First PSA Test

Jerry,

You posted at another thread your pathological stage as being  pT2C (Feb 15), in which case it would mean that cancer was contained. To that extent the PSA also at that time should be low in levels close to  0.05 ng/ml. I wonder if your doctor has done any test during the period of one month post op, without you knowing it.

The PSA of May 16 at 0.18 ng/ml is high for a guy that did surgery which corresponds to surgery failure and it could have the meaning of recurrence. In any case, physicians name it "biochemical failure" if such value is the first test done post op. Recurrence is identified by norm from continuous increases of PSA post op (your doctor's wish in repeating the PSA) and when this value gets over the 0.2 mark.

I think that your doctor may have not bother in checking the surgery outcome testing the PSA because of the pathologist's report. It confirms the matter to be contained. However, no one is ever assured of a perfect hit in a treatment because the pathologist only carefully analyses the logical places dangerous for spread (at dissected points in the base and apex, the areas identified by the biopsy, at nerves, the vesicles, etc) the other areas is done on random basis. The biopsy analysis 1/28th of the gland tissue (14 needles), and on the gland specimen only approximately 30% of the sliced prostate is analyzed. Missing to find cancer or a point of capsule rupture can happen and in your case the existing PSA could mean such occurrence, if a lab error is not the conclusion.

Let's hope for lab error.

Best wishes,

VGama

JM

I am sorry for the news. This test confirms you having biochemical failure. I wonder if your doctor has spelled out the word "recurrence" but surely he is thinking on that because he wants to advance with a salvage treatment. In any case, that doesn't need to be done straight. You should allow time for full recovery from the surgery. I do not know about your present condition but the three months waiting to start radiation (SRT) may be enough. Though, I disagree with your doctor's wish in starting the Lupron shot next Wednesday. The hormonal treatment (ADT) should start with two weeks of antiandrogens (bicalutamide, etc) and then followed with the Lupron shot. This is the "standard" for the administration of LHRH agonists.

Again I am surprised on the actions of your doctor that seem not to follow common practice. He did not check the surgery outcome at the 1-month mile stone and now he wants to fast forward the salvage treatment without concern to consequences. I wonder if he judged your case as high risk for recurrence and has established back in February your full treatment protocol that would be surgery followed by adjuvant radiation done with hormonal treatment. The facts all point to that; 1) No need to check surgery outcome at one month. 2) straight radiation administered adjuvant, 3) no need in identifying cancer location, etc.

Something is missing in your shared information. Can you provide us with the details of your diagnosis, biopsy, PSA and symptoms, before surgery? What is your age?   

Both treatments (ADT plus RT) will add side effects to the ones you got from surgery (RP). Patients with cardiovascular issues will be affected with agonists (Lupron, etc) and those with ulcerative colitis may not be fit to receive radiation. I think that before starting the salvage therapy one should do a series of exams to verify any hidden illness or condition. This work is not done by urologists. I believe you should be in "command" and be more inquisitive in consultations. You are the one that will suffer consequences apart from signing an agreement before any intervention, relieving the doctor from wrong outcomes. I suggest you to get second opinions on his advices before accepting any thing.

Medical oncologists are the proper physicians for ADT administration and radiologists for the RT administration. Urologist's expertise are minimum once one recurs. Surely many urologists got a certificate in oncology so that they also practice that medicine but they do not check details regarding the overall health status of a patient that could be in jeopardy.

The main component in the combination therapy (ADT plus RT), recommended by your doctor, is the radiation. Lupron will just sensitize the cells for these to better absorb the radiation (administered three month later) and die. From trials it was found that the combination provides improvements (30%) in the outcomes of the therapy. However, good outcomes are only guaranteed if the rays are directional to the cancerous cells. Without a picture of the bandit's hideaways, missing the targets is possible as no one can expect a perfect hit in the bull's eye throwing arrows in the dark. Worse still is that once radiation is applied this cannot be repeated at the same area if the first one misses it. I think that you should try a PET scan if you wish to have more assurances of treatment success for its higher capability in locating the cancer.

