Rising PSA after Radical Prostatectomy - Doubling time

Hi Carlos,

I am sorry for the PSA increase. In any case you should try to be positive avoiding anxiety. At first instance the increase could be thought to be recurrence but it could also be a laboratory error. Either you confirm the result (laboratories keep the blood sample for ten days) requesting a repeated test (they do it free of charge) or wait for another PSA test done in preference at the 6th week (or later) from the first test. For peace of mind you can do the test by yourself at a reliable laboratory (I use Aqualab) if your doctor doesn’t agree with your wish in having it earlier.
Please note that our NHS covers this test so that any GP can give you the referral. At your own expense it would cost you 32 euros.

When a constant increase of the PSA is verified, the status is called Biochemical Failure. Once the increase passes the PSA=0.20 ng/ml mark, the status is upgraded to Recurrence. Intervention (salvage treatment) is done at a PSA >0.40 ng/ml. The above is typical but one may decide to have it earlier or much later; however, there is no evidence that having a salvage treatment done earlier (as soon as we get an increase) one get better outcomes. You have time…..don’t panic.

It is true that the PSA after radical prostatectomy should stay low (< 0.05 ng/ml) because we have no gland producing PSA serum, but there are rare cases when tiny pieces of the prostate tissue is left behind (at negligence of the surgeon), which will grow and increase the PSA serum. These could be benign or cancerous cells. That is the reason for doctors to consider at least two consecutive significant increases (PSADT < 14 months starting from the first increase) for declaring recurrence at an earlier date.

I recall that post manual laparoscopic surgery your pathological stage was classified pT2c N0 M0. The report upgraded your Gleason score to 7 (3+4) and it neither found extra capsular extensions nor seminal vesicles involvement. I wonder if any check has been done of the lymph nodes. I do not know where you were treated or how reliable the doctors and facilities are. To continue treatment you may consider changing to medical oncologists or specialists on radiotherapy (both; oncologist radiologists and modern radio facilities).

Recurrence doesn’t mean that you are doomed. You can kill the bandit with salvage radiotherapy (SRT). This is the sequential treatment that better can assure cure. Typically it is done at by IMRT machines which facility is found at major hospitals or at radio-nuclear facilities. There are differences in equipments so that you should look for the latest models and modern machines. Coimbra and the Porto’s IPO may have the best in Portugal.
In any case your first step would be trying to locate the hideaways of the bandit so that you can have higher assurances of a successful outcome. In Coimbra hospital they do the latest technique in image studies, using special contrast agents in PET scans. These may find tiny tumors at a PSA level above 1.0 ng/ml. Can you wait for your PSA to increase to that level?

In your next meeting try discussing about salvage treatments and means of locating the cancer (ga68 PSMA PET/CT scan). The traditional way uses the data from an MRI and is done in the dark (kind of guessing). They radiate the prostate bed and local lymph nodes but the cancer cold be at another location. That was my case so that I recurred again after the SRT.

I hope that the all saga was due to a laboratory error. Probably your next post will confirm that. I am available to help you in understanding facts based on my experience (send me a csn mail). Just do not panic. Read my story regarding PET exams in here;
https://csn.cancer.org/node/290854

Best wishes,

VGama

CarlosAlberto2 said:

Friday cisit to doctor

Thanks again Vasco for your advices. I´m very thanhkeful for your comments. I went to the doctor last friday, and basically he was a bit surprised with the result of 0,14 ng/ml. He says first is not common such a fast progression in six months from 0.02 to 0.14, and even when my margins and nodes pós- cirurgy forense analysis were clean. So first of all he want me to repeat the test 1 month later, on same lab. Base on the result we will proceed. If it was a wrong test by some reason, everything is OK, but if the result is the same or if there is any progression his opinion is to go for salvage radiation. His opinion is that is preferable earlier than wait for further progression. I´ve asked about simultaneous hormon treatment, and he told that depends on the result and speed of variation, but he was not yet clear. Just said that we will discuss later with the second test result on hand.

My previous test was made at 12 of February so I will a bit anxious up to middle of March to know this second test result.

Thanks again and Regards

Carlos

 

 

to repeat the test in a month and go from there.

Good luck!

CarlosAlberto2 said:

Thanks Old Salt. I´ll do it,

Thanks Old Salt. I´ll do it, and try to stay calm up to get the new results. Anyway I´m not very hopefull on this eventual lab error. So, I´m trying to prepare the best decision when needed to next step. And my main questions here are:

When to make the radiotherapy? immediattly even with 0.14 or wait up to two consecutive readings of 0.2?

Do the radioterapy alone or with simultaneous Hormone therapy? I heard that efficay of RT with HT is higher, but I am afraid that starting now the HT I am shortening the life time of possible HT if there is no cure.

 

Vasco I´ve tried to pick up your mail adress to send you a message in portuguese and local informations, but I had no sucess. 

 

Regards 

 

Carlos

I have sent you a mail. I understand your worries but you need to do things coordinately and timely. A PSA of 0.14 is very low. There are guys with PSA levels much above 20. The doubling time may be critical but it is too early to certify such velocity. You doing it well in researching means for a SRT in case recurrence becomes apparent.
You should also look for RT facilities in Portugal, as well as gathering information regarding the side effects that RT may cause.

The combination treatment of hormonal plus radiation is better but in SRTs done in the "dark" (without identified targets) the hormonal portion will cause the PSA to go down, making this marker unpractical to judge treatment success. You should also research about the side effects caused by HT before deciding.

I recommend you to wait till the next PSA test to verify recurrence. Be positive.

Best wishes,

VG

CarlosAlberto2 said:

Update to my last post
After

Update to my last post

After my PSA test of 0.14, and following the recomendation of my doctor urologist, I´ve made another PSA test 2 months after on same lab and just received the result. It cames surprising lower with 0.06. I asked the lab to repeat the sample and they confirmed same result. Well, is still an increase from previous 0.02, but came to a level where my doctor urologist says to do nothing, and repeat the test on June.

So I have for now a relax period of 2 months.

Wish to all the best

Regards

 

You can breathe more easily now.

Have a glass of (your best) port!

VascodaGama said:

Good News

I also join the party with glass of Port.

I am glad for the news about the PSA. Please contact me whenever you want to talk on the matter. We can go over it while enjoying a golfing day.

Best

VG

I will also join all of you tonight with a toast to the news!

Carlos,

I think you are still navigating tranquil waters. The increase may have a meaning but it's still very low and far from the 0.2 you commented above. Constant increases mean biochemical recurrence, leading through wards clinical failure. For such timing, your urologist will have a threshold to trigger intervention. Typically NCCN (AUA) guidelines use PSA=0.2 to declare recurrence and PSA=0.4 to start a salvage therapy. There are no studies confirming that treatment at <0.2 would provide longer survival than at 0.4.

Most probably your doctor will suggest salvage radiotherapy (sequential after RP) when your PSA reaches his threshold. However, I would recommend you to try getting a PSMA PET image study to locate the bandit. This can shorten the scope/field of radiation and probably limit the risks and RT side effects. Surely the probabilities of detecting the bandit are higher if the PSA is above 0.2 (higher better) at the time of the scan.

I know how easily you become worried so it wouldn't surprise me if your golf handicap has increased to 36 (the capicua of your age, I guess). Again, I advise you to wait till such PSA gets a definite meaning and then proceed coordinately. This might take years (if any). Radiation in PCa therapies affects the colon so that you should start thinking in including in your annual health check up a colonoscopy.

Best wishes.

VGama