI would be a good start. This should clear the air, somewhat. If your PSA has risen that much in just over a year you should be concerned. I must be missing something because the two times I had radiation they sent me back to my Oncologist, and urologist. They were done. Why are you still seeing a radiologist?

Mike

Interpreting Nadir Criteria
Mike:
There have been CT and MRI scans performed in 2008 as well as 2011 - both indicating no signs of metastatic disease. My testosterone level was ~350 ug/ml in November, 2011 and yes, we have met with an Oncologist. Based upon this background information, though, the interpretation of the rising PSA (PSA velocity, doubling time, correlation with testosterone, minimum PSA +2 rule) will determine next step my treatment. My radiologist still believes that the treatment may still be successful based upon this interpretation. Obviously the longer that I remain under the minimum(+2)the better chance of remaining metastatic free. I was just what other experiences others have had....

DougS

Samsungtech1 said:

Tests
Doug,
I had a urologist whom I didn't feel comfortable with. My GP gave me my biopsy results four days after. Urologist had me waiting a month. I went to another urologist gave him a copy of biopsy and he sent me for tests and scheduled RP. Urologist #1 when we met told me no worries he had seen it all before and he would schedule surgery in a couple months because it was nothing. Quit him. Surgery showed it was in the bladder, etc.
My point being when it is your life on the line you have to get it right.
Have you got an Oncologist? I would think that CT scans and an MRI would be a good start. This should clear the air, somewhat. If your PSA has risen that much in just over a year you should be concerned. I must be missing something because the two times I had radiation they sent me back to my Oncologist, and urologist. They were done. Why are you still seeing a radiologist?

Mike

Interpreting Nadir Criteria
Mike:
There have been CT and MRI scans performed in 2008 as well as 2011 - both indicating no signs of metastatic disease. My testosterone level was ~350 ug/ml in November, 2011 and yes, we have met with an Oncologist. Based upon this background information, though, the interpretation of the rising PSA (PSA velocity, doubling time, correlation with testosterone, minimum PSA +2 rule) will determine next step my treatment. My radiologist still believes that the treatment may still be successful based upon this interpretation. Obviously the longer that I remain under the minimum(+2)the better chance of remaining metastatic free. I was just what other experiences others have had....

Kongo

Doug,

I think what you are describing is the technical definition of BCR or biochemical recurrence which is a PSA rise of 2.0 above nadir. Nadir is simply another name for the low point.

As you point out, the definition of BCR does not take into account the effect of HT on your PSA levels. You don't see an unbiased nadir until you are off of HT and your testosterone levels return to normal.

Establishing PSA doubling time and PSA velocity in conjunction with monitoring T-levels is a very smart and thorough approach to establishing baselines and crafting an appropriate treatment protocol. What type of "preemptive" measures were you thinking about?

Best to you.

K

DougS

Kongo said:

Doug,

I think what you are describing is the technical definition of BCR or biochemical recurrence which is a PSA rise of 2.0 above nadir. Nadir is simply another name for the low point.

As you point out, the definition of BCR does not take into account the effect of HT on your PSA levels. You don't see an unbiased nadir until you are off of HT and your testosterone levels return to normal.

Establishing PSA doubling time and PSA velocity in conjunction with monitoring T-levels is a very smart and thorough approach to establishing baselines and crafting an appropriate treatment protocol. What type of "preemptive" measures were you thinking about?

Best to you.

K

Delaying and Additional Testing
The question is whether I want to delay any additional testing/treatment when currently I am at 93% of the nadir limit. If I wait until November, it may be an additional 4-5 months from now until further testing (biopsies) and more elaborate scanning can be performed to tell me more information.

I would probably be put back onto Luprone immediately since the cancer was still responding in April, 2011.

Since I have gleason 9 type PC (and from reading other posts), it seems that the delay of a few months can matter.

Samsungtech1

DougS said:

Delaying and Additional Testing
The question is whether I want to delay any additional testing/treatment when currently I am at 93% of the nadir limit. If I wait until November, it may be an additional 4-5 months from now until further testing (biopsies) and more elaborate scanning can be performed to tell me more information.

I would probably be put back onto Luprone immediately since the cancer was still responding in April, 2011.

Since I have gleason 9 type PC (and from reading other posts), it seems that the delay of a few months can matter.

Radiologist
Doug,
Sorry but I still have a hard time understanding why you are with a radiologist, and why he did not hand you off to an Oncologist. It might not be pertinent, but the only thing he has is radiation, unless you are saying that he was giving you HT. in which case he is covering all the bases, but like any thing else you do too much you will do nothing correct, just close. As I just posted to someone else, it is up to you to do the homework and ensure you get the best treatment.

Good luck