PSA result came back with 0.2 ng/ml - 3.5 year after RP

sabhen said:

Thanks VGama, really

Thanks VGama, really appeciate your input. 

I am 60.  

My initial diagnosis from pathology report from August 2014 is shown below. 

Clinical history: elevated PSA (790.93)  

12 samples 

a) right medial apex: positive for adenocarcinoma, gleason score: 3+4=7, 35% of entire tissue volume, perineural invasion: not identified

b) left medial mid: positive for adenocarcinoma, gleason score: 3+3=6, 7% of entire tissue volume, perineural invasion: not identified

c) left lateral apex: positive for adenocarcinoma, gleason score: 3+4 =7, 25% of entire tissue volume, perineural invasion: not identified

Bone scan and other tests done prior to surgery did not show cancer spreading to other organs. 

I am waiting to hear from the urology department on their input in the next few days.  

Additional infos: 

I also checked the the surgical pathological exam after RP (Oct 2014)

Histlogical grade: Gleason (3+4 =7), tumor: 5 to 10% of tissue, extraprostaic extension: not present, seminal vesicle invasion: not present, margins: uninvolved by carcinoma, lymph-vascular invasion: not identified, perineural invasion: present (this was diffrent from pathologcal report). 

pathological staging: T2c bilateral disease, regional lymph nodes: No, number examined: 13, number involved: 0, distant metastatis: NA

Thanks a lot.

sh,

Your case interests me very much, since my biopsy and post-surgical pathology results were close to identical to yours. Three years post-op, I remain PSA "undetectable."

If you have relapse, the perineural invasion suggests itself as the avenue of escape, but how metastasis occures is often not able to be established. Perineural invasion means cancer was found inside the nerve sheathing inside the gland. By itself, the finding does NOT prove metastasis, but suggests the possibility thereof.

I 'second' every comment that Vasco made.  A confirmation PSA draw is still required, and best practices do state that second-line therapy begin by the time the number becomes .4  Put another way, it is usually written as "Salvage therapy begun after .5 PSA is less effective than salvage therapy begun sooner."   (These two ways of wording the recommendation are of course numerically identical.)  One often also reads a blurb that states that "Salvage therapy for previous R.P. patients begun after 2.0 PSA is often NOT effective" (toward cure).

Current science holds that your case is still potentially curative -- able to eradicate all detectable PCa disease for life.  But unlike most PCa situations, timliness is now important; it matters how fast the doctors get started.  No cause for panic, and waiting for the next PSA draw is fine. Just don't dally.

Please share all future developemnt on this if you will,

max

sabhen said:

Thanks Max.   Appreciate your

Thanks Max.   Appreciate your comments.  I spent all of yesterday thinking about this. 

You are very welcome.

Know clearly that IMRT/IGRT (types of radiation) after surgical relapse is regarded as routinely curative.

Max Former Hodgkins Stage 3 said:

Dear to my heart....

sh,

Your case interests me very much, since my biopsy and post-surgical pathology results were close to identical to yours. Three years post-op, I remain PSA "undetectable."

If you have relapse, the perineural invasion suggests itself as the avenue of escape, but how metastasis occures is often not able to be established. Perineural invasion means cancer was found inside the nerve sheathing inside the gland. By itself, the finding does NOT prove metastasis, but suggests the possibility thereof.

I 'second' every comment that Vasco made.  A confirmation PSA draw is still required, and best practices do state that second-line therapy begin by the time the number becomes .4  Put another way, it is usually written as "Salvage therapy begun after .5 PSA is less effective than salvage therapy begun sooner."   (These two ways of wording the recommendation are of course numerically identical.)  One often also reads a blurb that states that "Salvage therapy for previous R.P. patients begun after 2.0 PSA is often NOT effective" (toward cure).

Current science holds that your case is still potentially curative -- able to eradicate all detectable PCa disease for life.  But unlike most PCa situations, timliness is now important; it matters how fast the doctors get started.  No cause for panic, and waiting for the next PSA draw is fine. Just don't dally.

Please share all future developemnt on this if you will,

max

Salvage therapy for previous R.P. patients begun after 2.0 PSA is often NOT effective" (toward cure)

That is the bit that messes with my head.

I had to wait until 0.24 for them to take action.

