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

sabhen
Posts: 12
Joined: Jun 2018

I went through RP (DaVinci robotic surgery) in October 2014.  I was diagnosed with PC after biopsy results.  at the time (Sept 2014):  PSA= 5.2, positive biospsy cores: 3, T grade: T1c, Gleason score: 3+4 /3+3.

PSA has remained <0.1 since the surgery.  Update added the following PSA history.

  • 4/28/16
  • <0.1
  • 4/28/17
  • 0.1
  • 6/20/18
  • 0.2

I asked my family doctor to get the results reviewed by a specialist.

Is this a case of biochemical recurrence?

Any thoughts?

Thanks.

 

sh

 

 

VascodaGama's picture
VascodaGama
Posts: 3041
Joined: Nov 2010

Sab,

The term "biochemical recurrence" is given when the PSA increases from a nadir, but it could signify "cancer recurrence" if such increase is verified as a continuous occurrence.

If all previous PSA tests were done with the same type of assay (at the same laboratory), your nadir was PSA <0.1 ng/ml. Labs typically indicate the value with a "<" (lower than) mark representing the lower limit od detection of used assay. The "<0.1" could be a true value between 0.01 to 0.1. In such regard, the last year's PSA of 0.1 (Jul 2017) was the first rise indicating biochemical failure and this has been confirmed with the last test of PSA=0.2 ng/ml.

The AUA -Urological Association guide lines considers the PSA threshold of 0.2 as "Recurrence" (of cancer) and recommends salvage therapies to be done/started when the PSA reaches the level of 0.4 ng/ml. Surely one could think that recurrence as been already verified when the PSA continuously increases, even at lower levels than the 0.4 threshold. However, these are tiny PSA values that can easily be errors, therefore using the AUA guidelines may be the best choice. I wonder what your doctor has told you. I believe he is following the AUA guidelines.

Can you tell us what is written in the pathological report after surgery? What was the pathological stage? Were there any positive margin? How about the lymph nodes involvement?

The increase from 0.1 to 0.2 in eleven months has a PSADT approximately 10 months. Recurrences with PSADT lower than 6 months are grouped in worse cases. PSADT above 24 months have better prognosis. I think that you should repeat the PSA in three month time using a two decimal digits (0.XX ng/ml) assay (proper for guys without the gland in place) and if found increasing then get second opinions from an urologist plus a radiologist and start your due exams and test required for a salvage treatment, if any. Do not rush but get informed on options just as precaution.

Let us know details of your initial diagnosis before Sep 2014. What is your age?

Welcome to the board. Best wishes.

VGama

sabhen
Posts: 12
Joined: Jun 2018

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.

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3323
Joined: May 2012

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

hewhositsoncushions
Posts: 279
Joined: Mar 2017

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 :(

Old Salt
Posts: 720
Joined: Aug 2014

Lab errors do occur. Ask for a 'regular' PSA test and an 'ultrasensitive' one. 

PS: In the absence of, what I consider, good/reliable data, it's too early (IMHO) to conclude 'biochemical recurrence'.

Hoping it won't be, of course.

sabhen
Posts: 12
Joined: Jun 2018

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

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
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Joined: May 2012

You are very welcome.

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

VascodaGama's picture
VascodaGama
Posts: 3041
Joined: Nov 2010

Your pathological stage of pT2c is worse than the clinical stage T1c (based on the biopsy results, DRE and image studies), but it also judges a confined disease and negative lymph nodes N0 (13 numbers inspected). The next PSA will be significative because of its present level out of remission. Probably your doctor will recommend you radiotherapy (IMRT) delivered to the prostatic bed and surrounding areas, and some lymph nodes at deep places. In any case, I do recommend you to get consultations with a radiologist experienced in treating prostate cancer recurrences only once the PSA confirms such status.

Best of lucks,

VG

 

sabhen
Posts: 12
Joined: Jun 2018

Thanks VG. I updated the PSA history from the hospital records at the top of this thread.  I set-up a follow consultation with an urologist and requested an ultrasenstive test prior to the consultation. 

Any recommended list of questions to ask at this consultation? 

Thanks

VascodaGama's picture
VascodaGama
Posts: 3041
Joined: Nov 2010

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

sabhen
Posts: 12
Joined: Jun 2018

The Urologist has told my family doctor that he does not recommend ultra sensitive PSA test (2 decimal points) for people who have already gone through RP.  I was surprised by this position.  

Is this standard practice?

