rising psa after radical prostatectomy

worriedwife said:

Upsetting
My husband had the RP in 2000. Over 10 years now. His PSA was always around 0.02
His last test in April was still at 0.2.

He just had his PSA done this month and it was 3.7!!!! I am really worried.
I met with his doctor who is not the original doctor. We moved in 2004.
He said not to be worried yet. He will retest his PSA in 3 months. Then he
will make a decision to do further testing if it does not go down.

When my husband had the cancer last time his PSA was 1.4, no outward signs,
and found by accident during a TURP procedure. I explained all this to the
doctor.

My husband is comfortable with the test being redone in January. He doesn't
really want to talk about it anymore. He was even hesitant when I wanted to
talk to the doctor myself. The doctor did say that, if I could not wait the
3 months, he could do a CT scan or MRI. I wish we still lived up north. His
original doctor was so much more concerned about these things.

Since it was at 0 in April, could this be just a bad PSA test. He has been cancer
free for 10 years, now this????????
My husband is only 64. He was 54 when he had the RP.

Waiting 3 months
I had replied to your post above, and now see this one. Over 60.... waiting 3 months really won't hurt.

I personally just faced this same decision, and we chose to immediately have the ct and a nuclear bone scan, but since my DH is only 42 our hormones would make things move much faster.

This has to be scary since your husband's psa is higher now than with his initial diagnosis. We were up to a 7.2 and our doctor at Mayo clinic in Rochester Minnesota still waited a full month for RP surgery after biopsy (swelling/nerve sparing concerns.) Even with psa that high and only 38 years old, concerns of spreading within months was not a problem, with our gleason numbers.

I hope this makes you feel better. I totally feel for you. We just had the CT and Nuclear bone scan yesterday and are facing a 48 hour wait for results. We will also be repeating PSA in 3 months too.

Not a fun journey, but at least you are not alone!
Prayers from Nebraska-
Darci

buzzz said:

biopsy?
This is horrible to read, all these recurrances after surgery, I though with surgery they took the gland so the threat was very low, and that they wouldn't do surgery if cancer was outside the gland. Now I read this thread, does anyone think that maybe it's because of the biopsy, that it spread one tiny speck of cancer? What else could cause so many relapses?

Not from biopsy
there is a urban legend that the biopsy causes the cancer to spread, but this is not true.........tis has been dcoumented...one doc, Dr. Scholtz, in his book "Invasion of the Prostate Snachers" wrote about this.

Kongo said:

Ira, while many doctors do not subscribe to the notion that biopsies or surgery contribute to the spread of cancer, there is a rather large body of evidence easily found on the web that suggests that indeed, biopsies can contribute to metastasis of many cancers, including prostate cancer. Even though the idea of cancer spreading as a result of a biopsy is not generally accepted (otherwise, why are they continuing to do biopsies?) there is enough out there that I would not classify it in the “urban legend category.” Instead, I would classify this as “maybe in some cases.” But in general, I don't think we yet know enough about this do be able to state definitively that it isn't a factor with any more conviction that when the "experts" dismissed Rachel Carson when she suggested that the chemicals we were putting into the environment was causing cancer.

The phenomena known as needle tracking where cancer is observed growing along the path of a prostate needle is fairly common in post RP pathologies, and other soft tumor cancers where surgery is involved following a biopsy. Women who have had a biopsy for breast cancer have a 50% higher risk of seeing their cancer spread than those women who have their tumors removed through a radical mastectomy or lumpectomy.

A recent study done at UCSD indicated that damage to the tumor during a needle biopsy may cause inflammation which is correlated to cancer metastasis. See http://ucsdnews.ucsd.edu/newsrel/health/03-07prostate.asp

Generally doctors will state that “there is no evidence that a biopsy can spread cancer” but it seems to me that that this is a plausible statement because they simply haven’t done any studies to determine if this is the case. Biopsies are such an integral part of the way cancer is diagnosed today that few physicians would ever challenge it. Without a biopsy they can’t give a definite diagnosis and none of the treatments that flow from that diagnosis could be undertaken. In the case of prostate cancer, 25% of needle biopsies show some level of prostate cancer and frequently these lead to follow on treatments that also make a great deal of money for the doctors. For all cancers, biopsies are not only a very large money making operation for doctors and pathologists, they lead to further treatments which also make a lot of money. Doctors have a vested interest in conducting biopsies.

