9 MONTH PSA RESULT

dav5942 said:

Was it .04 or less than .04?
Was it .04 or less than .04? My nine month(and 6 month) was less than .04 but the test measurement was only able to go as low as .04.

It would seem to indicate
It would seem to indicate that something might be going on. My own doctor does not like the ultrasensitive PSA test since it causes much concern in the patients mind with the minor flucations as you are seeing. Typically they start followup radiation when you reach .2 or Greater unless you were a Gleason 8 or 9. You have a ways to go yet to reach the .2 mark.

Discuss with your doctor for input.

Best wishes,
Larry

VascodaGama said:

A PSA=0.04 is within the brackets of “remission”
Hi Bob01

A PSA=0.04 is still within the brackets of “remission”. As Larry says, recurrence is usually considered at PSA=0.20 however, on your third rise your case will be on biochemical failure. That’s when “flags” are raised, and with other elements from your diagnosis, (Gleason score, pathological stage, prostate size, cancer volume, extra-capsular extension and PSA level before surgery) together with your age and health status, will be considered to access your present status.

Your PSA doubling time is >3 month which is a good signal but you should wait for the third rise and consult a specialist in prostate cancer (oncologist) with the above data. Do not rush without becoming acquainting with all the causes and possibilities considered. You have time to investigate about the need, if any, of salvage treatments and their side effects.

Take care
VGama

BCR Definitions
Hi, Vasco

While your definition of three consecutive rises of PSA conforms to the ASTRO definition of BCR, there are many different perspectives on what constitutes biochemical recurrence (BCR) following RP. There are definitions that try to pinpoint when salvage treatment might be in order and those which attempt to define that metastasis has occurred. The literature is quite confusing on this and many oncologists have widely divergent views.

I would invite your attention to a particularly cogent article on this subject that was published in the Journal of Clinical Oncology and can be found at the following link:

http://jco.ascopubs.org/content/24/24/3973.full

This paper, in my opinion, is one of the most complete and relevant in addressing the thorny issue of BCR following RP and looks at most of the working definitions in use today. I would encourage any man worried about BCR following RP to take the time to fully understand the nuances of what BCR means and what and when additional options should be pursued.

Best,

K

Kongo said:

BCR Definitions
Hi, Vasco

While your definition of three consecutive rises of PSA conforms to the ASTRO definition of BCR, there are many different perspectives on what constitutes biochemical recurrence (BCR) following RP. There are definitions that try to pinpoint when salvage treatment might be in order and those which attempt to define that metastasis has occurred. The literature is quite confusing on this and many oncologists have widely divergent views.

I would invite your attention to a particularly cogent article on this subject that was published in the Journal of Clinical Oncology and can be found at the following link:

http://jco.ascopubs.org/content/24/24/3973.full

This paper, in my opinion, is one of the most complete and relevant in addressing the thorny issue of BCR following RP and looks at most of the working definitions in use today. I would encourage any man worried about BCR following RP to take the time to fully understand the nuances of what BCR means and what and when additional options should be pursued.

Best,

K

“recurrence” after surgery
Hi Kongo,
Thanks for drawing my attention to that paper from JCO. It explains well the meaning of “recurrence” after surgery.
Terminology in medicine with constant developments and research should have a “fix” before becoming confusing. (in HT we have ADT, TIP, CAB, all referring to the same principle).

I come from the “old-school” where doctors (mine) use the term “biochemical failure” with a different meaning from “biochemical recurrence”. Failure is more related to the event before “recurrence” is established, and Recurrence is more as a threshold marker where cancer occurrence is declared active.
(0.2 as recurrence and 0.4 as metastasis)

As you know there is all that caution in the medical community to definitely identify recurrence (BCR) through PSA behaviour. Since the existence of high sensitive PSA tests, there have been cases of insignificant PSA rises, many caused by the difference in testing assays and biochemical rhythms on the day of drawing blood, etc, that can be as high as 0.1.
After surgery (in the 1990Th) two or three rises in PSA were markers of caution and many doctors (the Old Boys) still use that in diagnosis. I believe that ASTRO definitions were established from the same roots.

Thanks for the post.
VGama
(PS; any symptoms in your CK progress?)

Kongo said:

BCR Definitions
Hi, Vasco

While your definition of three consecutive rises of PSA conforms to the ASTRO definition of BCR, there are many different perspectives on what constitutes biochemical recurrence (BCR) following RP. There are definitions that try to pinpoint when salvage treatment might be in order and those which attempt to define that metastasis has occurred. The literature is quite confusing on this and many oncologists have widely divergent views.