On top of a 8 month BCR with a fairly fast PSADT I don't think I'm in this for the long haul

You may question about his idea on the location of the cancer, if recurrence is confirmed. In his initial judgment the cancer was contained (T1c) and after surgery the status was similar. You can also inquire on the details of the salvage treatment and if it is planned as a localized affair. You can ask him about the odds that cancer is located at far places?

The same questions should be forwarded to the radiologist, including items regarding the risks and side effects. What to expect and how to counter. In regards to the preparedness, you should request to have a colonoscopy to check the colon status. Ulcerative colitis would limit the field of radiation or alter its isodose planning. If hormonal is added to the protocol, then I would request to include a testosterone test together with the PSA (in fact I would do this test this time even before the consultation. The same blood sample is ok.). This is important to verify ADT effectiveness but never requested by urologists.

Well this is still earlier but you can do some researches on the above matters.

Best wishes,

VG

Max Former Hodgkins Stage 3 said:

??

Sabhen,

I did a little Googling (not always the best way to get good information), and most medical school sites seem to say that ultrasensitive PSA tests are the preferred type following R.P.

That's my understanding as well.

One reason for using the 'regular' PSA test is that slight (!) changes in results from the 'ultra' test may cause patient anxiety. 

PS: My rad oncologist orders both (at the same time) even though I didn't have surgery. As a former lab guy, I do like that approach.

There is no standardised practice in the use of sensitive assays to test the PSA serum. Each physician does what he most trusts, but the patient can chose what he prefers. In fact the ultra sensitive test exists from the beginning of its use in the screening of PCa (1990th) but not all doctors at the time believed in the test, leading them to use other markers in the screening. My GP of 1995 (I was 45 years old) used PAP to check for PCa which erroneously lead to 5 years of continuous false negatives in the screening of my case. He was of the group that did not believe in the PSA.

The controversy in the use of ultra sensitive PSA tests started with the study done by Dr. Thomas Stamey, published in the medical journal "Clinical Chemistry" back in 1996. He explains in detail the meaning of the very low levels (LLD-low limit of detection) and the problems involving its use. There are also differences in lab’s reports as some of these do not report values below 0.1 and instead use the sign “<”. For those and several other reasonsmany doctors give preferences to the one-digit decimal PSA result and many use the two-decimal digits (ultra sensitive) which value, in time (study after study) has become thresholds to judge treatment outcomes, recurrences and management/control in continuing cases of PCa. Later some of the laboratories providing the assays started to produce a higher sensitive assay of three decimal digits (Hypersensitive PSA test also known as the 3rd Generation ultra sensitive test).

Back in 2000 it was well known the influence that JH and MSKCC had in the affairs of prostate cancer, around the world. Some hospitals/doctors paired their practice with one of them and would follow their recommendations. JH is known for its tendency in recommending surgery over radiation (the great Dr. Patrick Walsh) so that ultra sensitive tests would not be the preferred. It would lower the number of successes in surgeries at a time when RP was the golden standard of treatments.

I belong to the group that believe in the ultra sensitive assay of two decimal digits for guys without a gland in place. Even in the screening pre-treatment assays providing one-digit sensitive are justified in view of the newer standards of PSA levels. The PSA=4 (true number) is no longer considered normal. The max in a 50 years old is 2.3 ng/ml in a 60yo is 2.6 ng/ml and in a 70yo is 3.6 ng/ml.
I cannot understand the use of hypersensitive assays (0.XXX ng/ml) in cases with PSA lower than 0.05.

Sab; you should follow what you trust, not what your doctor likes. He may recommend but you will be the ultimate in the final decision. Any consequences will always lay on you.

Here is a link on the Ultra sensitive PSA;

http://www.yananow.net/UltraPSA.shtml

Best wishes.

VGama

that your current PSA (0.2) may be too low for even the most sensitive scans such as the PSMA focussed ones. The latter is being tested in clinical trials in the USA. Quite a few are listed on clinicaltrials.gov and you can see if you might qualify. 

With the information shared by you here on your case, I believe that your present status will not differ much in two three months time, and that would not alter the course of the events or actions. In other words, the outcome of an intervention started now or in three month time would be expected to be the same.

The doubts in existing recurrence leads to the RO's opinion. I think that he prefers to gather a more solid evidence of your "real" status before starting the therapy. The ball is in your hands and only you can roll it into play. I cannot understand why you bring into the decision process the worries in short or long term side effects. They also will be there if you act in three months time if the "field of attack" is the same.

Get the opinion of your family and follow your instint, what gives you comfort.

VG