Cancer can spread in many ways, such as through the lymphatic system called "embolization". The lymph system has its own channels that circulate throughout the body, similar to the veins and arteries of the bloodstream. These channels are very small and carry a tissue fluid called lymph throughout the body. Cancer also metastasizes when cells break off from the original tumor and travel through the blood stream to other parts of the body. Cancer can also spread directly to adjoining healthy cells such as occurs in skin cancer. For prostate cancer to metastasize to a distant organ such as the bone, lung, liver or whatever, it is probably traveling by the bloodstream. While cancer needs blood like any other cell, sometimes cells slough off and enter the bloodstream naturally and eventually find someplace that provides a home for a new colony.

My personal feeling is that when the tumor is pierced with a needle that some of the cancer cells also enter the bloodstream. Another way intervention can cause a spread is when surgery cuts across a margin where cancer is present and cells can then enter the bloodstream. The study I cited earlier suggests that the inflammation caused by a biopsy creates a chemical condition that accelerates the shedding of cancer cells that can spread through lymphatic action or by the bloodstream. The frequent manifestation of “needle tracking” suggests that SOMETHING abnormal is going on along the path that the needle takes during a biopsy. The needles in a biopsy gun that are used today (18 gauge) are much smaller than those used years ago, and may reduce the likelihood of cancer spreading as a result, but needle tracks still occur, and to in my opinion, the fairly frequent recurrence of cancer years after initial treatment when it was originally considered to be “contained within the prostate” makes sense if you consider that the original biopsy and treatment caused cancer cells to enter the bloodstream.

I wish there was a better, non-invasive way to determine prostate cancer without a biopsy and I am sure that our generation will see such a development given the pace of modern research. In the meantime we must take our chances as the only way to confirm a suspected cancer is to conduct a biopsy.

Kongo

Actually, since I guess that I waved a red flag for you, I'm surprised that it took you so long to respond......

My view is that it is current establisted practice by the medical profession to do biopsies...it is up to nay sayers to provide concrete information to validate problems caused by biopsies, other than possible infections...I have not seen any information that does this....I believe that you are presenting a well thought out hypothesis, but the facts are lacking.....anyway my opinion.

I looked at the article that you referenced......as I read the article published in 2007, where mice were the subjects, it suggests...( I wonder if there has been any follow up in response to this study) more needs to be done to investigate the hyposthesis...(that's what I get from it, however others may see differently, so I pasted the article below.

You wrote "

"I wish there was a better, non-invasive way to determine prostate cancer without a biopsy and I am sure that our generation will see such a development given the pace of modern research. In the meantime we must take our chances as the only way to confirm a suspected cancer is to conduct a biopsy."

I agree, by the way a few weeks ago there was something on TV about colon cancer, and examining stools to determine cancer, I think looking at genes instead of a colonoscopy.So I'm thinking that a colonoscopy may go by the wayside

Anyway that's my take.


> News Releases > Health Sciences
Inflammation May Play Role
in Metastasis of Prostate Cancer

March 19,2007

By Debra Kain

Many would assume that “mounting an immune response” or “having your body fight the cancer” is a good thing. Now, research at the University of California, San Diego (UCSD) School of Medicine strongly suggests that inflammation associated with the progression of tumors actually plays a key role in the metastasis of prostate cancer.

The research, appearing online March 19 in advance of publication in the journal Nature, identifies a mechanism which triggers metastasis, which is the spread of cancer in late stages of prostate cancer development. The findings by Michael Karin, Ph.D., professor of pharmacology in UCSD’s Laboratory of Gene Regulation and Signal Transduction, and colleagues may help solve the puzzle of why it takes so long for cancer to metastasize, as well as what causes it to do so. Furthermore, this new work may lead to development of anti-metastatic therapies.

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A major hypothesis in cancer research has been that whether the cancer metastisizes or not is determined by genetic changes within the cancer cell itself. But this hypothesis didn’t explain why metastases appear many years after the initial tumor.

“Our findings suggest that promoting inflammation of the cancerous tissue – for instance, by performing prostate biopsies – may, ironically, hasten progression of metastasis,” said Karin. “We have shown that proteins produced by inflammatory cells are the ‘smoking gun’ behind prostate cancer metastasis. The next step is to completely indict one of them.”

More than 200,000 men are diagnosed with prostate cancer in the United States every year. As many as 25,000 men will probably die of prostate cancer in 2007, most as a result of metastatic disease.