I would invite your attention to a particularly cogent article on this subject that was published in the Journal of Clinical Oncology and can be found at the following link:

http://jco.ascopubs.org/content/24/24/3973.full

This paper, in my opinion, is one of the most complete and relevant in addressing the thorny issue of BCR following RP and looks at most of the working definitions in use today. I would encourage any man worried about BCR following RP to take the time to fully understand the nuances of what BCR means and what and when additional options should be pursued.

Best,

K

What to do when PSA starts rising after RP
My experience tells me thus far to get radiated soon as possible. If applicable when the rise reaches 0.1. If you're already over that, immediately get done. Don't waste time dithering about whether the rise is due to remaining tissue etc etc. Comforting thoughts, but I found fantasy. Remember, time is not on your side. It is very much on the side of the malignancy.

I didn't heed that advice. Waited until 0.2 - a 100% increase last time I checked! In effect, gave my malignant cells a chance to double, a year to consolidate, possibly to metastasize. Ask yourself at which point in time does a bad cell do that? We don't know. So limit the chance of that happening. TomoThrerapy is highly accurate. An empty rectum, a filled bladder ahead of treatment places both organs out of the way of the modulated beam. I see that on the computer screen before each treatment. It is pointed out to me. It means collateral damage is going to be minimal.

sbj

mrspjd said:

question
Question for sbj. I find your comments interesting related to RT txs such as "Bed only has minimum side affects. Bed + lymph nodes generally hits more bowel and bladder cells, that can become problematic later." Wondering if you might elaborate by providing more info, such as what, if any, hard data or research supports or substantiates those thoughts. Thanks.

Deleted post

sbj said:

PSA Range Anxiety
mrspjd,

Hopkins' Partin/Walsh/Chan papers was my gold standard. The consensus of these superbly qualified gentlemen is that the earlier post RP radiation is started, the longer survival chance the patient has - provided PSA is at least 0.1 (Chan) to begin with. That said, listening to those who'd been through it, who'd had post RP radiation and suffered its IBS-like side effects, the advice given by my urologist MD, my radiation MD (during review of my post RP pathology report) finally decided me on a prostate-bed course of treatment. For those with higher Gleason, higher velocity - faster doubling times than mine - then according to what I have learned from my ordeal, a wider treatment zone is called for, perhaps with added HT.

Based on my small sample of experience, my advice to guys suffering PSA reoccurrence should not be to wait wringing their hands to see if it gets worse - like I did when at 0.1.

As an aside, I find, that the awful unique thing for the prostate cancer patient, is that he needs to get involved in this chemical dance at all. To become so well self-informed, to counter the sad lack of hard trial data available for his doctor to make an optimal decision. That, and WSJ articles that detail medical practices designed to push patients into over-treatment schedules, simply to meet loan payments on capital cost of equipment, made me wary in coming to any decision. One has to be careful too on what one reads. I found some seeming authoritative, well authored papers biased around a treatment method the authors surgery offered, that as a doctor the writer had invested in!

Daniel W Chan, Ph.D., who is professor of pathology, oncology, urology and radiology, and Director of Clinical Chemistry at Hopkins had this to say on the subject of PSA range anxiety:

"The only thing that really matters is at what PSA level does the concentration indicate that the patient has had a recurrence of cancer? The number to take seriously is 0.2 nanograms/milliliter. ''That's something we call biochemical recurrence. On a technical level, in the laboratory, I trust the sensitivity of assays down to 0.1, or slightly less than that. You cannot reliably detect such a small amount as 0.01. From day to day, the results could vary - it could be 0.03, or maybe even 0.05 - and these analytical variations may not mean a thing. It's important that we don't assume anything or take action on a very low level of PSA. In routine practice, because of these analytical variations from day to day, if it's less than 0.1, we assume it's the same as nondetectable, or zero."

sbj

SBJ; Problematic ways in diagnosis
Hi SBJ
I like your post and want to wish you a treatment uneventful. Good results and successful outcomes.

A close colleague of Walsh, Dr. Eisenberg (one of my “supervisors”) was probably the first to ignite fire on the controversial “earlier is better” comment. The standard BCR at the time (2000) was PSA=0.4 and he pulled that marker to 0.2 for localized PCa cases. Maybe he was shy and actually this value should have been established at 0.1.
Soon this threshold was contested because of the higher sensitive results from assays which can express a relapse of the activity of cancer or benign cells at much smaller levels.
Dr. Daniel W Chan, as you comment on your post, was cautious about the constant difference of PSA in those low levels actually not related to cancer activity but to the difference in testing assays and daily biochemical rhythms. As he comments, “….The number to take seriously is 0.2 nanograms/milliliter. That's something we call biochemical recurrence…”.