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
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Joined: May 2012

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.

Old Salt
Posts: 720
Joined: Aug 2014

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.

VascodaGama's picture
VascodaGama
Posts: 3041
Joined: Nov 2010

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

sabhen
Posts: 12
Joined: Jun 2018

I had the consultation with urologist.  He provided a couple of options: wait a bit or go ahead with salvage therapy with radiation. He said he would not recommend hormonal therapy.  I am having anothe PSA test and I am seeking a second opinion.   I also discussed with some folks and they suggested to do a PSMA to pinppoint location of cancer.  Any thoughts on this technique?

Old Salt
Posts: 720
Joined: Aug 2014

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. 

VascodaGama's picture
VascodaGama
Posts: 3041
Joined: Nov 2010

I agree with Old Salt. The PSA at 0.2 ng/ml is too low to reliably detect cancer using present image exams. The 68Ga PSMA PET scan is the most recommended but PSA lower than 0.5 is often linked with false negatives. The break point is 0.4/0.5 ng/ml. These thresholds were obtained by experience and are reported as averages numbers so that some cases were detected at low levels of 0.2 but so there were negative detections at higher levels of PSA=1.0 ng/ml.
It seems that some cancerous cells do not absorb/metabolize well the G68 which causes the limits in the efficacy of this great image exam in PCa screening (for me the best at present times but there are others in investigation).
I believe that you are not interested in getting a negative image. You want a positive detection that will provide the data for the best planning of the RT. I would recommend you to get the opinion from physicians at the clinics doing this test.

A note on your urologist's opinion regarding HT (hormonal treatment); I think that his negation on the combo (HT+RT) as a salvage therapy is again a divergence on the approaches followed by the big medical groups: the JH and the MSKCC. JH is famous for its low preferences in treating with hormonal manipulations. The combo is known to improve outcomes in terms of longer biochemical free failures. In any case, nothing is wrong in having RT alone and start HT if and when recurrence is verified again (sequential approach). The PSA will be the marker to judge successes and this should be unmasked from any HT effects. One knows the results of the RT earlier.

Please reread my lay advice in regards to the preparedness items.

Best.

VG

sabhen
Posts: 12
Joined: Jun 2018

The URO did not provide a good rationale for why he thought RT without HT should be adequate. He even said I could still wait a bit before deciding. I do not want to dally. I am having a second opinion.

I will have a consultation with the RO within the next few days. 

I checked one of the calculator on the MSKCC. With my data, the success of non-recurrence after 6 years jumped from 64% (RT) to 81% (RT+HT). Not sure how much reliability can one put on these on-line calculators.

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3323
Joined: May 2012

I've been away a bit, sabhen. Share what the second R.O. tells you.

The most important thing is to begin the R.T.  Whether to add or not add the H.T. is something only experts can advise on, and a secondary consideration. I do know that at times HT will mask or obscure the effectiveness of the RT.   If anyone above mentioned that, my apologizies, since I do not have time to read every post, even on threads that I rerspond to.

I do agree with what Old Salt wrote regarding scanning. Disease as minor as yours most likely would never be detected on any form of scanning available today in medicine.

max

sabhen
Posts: 12
Joined: Jun 2018

update 

PSA = 0.2 (07/13/18)   - was 0.2 (6/20/18)

Had a consultation with RO today (7/25/18).  RO surprised that I had a recurrence given negative margin, no cancer in nodes, cancer contained in prostate gland etc... say it happens to 9% of the patients. 

unlike URO (who ecommends RT only), RO recommends combined approach (RT and HT) to maximize cure before PSA hits 0.5.   Protocol: 2 Lupron injections (3 months apart) and concurrently RT (7.5 weeks). 

I was worried about short and specially long term side effects.  The big question is wait a bit say 2-3 months to check PSA or dive into treatment next couple of weeks. 

 

Appreciate your comments. 

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
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Joined: May 2012

Sabhen,

It is interesting that the R.O. said that metastasis occures in 9% of cases post-RP, when there was NO EVIDENCE of escape from the gland in the post-surgical reporting.

I was speaking to my own surgeon about 1.5 years after my own RP, and asked about potential for relapse. He said that there was a 90% or better liklihood that I would never see PCa again.    Because I have not seen much data on such cases, I appreciate the R.O.'s comments.

max

VascodaGama's picture
VascodaGama
Posts: 3041
Joined: Nov 2010

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

hewhositsoncushions
Posts: 279
Joined: Mar 2017

Sabhan

I am in exactly the same boat (PSA 4, G7/4+3, T2c N0 M0 G7) with BCR just under a year with sadly a failr quick PSADT so I am probably (far?) worse off than you.

