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Aug 12, 2015 - 1:32 pm
Looking for some advice or comments on the retreatment of prostrate cancer. I had my prostrate removed in July 2014 because it was aggressive. Had the Da Vince removal and everythig came out great with no bladder control problems. Had a PSA test done in Sept. 2014 and the readings showed <0.1. Because of miss communications with the doctor office, I decided to be tested again this July 2015, a year later. The PSA test showed 0.1 and tested 10 days later after a discussion with the doctor to make sure the reading was not in error and it came back 0.1 again. My question is the doctor is recommending that I have radiation done because the PSA has gone up from less than <0.1 to 0.1. Not sure these numbers mean the same thing. I would prefer to wait until I am retested in October 2015 to see where or if it has progressed. Thanks for any input that you provide for helping me to a educated decision. |
Joined: Mar 2015
Welcome to the board.
Surgical failure is defined as having the PSA go to or above 0.02 after RP. That means that the surgery did not remove all of the cancer and what remained has fired back up to try and eat you. 0.1 is more than 0.02 so......
It is my preception - in advanced cases - the current thinking is to hit the cancer hard, then hit it again then hit it again. I got my RP then 2 weeks later started ADT chemo. 3 months after I started chemo I got ~80 Gy of radiation. 2 & 1/2 years later I am coming off the chemo, but blood tests assure me that I still have no T and no PSA. I remain confident in my doctors decisions thus far. A prostate cancer stem cell can live for 3 years. I don't want any left when I am done with this.
Joined: Apr 2009
This article indicates that recurrence is a PSA of 0.2 not .02
http://www.pcf.org/site/c.leJRIROrEpH/b.5837041/k.8FFF/The_Role_of_PSA.htm
PSA as a Marker for Disease Progression
When it comes to assessing disease progression, PSA is widely accepted as an invaluable tool.
PSA is produced by all prostate cells, not just prostate cancer cells. At this point in your journey, your cancer cells have either been removed or effectively killed after being bombarded with radiation. But some cells might have been able to spread outside the treatment areas before they could be removed or killed. These cells at some point begin to multiply and produce enough PSA that it can again become detectable by our lab tests.
Therefore, PSA is not really a marker for disease progression, but a marker for prostate cell activity. Because the two correlate well after initial treatment for local therapy, tracking the rise of PSA in this setting is an important way of understanding how your prostate cancer is progressing.
However, in order to determine whether your PSA is rising, you need to first determine where it is rising from. Often, imaging tests will not be able to determine this when the PSA is at very low levels. Tests such as bone scans, Prostascint scans, and CT/MRI scans in this setting are often negative and thus most decisions on the next therapy (ie radiation or hormonal therapy) are based on probabilities of cure with radiation rather than by seeing the cancer on scans. Prostascint scans in this setting are often not very helpful, given their high false positive and false negative rates, and thus can be misleading.
After prostatectomy, the PSA drops to "undetectable levels," typically given as < 0.05 or < 0.1, depending on the lab. This is effectively 0, but by definition we can never be certain that there isn’t something there that we’re just not picking up. By contrast, because normal healthy prostate tissue isn’t always killed by radiation therapy, the PSA level doesn’t drop to 0 with this treatment. Rather, a different low point is seen in each case, and that low point, or nadir, becomes the benchmark by which to measure a rise in PSA.
Because the starting point is different whether you had surgery or radiation therapy, there are two different definitions for disease recurrence as measured by PSA following initial therapy.
In the post-prostatectomy setting, the most widely accepted definition of a recurrence is a PSA > 0.2 ng/mL that is seen to be rising on at least two separate occasions at least two weeks apart and measured by the same lab. In the post-radiation therapy setting, the most widely accepted definition is a PSA that is seen to be rising from nadir in at least three consecutive tests conducted at least two weeks apart and measured by the same lab. It’s important to always use the same lab for all of your PSA tests because PSA values can fluctuate somewhat from lab to lab.
The reason that we need to look for confirmation from multiple tests following radiation is that the PSA can "bounce" or jump up for a short period after radiation therapy, and will then come back down to its normal level. If we relied only on the one elevated PSA, it’s possible that we will have tested during a bounce phase, and the results will therefore be misleading. This PSA bounce typically occurs between 12 months and 2 years following the end of initial therapy.
If your PSA is rising but doesn’t quite reach these definitions, your doctor might be tempted to start initiating further therapy anyway. Remember that PSA is only one of many factors that help to determine your prognosis after treatment. The original clinical stage of disease, your pre-diagnostic PSA, and your overall health and life expectancy are also key factors in assessing the aggressiveness of your disease, so be prepared to discuss treatment options even if you don’t fit the classical categories for PSA rise after initial therapy.