Early tumors confined to the prostate can be treated, but no effective treatments are available for metastatic disease, according to Steven L. Gonias, M.D., Ph.D., professor and chair of the UCSD Department of Pathology, a study investigator.

“This study helps explain the paradox that, in certain types of malignancy, inflammation within a cancer may be counterproductive,” said Gonias.

In research using mouse models and confirmed in human tissue, the scientists observed that a protein kinase called IkB kinase α (IKKα) turns down the expression of a single gene called Maspin, which has well-established anti-metastatic activity in breast and prostate cancers. They found that the production of Maspin is repressed by a series of events triggered by tumor inflammatory cells, with the result that prostate cancer cells spread.

“An excellent inverse correlation between IKKα activation and Maspin production was detected, such that advanced prostate cancer cells contain high amounts of activated IKKα in their nuclei and express little or no Maspin,” said Karin. He noted that a perfect correlation between nuclear accumulation of activated IKKα and reduced maspin expression was also seen in human prostate cancer, and both correlated with the clinical stage of the disease.

Karin and his colleagues discovered a signaling pathway that increased metastases in a mouse model of prostate cancer. The pathway is activated by a ligand that binds to a Receptor that Activates Nuclear factor Kappa-B (RANK). RANK ligand has been shown in previous studies to be an important inflammatory protein (cytokine) that can lead to bone loss through activation of bone resorbing cells.

RANK ligand, produced by inflammatory cells that invade advanced prostate tumors, triggers a chain reaction in which IKKα is activated, allowing it to enter the nucleus of the cancer cell, repressing Maspin. IKKα is a key linchpin in the pathway that turns off the Maspin gene and activates the metastatic program. The new results also support the view that RANK ligand is a general promoter of prostate, and possibly breast, cancer metastasis.

“Maspin is a very potent inhibitor of metastasis; in a patient with metastasis, cells have found a way to turn off Maspin, which may depend on invasion of the tumor with RANK ligand-producing cells that activate IKKα,” said Karin.

Malignancies progress through stages. In early, non-metastatic tumors, a high level of Maspin is present, but it is turned off in late stages. Early tumors contain low amounts of active nuclear IKKα, whereas late-stage tumors contain the highest levels of active nuclear IKKα. The researchers also found a striking elevation in expression of RANK ligand in late tumors, but it was not expressed by the cancer cells. Instead, it is expressed by invading inflammatory cells. Interference with RANK ligand production or activation, as well as interference with IKKα activation, may offer new therapeutic strategies for prevention of metastatic disease.

The study was funded by the National Institutes of Health, the U.S. Army Medical Research and Material Command, the Prostate Cancer Foundation, the Aventis-UICC Translational Cancer Research Fellowship, the Lopiccola Fellowship of the UCSD Moores Cancer Center, and the Life Science Research Fellowship.

Additional contributors include first author Jun-Li Luo,Wei Tan and Olexandr Korchynskyi, UCSD Laboratory of Gene Regulation and Signal Transduction, Department of Pharmacology and Moores Cancer Center; David A. Cheresh and Jill M. Ricono, UCSD Department of Pathology and the Moores Cancer Center; and Ming Zhang, Baylor College of Medicine, Department of

Kongo said:

Ira
Hey, Ira. No red flags. Obviously I don't have the "facts" on this issue other than the ones I referred to earlier. I just get very suspicious of one-liner dismissals about the potential impact of things relating to cancer. I don't think we know enough about too many things and in this case there is so much vested interest in continuing biopsies that I doubt we will ever see a costly study to examine it...who would sponsor it? Way too political.

I have recently read that dogs can be trained to sniff urine to determine if there is prostate cancer. Of course, dogs spend most of their lives sniffing urine so maybe they have a good nose for it. I would draw the line on a DRE though...wouldn't want a pit bull going there!

It seems to me that the hardest part about diagnosing cancer without a biopsy is determining the right Gleason equivilent without actually looking at the cell structure and the only way I can imagine doing that with technology today is via biopsy. But I do think some savvy researcher will find a way to do it in our lifetime.

Although given that we do know that cancer spreads via the bloodstream and lymph system and we do know that even a thin biopsy needle pierces these systems while drawing core samples, it makes sense to me that there is a very likely chance that there are some cancer cells that are going to get loose during the process. Studies or no, I will remain suspicious of the procedure and avoid it where I can.