It is really annoying, isn't it.

My onco was clear that it was BCR (would not give prognosis) and stuck me on HT and am due RT.

I would not hold off too long as 0.2 appears to be a threshold number - that being said your PSADT is slower than mine so maybe shorter intervales between tests to determine status to derisk?

Good luck,

C

sabhen
Posts: 12
Joined: Jun 2018

Thanks for the feedback.  I had my testosterone measured (around 600) within "normal range.  I  am having a second opinion with another URO in early august. Then I will make my decision. 

sabhen
Posts: 12
Joined: Jun 2018

I got my  first shot this week to be followed by another one in 3-months.  After one day. it looks as a non-event.  It seems it takes a couple of week before the impact becomes noticeable. Plan to start RT around mid-august for a duration of about 8 weeks.    

 

Cushions,

Good luck to you as well.   

 

Sab

sabhen
Posts: 12
Joined: Jun 2018

Got my first PSA test after 1 month on Lupron.  PSA  <0.1 ng/ml.  Next week, I need to make a decision whether to go with salvage radiation or put it on hold.  I asked my Uro for his opinion. 

VascodaGama's picture
VascodaGama
Posts: 3041
Joined: Nov 2010

Sab,

This last PSA result signifies that your cancer is hormone dependent. Lupron has driven your circulating testosterone into castration levels (< 25 ng/dL) depriving the bandit from having it so that the bugger gone into submission. ADT works by turning the cancer indolent but the bandit never dies. It continues living using other means for survival such as feeding on the androgens from the adrenal gland (approximately 5% of total in circulation) or even from low levels of the powerful dihydrotestosterone which is refined from the low volume of any androgen still in circulation. Surely a fewer number of low aggressive cells die in the process.One should note that our body needs androgens to function so that we cannot eliminate them (or the sources producing it) all for good.

ADT is palliative. Radiation (RT) in the combo is the killing weapon. This is the blow we all aspire to occur from a treatment. Delaying RT can be done but in this battle of palliative weaponry the bandit becomes the winner for giving it the opportunity to adapt to the newer environment of low testosterone. These buggers manage to modify their androgen receptors and in time cause refractory by starting to produce androgens by themselves. This is human's natural means of adaptation and survival as explained in Darwin's theory. Our cells, benign and cancerous, got the switches require to survive if given a chance.

I know of guys that did ADT as solo prime treatment controlling the advancement of the cancer for over ten years. I myself am in IADT (intermittent approach) since 2010 after failed SRT. However each case is different and nobody knows how things turn out if not by experience.

Statistics say that salvage radiation in RP recurrences work better at unmasked PSA levels not much higher than 0.4 ng/ml. But the best results can only be expected from cases where the radiation planned field includes the whole cancer, which assurances at present days with available tools seems to be an impossible mission. SRT is typically done on guessing based on past experiences (higher number of successful cases). One needs luck in the process.

I have followed similar steps to yours at RP recurrence in 2001. Salvage radiation was also at the time the recommended standard but there were no fixed PSA thresholds set to trigger treatment. Radiating in the dark was not in my mind at all and therapies based on assumptions did not satisfy me. I researched and did all I could to locate the hidden bandit. ProstaScint and PET were the best options but these in those days used isotopes not totally specific to detect PCa. A famous oncologist recommended me for WW (AS in those times) allowing time for the cancer to develop further and become bigger to try detection in a scan. I did all sorts of exams every year till 2006 without a successful detection. The results were all false negatives to the exception of the PSA that grow from 0.42 to 3.60 along the 5 years. Salvage radiation was also done solo (ADT was not yet recommended in combies). Recurrence was diagnosed again in 2010 when I started the present IADT.

I had the ball in my hands back in 2001. You got it now. Time to roll it in your favor.

Best,

VGama

sabhen
Posts: 12
Joined: Jun 2018

Thanks, VGama for sharing your personal experience. My goal is to aim for a cure. A combo looks like the best option after BCR. By the way, I did not experience any significant side effects from Lupron as I was expecting. My health insurance is up for renewal in October.  I can upgrade to a different plan that has a lower cost deductible.  I want to have SRT started about mid-October after the new plan. I will consider that still not too late...

Sab

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