On the other hand, if your PSA is rising and you do fit the categories defined above, that doesn’t necessarily mean that your situation is dire. What researchers have been finding over the past few years is that universal PSA cut-offs might not be sufficient for truly understanding how prostate cancer grows.
PSA Velocity
Suppose one man underwent intensity-modulated radiation therapy (IMRT), and his PSA nadir was 0.15 ng/mL. Over the course of nine months, it slowly creeps up until it hits 0.45. But his brother, who also underwent IMRT, nadired at 0.32 ng/mL. If after the same progression over the course of nine months his PSA also rose to 0.45, are they now in the same place? Or is there some significance to the fact that one man’s PSA rose much more rapidly than his brother’s?
The rate at which your PSA rises after prostatectomy or radiation therapy can be a very significant factor in determining how aggressive your cancer is, and can therefore be useful in determining how aggressively it might need to be treated.
When looking at PSA velocity in a few hundred men who had undergone either prostatectomy or radiation therapy, researchers found that men whose PSA doubled in under three months had the most aggressive tumors and were more likely to die from their disease, whereas those whose PSA doubled in more than ten months had the least aggressive tumors and were less likely to die from their disease.
If we go back to our two hypothetical cases, although both have a PSA of 0.45 ng/mL, the first one, whose PSA rise represents a doubling within nine months after treatment, would likely be considered for an aggressive therapeutic regimen. And the second case with the smaller rise in PSA? He might be watched closely to see how rapidly his PSA rises, and to determine when it might be time to intervene.
However, PSA doubling time or velocity does not always remain the same over time. So even if you have a very slowly rising PSA now, continued monitoring with your doctor is important. Also, if you’ve consistently kept to a very low PSA rate after treatment, any rise will likely be seen as a signal that the tumor might be starting to grow again.
Measuring and using PSA velocity is an art, not a science. There’s no magic number of times that your PSA has to be tested in order to determine the rate of rise, although most researchers would agree that more frequent tests over longer periods of time will likely give a better sense of how your tumor is growing.
Ultimately, PSA is only one of many factors that can influence the decision to pursue additional treatments. You and your doctors will need to weigh all of the different factors before deciding on the course that’s right for you.
What to Consider When Your PSA Is Rising After Initial Treatment
Below is a list of questions to ask when your PSA is rising after initial treatment.
The list below of important issues is by no means exhaustive, and there might be other points that you want to think about as well. The goal is to help you focus on what you need to know about each stage of disease so you can hold meaningful, regular dialogues with all members of your health care team as you find the treatment path that’s right for you.
Joined: Nov 2010
Ultrasensitive PSA assays for RP patients
My opinion is that both results mean the same. The value of (<0.1) expressed at the doctor’s laboratory could be the same value of (0.1) expressed by the laboratory you used. Still in some laboratories instead of a value they use the expression of “Undetectable” meaning that the value is lower than the threshold recommended at their facilities for RP patients.
Moreover, some assays read only up to one decimal digit (0.X ng/ml) which could be any value between 0.01 and 0.09. In both, <0.1 and 0.1, the result are just rounded up. This confusion can easily be addressed if one uses ultrasensitive PSA assays of two decimal digits (0.XX ng/ml), which type I recommend you.
Nevertheless, I am surprised with your doctor apprehension for you to have the PSA tested at an earlier date. Most probably he had already scheduled you for radiation independently of the PSA results. You could be in remission and cured but he plans to radiate you for whatever reason or agreement it may exist between both of you.
He doesn’t want to be contested. This is the type of doctor you should avoid at first instance.
I do not know details of your diagnosis and age or if you are confronted with an aggressive case, but after prostatectomy (RP) the PSA becomes the most important marker to judge cancer progression or remission. The PSA therefore should be tested only at reliable laboratories and timely. Typically the first PSA after RP is done at the three weeks pos op and it is followed periodically every two to three months during the first year, and later every six months to one year. Assays used for these tests should be ultrasensitive types because, without the gland, one is confronted with low serum values.
Remission levels varies by doctors and institutions but none use higher values than 0.06 ng/ml. Recurrence is typically attributed to cases where the PSA has never reached a remission value or it has increased reaching a value of PSA=0.20 ng/ml. This is the threshold used by most of the urological associations around the world.
Please read these;
http://www.pcf.org/site/c.leJRIROrEpH/b.5837041/k.8FFF/The_Role_of_PSA.htm
http://www.ncbi.nlm.nih.gov/pubmed/12597949
I absolutely agree that you should have the tests before any commitment. Radiation is not a walk in the park. It got its risks and side effects that you should be aware of. You should only get involved in the treatment when you are confident and feel comfortable with the decision.
Best wishes and luck in your journey.
VGama
Joined: Mar 2015
Yeah, I mistyped, apologies...
...threshold should have been 0.2. My bad, thanks for the correction Vasco.