In your PSA chronology, in 2008, you were on chemical failure and you would be considered on recurrence by my doctor for your third PSA rise. Maybe he would have suggested you to start a salvage treatment because you were a Gs 7. However, the majority of doctors follow those statistics and recommendations established by groups from where Dr. Chan belongs. They have good and valid reasons to respect those principles.
We as part of the problem need to be informed of the problematic ways in diagnosis and should be active in the decision process. Otherwise we must accept what others choose for us. Consideration should also be given to the fact that not every case is equal.
The success of your RT will give you the final answer to your quest. Do not regret the past and expect for an excellent outcome.

Wishing you the best.
Vgama

paterjak said:

When (if?) to radiate...
Interesting discussion. The great problem for us (as I see it) is that our decisions in these matters are essentially based on educated guesswork. I just read the 2006 paper by Scardino and colleagues, which seems to propose 0.4 definition for recurrence. Isn't the problem that no one can say when metastasis is going to occur (or has occurred)? It makes me wonder whether prostate bed radiation ought to be considered soon after surgery (after, all you've just decided on a radical course of treatment--why not optimize the chances of its success?).

Paterjak; A situation of probable relapse
Hi Paterjak

Treatments are not done based on guesswork. Doctors follow protocols which were established by institutions based on past experiences and statistics. All treatments cause side effects which are taken into consideration too, and added treatment usually bring about added side effects which must be avoided.

Radical courses do not envision in salvage treatments. They aim at cure in one solo treatment. The same goes to Surgery that is not done if radiation is deemed to be needed later. Many surgeons decide to abort surgery while in performance if extraprostatic disease is found in the lymph nodes.
Small variations of PSA measurements in the sensitivity of 0.XXX or 0.XX also tend to be different between assays as well as it can be influenced by other causes extra to cancer activity. Using that information alone could lead to erroneous decisions too.
To avoid this sort of errors or any wrong judgment in the start of a treatment (including salvage treatments), threshold markers are set and followed so that success can be expected in the majority of the cases.

Not everybody require salvage treatment. Many do just fine until the end of their lives and die of other causes. Hormonal treatment is also a way of keeping the cancer stable for several years (many cases over ten years). In SRT the threshold followed by Dr. Peter Scardino from MSKCC is indicated in the statistics which represents a smaller difference in percentages of prostate cancer–specific mortality (PCSM), for PSA=02 vz PSA=0.4.

You are confronting a situation of probable relapse. I would suggest you to research and get second opinions from oncologists specialized in prostate cancer. SRT may be a solution but you should consider other choices too.
I wish you the best in your case.

Welcome to the board.
VGama

mrspjd said:

sbj
Thanks for your Feb 10th post in reply to my question. If I could just drift slightly off topic for one more question, and not to beat a dead horse but, I understand your reply in relation to the Hopkins' Partin/Walsh/Chan papers as a source for determining if/when recurrence is present and, how and when you decided to begin salvage radiation tx. However, were the Hopkins' Partin/Walsh/Chan papers (of course, along with input from your PCa and rad oncologists), also the guiding & instrumental factors in your decision not to include local pelvic lymph nodes in your IMRT txs? Just trying to understand the basis for several of your recent blanket statements, in this and other threads, that treating the local pelvic nodes, whether during primary, adjuvant, or salvage IMRT treatments, causes more harmful side effects (immediate or future) than treating the prostate bed alone. Are there specific clinical studies that support this concept with findings? Thanks again for any add'l info that might shed more light on the sources supporting your thoughts/statements that treating the local pelvic lymph nodes along with the prostate bed during IMRT causes more harmful side effects.

mrspjd
As I recall those papers did not cover that subject. The choice was either radiation or no radiation. I am not aware of any clinical studies done that show the degree of harmful side affect with extent of radiated tissue. However, my oncology radiation doctor told me (in answer to my question on the subject after he'd explained the two levels of radiation open to me) that in his experience (>10years at a major oncology radiation unit), generally, the wider field radiated the more patients tended to suffer side affects. He said this not only applied to prostate cancer radiation but to all such treatments where target area was in vicinity of organs. The differing outcomes in the prostate case were due to increased collateral cell damage to bladder and rectum. The most common symptom reported by his patients was continence and more rarely bleeding from the rectum, often accompanied with bouts of IBS-like diarrhea. In his opinion, increased accuracy of TomoTherapy had reduced the incident of these side affects - but not eliminated them.

The affects he said were typically not felt during and immediately after treatment, but later, often much later, when cell death nadir occurred. Side affect outcome varied between individuals. Sometimes a bed-only patient seemed to have worse side affects than others treated for both bed and nodes. He illustrated his talk by sketching the position of the organs relative to the bed area, then spotted in the pelvic nodes. Clearly, at least to me, a wider field of radiation was required to hit the nodes.