After considering the data/information you share above (G7, negative scans, pT2c) it seems to me that you have micrometastases. These are cases when cancer do not form solid tumours and instead spread in tiny colonies. These are hard to be detected by traditional image exams (BS, CT, MRI) causing false negatives. PET scan use tracers specific to prostate cancer so that these are more specific when identifying PCa, independently of its size. From the last information one knows that the PSMA PET is reliable when the PSA is above 1.0 ng/ml. In your shoes I would try everything before starting the therapy. ADT cannot be started before the PET exam as the medication would turn the cells less sensitive to absorb the image exam's tracers.

Please understand that we are not doctors but experienced survivors on the matters regarding PCa. The truth is that the cancer does not spread that fast and allows us time to educate on the subject, learn the risks involved, and do the proper tests before starting a therapy. Under the conditions you describe here, I do not think that your PSA will differ much in 6-month time from the present level of 0.15. Starting SRT when this level is lower than 0.4 has been associated with the best outcomes as found in trials. Take your time do your researches and accept the treatment when you feel ready.

Here are some materials for you to read;

https://www.sciencedaily.com/releases/2018/02/180205134241.htm

http://jnm.snmjournals.org/content/56/8/1131.full

http://www.cancernetwork.com/prostate-cancer/salvage-external-beam-radiotherapy-prostate-cancer-after-radical-prostatectomy

http://www.drcatalona.com/quest/quest_winter08_2.htm

https://www.cancer.org/cancer/prostate-cancer/treating/hormone-therapy.html

https://www.cancer.gov/types/prostate/prostate-hormone-therapy-fact-sheet

Best wishes and luck in your continuing journey.

VGama

Hi Jerry:

My dad is 72 and had his surgery back in September 2017, he was GS9 (4+5) with cancer spread to Lymph Nodes and his 6 month post surgery was 0.14 2 weeks back and 0.18 last week. He went in for a scan and we are waiting for the Dr. to review it and let us know the scan results. For now, the plan is to have him on Firmagon (HT) for a month and start with 35 sessions of RT soon after. Dad will be meeting the Dr. on Saturday and I will keep you posted. Wishing you only the best !

Avi.

Jerry Mac said:

Biopsy Report

VG,

Thank you. I am totally at a lost in regards who to contact now, my primary physician or what. I am 55 years of age. The biopsy report was originally a g9 4+5, g8 4+4, g7 3+4, g6 3+3. Per the post surgery path, the cancer was downgraded to a g7 4+3, g6 3+3, neg margins, sv neg, lymphnodes neg. My pre surgery psa was a 4.6. no symptons.......I am not ready to succumb to this disease; however, i do feel that time is running out. I am still in shock.

Jerry,

Vasco wrote above that "something was missing" from your work-up. He was correct.

1. The earlier Gleasons, as high as a 9, were a serious red flag, even if the numbers were edited later downwards. Most surgeons would not do surgery on a gland with Gleason of 8 or above, even with downward editing later.  Any Gland with a Gleason of 8 or above is assumed by most medical groups to have had metastasis (regardless of scanning results).   This is simply a safer way to do business.  An exception to this would be for "debulking," but such practice is very, very rare and of questionable value. And debulking, when it is done, is understood beforehand as not able, by itself, to cure

2.  I also totally agree that you should look for a medical oncologist, one who specializes in PCa.  As Vasco noted, most urologists are not very proficient in administering HT.  Because they are Board Certified in urology and surgery, they can perscribe it, but that is not the same thing as being highly proficient.  Some few urologists are Board Certified in Medical Oncology. Ask yours:  And specify that you do not mean "able to treat." You want to know:  Explicitly Board Certified in Medical Oncology.  If he starts a song and dance, walk.  And be aware, his receptionist or scheduler most likely will NOT know the answer to this question.  He might be fine to retain for urology issues, such as urinary flow problems, or ED, but not in treating the cancer.

3. Your comment, "I feel time is running out."  I understand your fear and this reaction, but scientifically it is profoundly unfounded.  Most guys with metastatic PCa disease live 10 years or more, even with marginal doctors.  Vasco is (if I recall correctly) currently 18 years past diagnosis, and doing great.