A similar corollary is the amount of vitamins and supplements many men with cancer take without hard studies showing value. There is much we do (or don't do) that can't be absolutely supported by studies.

CyberKnife compared to TomoTherapy
I am a young 70 recently diagnosed with PC, Gleason 3+3, three out of twelve hits on biopsy and a PSA of 7. I was going with AS until an MRI showed that the tumor was nestled up against the seminal vesicle. Bone scan normal and PSA actually went down to 6.7. The proximity to SV quickly put me in the same treatment maze that so many of you have been in. I am coming out of the maze looking strongly at radiation therapy and and am deciding between CyberKnife and TomoTherapy. I noticed from prior communications that Kongo chose CyberKnife after considering many options. I apologize for being off topic but this is my first post and I didn't know how to get in the conversation without just entering through this door. Does anyone have advice or information or anything else on TomoTherapy versus CyberKnife?

All of these posts I have read in the past have been very helpful to me generally and I appreciate the involvement and opinions of you fellow travelers.

Kongo said:

Ira
Hey, Ira. No red flags. Obviously I don't have the "facts" on this issue other than the ones I referred to earlier. I just get very suspicious of one-liner dismissals about the potential impact of things relating to cancer. I don't think we know enough about too many things and in this case there is so much vested interest in continuing biopsies that I doubt we will ever see a costly study to examine it...who would sponsor it? Way too political.

I have recently read that dogs can be trained to sniff urine to determine if there is prostate cancer. Of course, dogs spend most of their lives sniffing urine so maybe they have a good nose for it. I would draw the line on a DRE though...wouldn't want a pit bull going there!

It seems to me that the hardest part about diagnosing cancer without a biopsy is determining the right Gleason equivilent without actually looking at the cell structure and the only way I can imagine doing that with technology today is via biopsy. But I do think some savvy researcher will find a way to do it in our lifetime.

Although given that we do know that cancer spreads via the bloodstream and lymph system and we do know that even a thin biopsy needle pierces these systems while drawing core samples, it makes sense to me that there is a very likely chance that there are some cancer cells that are going to get loose during the process. Studies or no, I will remain suspicious of the procedure and avoid it where I can.

A similar corollary is the amount of vitamins and supplements many men with cancer take without hard studies showing value. There is much we do (or don't do) that can't be absolutely supported by studies.

My viewpoint is generally, less in better.
that there are side effects from everything....so as far as biopsies, I want to have less...less chance of infection, sexual problems, etc., and the same is true for vitamins...some of these vitamins , and also prescribed drugs have unknown negative effects.... ...there are people errors in what ever you do....


Frankly , at this time I also do not have the facts about biopsies spreading cancer, only input from various docs who I respect, who support biopsies and state that biopsies do not spread cancer.............however to be honest , many doctors used to support smoking, so who knows what we will come up with in the future, but for now, I believe that it is advisable to go along with current medical protocol, and not second guess....I for one am not qualified and do not know more that the vast majority of the personnel in the medical profesion, and I beleive that even you who I respect greatly are not qualifed.

I also believe that there will be improved diagnostic tests for PC... not needed for DRE's
.....airport security already does the best job.

dalindg said:

Test results
Our CT scan and Bone Scan came back with no signs of metastases. Now just waiting for 3 month psa follow up. I hope this time it doesn't continue to rise. Doubling time for his last 3 tests has been 14 months, so at least not going fast.

Great News
Darci, Glad to year all the recent tests came back negative. There are some interesting discussion threads in this forum recently about diet and its potential effect on PSA. Many of us have seen our PSA scores decline significantly when dairy is eliminated from our diet. You may want to poke around through past threads and see what folks have to say about it.

Best wishes for continued good news.

Kongo said:

Likely Recurrence
Worriedwife:

Was the doctor who recommended waiting three months your family doctor or a urologist. Most urologists define recurrence in men who have had a RP as >0.2 and rising. Apparently, your husband was at that point last April. The latest PSA of 3.7 is highly significant and without any other information available, I would strongly suspect that this is an indication of recurrence.

More than a third of men who have RP see a recurrence within 10 years and there are several treatments available that have been shown to be highly effective in treating a return of PCa, including hormone treatment, radiation, or a combination of the two. From what I have read, the earlier your husband receives treatment when there is evidence of recurrence the more likely that he will have a positive outcome with very high long term survival rates.