In my case, being a periodic SIBO (Small Intestine Bacterial Overgrowth) sufferer, (that he would be aware of from my filled in questionnaire form) he led me to believe that bed only would be my best option. But he would not take the decision for me. It had to come from me.

Even then I worried that if the malignancy was in the nodes, radiating the bed would have little or no affect. The doctor answered this by saying the same would be true for bed+nodes if malignancy happened to be in the bone. There is no telling where it is he said. Only where it's most likely to be.

Thank you for your interest and helpful comments in my case.

sbj

sbj said:

mrspjd
As I recall those papers did not cover that subject. The choice was either radiation or no radiation. I am not aware of any clinical studies done that show the degree of harmful side affect with extent of radiated tissue. However, my oncology radiation doctor told me (in answer to my question on the subject after he'd explained the two levels of radiation open to me) that in his experience (>10years at a major oncology radiation unit), generally, the wider field radiated the more patients tended to suffer side affects. He said this not only applied to prostate cancer radiation but to all such treatments where target area was in vicinity of organs. The differing outcomes in the prostate case were due to increased collateral cell damage to bladder and rectum. The most common symptom reported by his patients was continence and more rarely bleeding from the rectum, often accompanied with bouts of IBS-like diarrhea. In his opinion, increased accuracy of TomoTherapy had reduced the incident of these side affects - but not eliminated them.

The affects he said were typically not felt during and immediately after treatment, but later, often much later, when cell death nadir occurred. Side affect outcome varied between individuals. Sometimes a bed-only patient seemed to have worse side affects than others treated for both bed and nodes. He illustrated his talk by sketching the position of the organs relative to the bed area, then spotted in the pelvic nodes. Clearly, at least to me, a wider field of radiation was required to hit the nodes.

In my case, being a periodic SIBO (Small Intestine Bacterial Overgrowth) sufferer, (that he would be aware of from my filled in questionnaire form) he led me to believe that bed only would be my best option. But he would not take the decision for me. It had to come from me.

Even then I worried that if the malignancy was in the nodes, radiating the bed would have little or no affect. The doctor answered this by saying the same would be true for bed+nodes if malignancy happened to be in the bone. There is no telling where it is he said. Only where it's most likely to be.

Thank you for your interest and helpful comments in my case.

sbj

Treating Local Pelvic Lymph Nodes: Another Opinion
SBJ,
I, too, am unaware of any clinical study findings to support the blanket statement put forth that treating local pelvic lymph nodes along with the prostate bed during primary, adjuvant or salvage IMRT (for intermediate to high risk non-mets PCa) is more harmful to surrounding tissue/organs than treating the prostate and/or bed alone. Perhaps the notion that it is thought to be more harmful is rooted in the recent past, when older methods of delivering External Beam Radiation Therapy (EBRT) were commonly used for PCa tx. Since the External Beam was unfocused/unguided and radiation intensity was non-modulated, a wider area of tissue had to be radiated in order to "hit" the target area. Therefore, this outdated broad beam external radiation delivery approach was more likely to result in "harmful" toxic & chronic “collateral damage” & side effects to surrounding tissue/organs, such as to the bladder and/or rectum.

Today, newer IM/IGRT (Intensity Modulated/Image Guided) radiation technology aims precise (image guided) beams and delivers varying Gy rad intensities (modulated) to specific targeted areas identified by modern pre tx diagnostic tests such as MRI & CT. Along with better individual rad tx plans designed by a team of professionals, including a rad oncologist, a dosimetrist and/or a medical physicist, the risk of toxicity and “collateral damage” is greatly minimized when treating not only the prostate and/or bed, but the local pelvic lymph nodes in addition. With more accurate imaging & diagnostic techniques currently in development and on the horizon, IMRT may emerge to be an even more important tool in the tx of PCa.

While proctitis or cystitis (inflammation of the rectum or bladder, with urinary frequency/discomfort) may be side effects from IMRT for PCa, typically they are temporary and resolve with time. However, incontinence (involuntary emission of urine) is rarely, if ever, a side effect of IMRT alone. In cases where there are pre-existing urinary issues prior to RT, especially if there is unresolved incontinence resulting from RP (surgery), then RT is very likely to exacerbate those issues, perhaps even resulting in chronic urinary problems.

IMO, when weighing the risk vs benefit ratio of treating both the bed/margins and local nodes (and prostate if for primary tx), the benefit of including tx to the local pelvic lymph nodes heavily outweighs the risks. When you consider that one of the transport pathways of PCa cells to distal locations such as bones and organs is by way of the lymphatic system, it seems like a reasonable consideration to include tx to the local pelvic lymph nodes when also treating the prostate and/or bed in the same IMRT series.

But, as is everything PCa, there is a wide variance of opinion and ultimately, it boils down to a highly personal and individual treatment choice for each patient once the research is completed & the options are considered.