Played correctly, you have many years left, not months.  And there is a chance that the radiation will prove fully curative, eliminating PCa from you forever.  One last thing: I also agree that waiting on the HT is probably advisable, per V's time frame, shared above.  It sounds to me like your doc has simply somewhat paniced himself, and wants to start throwing treatments at you.  This is NOT the best response, by a long shot.

max

JM,

With these last added info, I have now a more realistic understanding of your situation and can understand why the doctor wants to get you the soonest on an adjuvant therapy. The protocol was in his mind from the beginning. You were initially diagnosed with Gleason score 9 which classification sets you in the group of high risk for recurrence. Apart of that some cores identified a Gleason score 8 that is viewed by many specialists as cases of a particular high risk (it is commented in several studies) similar to the highest Gleason 10.
The low PSA of 4.6 ng/ml is also a marker indicating that the cancer (if not Gs6) has aggressive characteristics. Poorly differentiated type of cells (Gleason pattern 5) is so disconfigurated that lost the ability in producing PSA serum. In other words, one is confronted with a low PSA but an aggressive form of cancer.

As commented by Max above, high risk patients with negative image studies are typically skipped from surgery and moved straight to radiation treatment, or, if the risk is greater, then they are recommended to the "mother of all treatments" that includes debulking the bigger tumor (the whole gland) and followed with a zip style of adjuvant radiation at the prostate bed and lymph nodes, or even further by adding chemo to the protocol. Physicians term it Multimodal therapy approach which has shown in trials longer periods of free biochemical failure. One may survive longer but his quality of life will get worse.

Your doctor surely was surprised with the pathologist's report indicating a lower risky affair in terms of cancer's grade and containment. I think that he waited for the PSA to confirm his initial judgment and decision (intentional treatment protocol of RP + RT). There is no wrong doing in such a therapy and many guys with high risk affairs have gone through this type of treatment successfully. Total cure is always obscure but people adapt (more or less) to the side effects and live reasonably well. Please read the story of our comrade Will Doran, a survivor in this forum;

https://csn.cancer.org/comment/1554048#comment-1554048

https://csn.cancer.org/node/301261

In view of your highly risky case, my lay opinion is that you need an additional image exam to certify that cancer is localized (no spread to bone or far lymph nodes), and for that, before starting the hormonal therapy, you should try getting a PET exam with proper/suitable tracer (68Ga-PSMA or F18 Choline), that would also be appropriate if you have micrometastases. You can discuss this with the doctor postponing the scheduled Lupron shot. You should also talk about the antiandrogens to be taken before Lupron or replace Lupron with a Firmagon shot (an antagonist friendlier in cardiovascular issues). Another exam I would do (but your doctor may discard) is a colonoscopy to verify the colon condition (ulcerative proctitis/colitis) that will receive the RT blow. Still another recommended test to be done before the hormonal treatment (ADT) is the total Testosterone that will be used in the continuous control of the efficacy of the ADT (urologists never request this cheap and simple blood test) along your journey. In future you should also consider having a DEXA scan (bone health) if the hormonal component is to be taken during a long period. ADT deteriorates bone so that one may need to add bisphosphanates like Fosamax. You can read on the matter in Will Doran's past posts. Some young guys are surprised when diagnosed with advanced osteopenia (an old man's disease).

The 68Ga PSMA PET exam is on clinical trials so that you could try to participate in the trial which is free of charge. Ask your doctor or contact the ones involved in the study. Here is the link;

https://clinicaltrials.gov/ct2/show/NCT02940262

I do understand your feelings and worries. You, as all of us in this forum experienced that initial fear once diagnosed with cancer, and later gets confused when one needs to decide on what to do but can't provide an answer because we're dealing with the unknown. There is always the tendency in following doctor's advices without contesting. It all goes well but it becomes questionable when the initial treatment fails and one sees himself back to the beginning. I recommend you to consider my first suggestion for not rushing. Get the exams and tests, discuss with your doctor the above issues and follow what most gives you confort. You are young and your family will also be affected so that they should be involved in the decision process too.

Guys here will try helping you. Just provide your details and inquires.

Best wishes,

VG