Frankly, I don't understand the strategy of waiting another three months. What is he waiting for, some evidence of definite metastasis?

A CT scan or MRI is unlikely to show anything definite unless the cancer has spread to bones or other organs and created a tumor big enough to be detected by this equipment. Given the rise in PSAs you described, I doubt that this is what has occurred, although if it makes you feel better, I don't see any harm in it.

If this was your family doctor who is making this recommendation, I would make arrangement to consult with a urologist immediately. If it was your urologist who made this recommendation, I would seek a second opinion.

Best of luck to you and your husband.

Urologist
It was his current urologist who he has been seeing the past 6 years. He has been having his PSA checked once a year. The test in April was with the VA doctor and last years PSA with the urologist both were under the 0.02 range.
Then this year with the urologist it came out 3.7 just out of the blue. He made an appt with the VA to double check in December and then depending on what that shows, he still has his 3 month follow up with the urologist. My concern is that his urologist does not seemed concerned at all. His original doctor was a Johnny on the spot doctor. When I asked why waiting, he said it could be a false read from another gland or recurrence, or a totally new cancer. Yes, that made me feel better. I asked what would happen if in 3 months his PSA was at 3.7 or above again. He said they do the ct or mri scan. He does not believe in the hormone therapy and said they would probably just do some radiation and that should bring his numbers down. It just did not seem like a real thought out process.

Thanks for helping with this and for so many to be so supportive of each other.

worriedwife said:

I had same questions
After this past test being 3.7, I had the same question. The urologist explained that when the prostate is removed, there are small parts that remain. There are usually no problems if all the cancer is removed, but, if a very small amount of cancer remains, over the course of years, the PSA can rise and thus the recurrence. My husband had been at 0.02 for 10 years. I still am a bit befuddled. He also said other glands could cause the sudden rise and that is why they wait the 3 months to be sure it just wasn't from another gland out of whack. Either way, my husband and I would do it again. He has been cancer free for 10 years and that is alot of stress relieved. We will work it out again if that is what the results show this year. I was really scared a few weeks ago but just chatting on this site has actually eased a bit of my fears. Keep the faith.

Not sure I understand
Worried Wife:

I'm about confused about what your doctor relayed to you when he explained potential rises in your husband's PSA reading. I certainly agree with his discussion about prostate tissue left behind after an RP. That is always the case after surgery. What I do not understand is his discussion about another gland being "out of whack." I don't know what that means unless he is suggesting that prostate cancer has spread to another place, such as a lymph node or seminal vesicle, liver, lung, or bone but technically those aren't "glands." PSA comes from prostate cells. When a man has a prostate, non cancerous PSA elevations can be caused by a urinary tract infection, BPH, a biopsy, or other inflammation. Short term PSA elevations can come from ejaculation, a DRE examination, a hard stool, or even bicycle riding. Since your husband had his prostate removed more than 10 years ago, there really isn't another potential cause of the PSA elevation except for a return of prostate cancer where these cells (regardless of where they now are in the body) are generating PSA. The only possibility I can imagine that could be an alternate explanation is an error in the PSA reading due to equipment calibration, human error, or some accidental contamination of the blood sample. I would be fascinated to know what other glands he is talking about when he suggested to you that "... other glands could cause the sudden rise..."

I am certainly not trying to scare you or give you gloomy news but I think you and your husband deserve accurate and precise information about what is happening and why and what options you have to deal with it. Doctors should take pains to explain to you what is going on in exact terminology and make sure you understand it. Terms like "out of whack" only make sense if you understand the chemistry and biology of what is going on at the microscopic level. I do hope that your next reading comes back at the very low levels you have experienced for so long but you should also be prepared for what you should do if it comes back and shows another increase.

I was also surprised to see than in antother post on this thread that you indicated that your urologist doesn't believe in hormone therapy and would probably do radiation instead. Radiation is a common treatment for recurring prostate cancer but so is hormone therapy or a combination of both hormone therapy and radiation. Most studies show that there is a much higher long term prognosis with a combination of hormone therapy and radiation than with either treatment used alone.

As with any diagnosis of this serious nature, I would seek a second opinion on your doctor's recommendations.

Best of luck to both of you.

Kongo said:

Upsetting
I know how upsetting this is but if you research the background on recurrence you will see that about a third of the men who have RP experience a rising PSA within 10 years. Many times, if the PSA rise is very slow, no treatment at all is required. If the PSA doubling time is less than 2 years (which your numbers suggest)it may be an indication that the cancer is starting to grow along the margins which is very easily treated. There are several treatment options that provide excellent long term results. Typically treatment includes some form of hormone therapy or radiation treatment or a combination of both.

There could also have been a small amount of prostate material left behind at the time of surgery that could be causing the rise in PSA.

While the tests your local doctor is suggesting are prudent, given the readings you have described I would be astonished if they showed anything but I think what they want to do is rule something out. If the cancer had moved someplace else where it could be detected by those tests, I believe your husband's PSA score would be much, much higher.

As you did before when your husband was first diagnosed, you have to take this one step at a time and make sure you are getting second opinions and doing your homework.

This forum is an excellent place to get good information and many men who post here have dealt with similar circumstances and you will receive a lot of strong support.

Three rising PSA tests
Having distanced myself from cancer for the last 10 years I find myself back on the internet and have come across this site which is very helpful, thank you for all the posts.

I had a RP 9 years ago at age 47. My annual PSA tests remained undetectable until 2008 when it registered .05, then 2009 it jumped to .09 and just last week it has come back as .18. My local GP had now recommended a bone scan and ultrasound. (He first recommended leaving it for 3 months and then getting another PSA test, it was only when I mentioned concern about levels between .1 and .2 that he changed his recommendation, not very reassuring!)

I just contacted my surgeon who has booked me an appointment next week for "seeing for biochemical failure", which I assume means seeing for recurrence of cancer. Do you think that radiation and or hormone therapy is likely, is there any way other than a recurrence, for the PSA to rise like this?

Thank you for your help

Kongo said:

Welcome
Bob,

Welcome to the forum and I'm so sorry that after several years you now find yourself dealing with all the issues again.

Most urologists today classify a biochemical recurrence (BCR) following a RP as 0.2 ng/ml and rising. You seem to be right there even though your latest score is technically less than 0.2. There are some nomograms available on the web where you can plug the date and the PSA value and it automatically calculates the doubling time. The quicker the doubling time the more worrisome the indications.

At the time of your RP there was undoubtedly a small amount of prostate tissue remaining from where the surgeon cut it away. Even though the margins may have seemed clear at the time, there could have been a very small amount of cancer left behind at the microscopic level. Since this is a slow growing cancer it took several years for it to generate enough PSA to be detectable. The other possibility is that the cancer had spread beyond the prostate before it was removed and these prostate cancer colonies at remote sites have now grown large enough to generate a detectable level of PSA. About a third of the men who have had their prostate removed eventually see a recurrence of PSA within 15 years. It seems that you have caught this pretty early on.

Prostate cancer is an inherently metastatic disease which means it will move to other parts of the body via the bloodstream or through the lymphatic system. However it got to where it is today, you now have to deal with it…or not. Older men with a slow growing recurrence may choose not to seek additional treatment. Given your relatively young age with a long life span in front of you I think you would want to seek some treatment.

Typically treatments for recurring prostate cancer include radiation, hormone therapy, or a combination of the two. If they can for sure localize the new tumors there may be some other options but my feeling given your relatively low PSA score is that a bone scan, MRI, and other tests are not likely to pinpoint exactly where the cancer is that is generating the PSA. I don’t think those tests really hurt; I just don’t think they’re going to give your medical team any useful information.

As you probably suspect, additional treatments carry a potential risk of side effects so when your doctors go over your options, make sure you understand the downside risk associated with them. Having said that, most studies show that early treatment of recurring cancer is extremely effective and has a long term prognosis.

There really isn’t any other reason for your rising PSA readings other than a biochemical recurrence. Of course there could have been some trauma to the remaining prostate tissue which caused the PSA to go up but it would most likely be a spike up and then down. Yours has been on an upward trend for a couple of years now. The other scenario is that the last two or three readings were errors…maybe the doctor changed labs or they’re using a different procedure or something. I would ask about it but it seems to me that’s a rather remote possibility.

I think you’re smart to start researching your options now and this is a great place to get advice from men who have experienced exactly what you’re going through now.

Best of luck and keep us informed.

Thank you so much for your
Thank you so much for your reply. I went to the hospital today to get another blood test, even thought I just had one at my local GP's office, this one is at the hospital where had my RP. I fully expect it to be the same reading of .18 or thereabouts. My appointment with the surgeon in next Thursday, I will let you know how I get on and the recommendations. Thank you again for your help.