Reconciling theory with observation

It is not a study, but simply my observation that there are many men who have untypical stats, latest one camerabug6´s husband, with PSA 5 and cancer in lymph nodes, which is considered systemic. There are a few posters here, who have bone mets with PSA < 10. There are many more posters who had a radical prostatectomy with PSA < 10, yet their PSA continued to climb after the surgery.

Books on PC, guidelines, nomograms, etc. express strong views/links that PC with PSA<10 is a localized disease, and term those that are not as "rare variants", but my observation has been, to a large degree, quite the opposite.

It seems common that a guy with PSA 7 can have lymph node and bone mets (my Dad one of them). It makes my faith in PSA a bit more shaky. If I were a man on AS, I would certainly use means other than PSA to make sure that the cancer is localized. Interested in how many guys here had further problems with PSA less than 10 before local therapy. Not that it solves any problems, just exchanging thoughts. And Happy New Year to all of you out there, the true heros!

---

Father (69 now) diagnosed with PCs in Jan 2011:
DRE positive, PSA 7.5, biopsy Gleason 6, second expert opinion: Gleason 7 and 8.
two inconclusive bone-scintigraphies, MR scan showed 2 bone mets
Feb 2011: Started hormonal therapy (Trelstar+Casodex) in Jan 2011
Jan 2012: Added Zometa
Mar 2012: went "off" hormonal therapy after PSA reached 0.055

yes the PSA test has it's problems and should really be viewed an indicator of what is going on - not an absolute measurement. I view it this way: Falling PSA good, rising PSA bad.

---

I'll be in the shop.
Age 52
PSA 4.2 10/11, 1.9 6/12, 1.2 12/12
GS 3+4
Stage T1C
2 out of 14 cores positive
Treatment IGRT - 2/2012
My PC blog

SpecialLady,
Poorly differentiated prostate cancer produce less PSA per tumor volume than well differentiated PCa. Localized treatment failure is common because of the uncertainty that exists at diagnosis. A biopsy result is representative of the sample but not necessarily of the cancer present in the prostate gland. Occult prostate cancer can progress from a larger majority of androgen dependent cancer cells to one of androgen independent cells.

When the ratio of androgen independent cells to the androgen dependent cells in the tumor load increases, the cancer becomes resistant and is able to progress using various growth sources other than androgen. PSA level is not representative depending of the degree of dedifferentiation present in the tumor volume. Other markers, like PAP, AlkP, CGA and NSE are available to support PSA monitoring.

How to explain what happen to men who are diagnosed with very advanced disease before the disease is detected? Their response to androgen deprivation is usually poor or not existent. In other words, in such cases through a process of dedifferentiation the cancer, before being detected or any treatment applied(including androgen deprivation), has mutated causing chromosomal gains or depletions that makes it very difficult to treat with our current forms of treatment. Hence, until the present, the high disease mortality in these men. New hormonal treatments have shown that what was considered androgen independence can be still treated with some survival benefits.

The rare variant forms of prostate cancer constitute a very small component of PCa diagnosed these days. The most common variant forms: Signet ring cell, Mucinous, Ductal or Intraductal, Squamous cell and Neuroendocrine. These constitute 1.6% of all the PCa diagnosed while plain old adenocarcinoma of the prostate makes the great majority of cases. Yes, these variants are rare and have a higher mortality rate than the common form of the disease.

Source: http://www.medscape.com/viewarticle/769835

D M Marcus et al. A Comprehensive Review of Incidence and Survival in Patients With Rare Histological Variants of Prostate Cancer in the United States From 1973 to 2008
Prostate Cancer Prostatic Dis. 2012;15(3):283-288.

RalphV

---

Phoenix, Arizona
The views or opinions expressed here are my own and are not endorsed nor supported by any agency or institution. Ask your physician for medical advice.
DX at age 58 in 1992. RP; Orchiectomy; GS (4 + 2); bilateral seminal vesicle invasion; tumor attached to rectal wall; Stage T4; Last PSA Dec, 2012: <0.1 www.pcainaz.org

SpecialLady -

You are absolutely right when you suggest that PSA alone should not be used as any kind of single, definitive guide to treatment, or anything else. Too many variables.

I am one more case in point. When my prostate troubles began last year (as per my signature below), my uro told me following his first exam of me that my prostate, sized at 156 grams (!), was "...one of the top 5 or 6 biggest I have ever seen," as he put it. He said that my PSA test results at that time, which were running 13-something and 14-something, were driven much more by my enlarged prostate size than by any PCa I might be having. It turned out that I did indeed have a case of PCa, as determined by a later biopsy, but he said the PSA numbers in my case were so badly skewed by my prostate size that they were unreliable as indicators of the PCa I had.

Clearly, PSA is only one tool in the toolbox, and must be used along with other measures to determine an accurate diagnosis and treatment plan.

Having said that, though, let's give credit where credit is due. The presence and use of the PSA test result in PCa diagnosis and treatment decisions over, what is it, the past 30 years or so, has been a tool of MAJOR significance in the fight against PCa.

Stop and imagine for a moment just where we would all be if the PSA test, with all of its warts, wasn't available to us. Think of all the posts here on the list over the years in which the term "PSA" appears, and what if all those posts just suddenly vanished. It's not a perfect tool by any means, but I know we'd all rather have it than not have it.

Think of it another way. Think of all the other cancers there are out there that do not have the kind of early warning detection system like the PSA that we have. If those cancers had something like the PSA, what an improvement it would be for all of them.

So I agree with you that a person's PSA score has to be interpreted properly, and in context, but on the whole let's remember that we are lucky to have it available to us, warts and all.

---

Age: 66
Chronic prostatitis (age 60 on)
BPH w/ urinary obstruction, 6/2011
TURP, 7/2011
Ongoing high PSA, 7/2011-12/2011
Biopsy, 12/2011: positive 3/12 (90%, 70%, 5%)
Gleason 6, T1c
No mets, PCa likely still contained
IMRT w/ HT (Lupron), 4/2012-6/2012
PSA (8/3/2012): 0.1
PSA (12/7/2012): 0.1

It's easy to find fault with the PSA test.  We all know it's less than perfect.  I can honestly say, though, that the PSA test was THE FACTOR that led my family physician to recommend I see a urologist, which led to the detection of a nodule, which led to a biospy, which led to.........where I am now, as opposed to where I would have been without the PSA test.

SpecialLady,

Odds of anyone who comes and stays here being "typical" is very small.

words like "normal" and "typical" don't mean much, when one is in the exceptions of the rule, for sure.

you make a good point. just like there are a handful of us here - with failed surgery/radiation with rising PSA'a >30, with no indications of mets or physical problems.

sometimes, the PSA, to me, is just a reference point, not a true indicator of what is actually going on with one's cancer itself. just another tool, but only a tool

david

---

Age: 60, 56 at PC dx, PSA 16.3
3rd Biopsy: 9/8 7 of 7 Positive, 40-90%, 4+3
open RP: 11/8, Catheter in 63 days
Path Rpt: 3+4, pT2c, 42g, 20% tumor, 1 pos margin
Incont & ED: None
Surgery Failed, recurrence within 9 months
Salvage Radiation 10/9-11/9, SRT failed within 9 months, PSA 4/12 = 37.x
Spent total of 1 ½ years on 21 catheters, Ileal Conduit Surgery 9/10,
7 other PC-related surgeries
Member of Prostate Cancer & Chronic Pain HW Communities since 10/2008
“I live in the weak and the wounded” – Session Nine (Movie)

Special Lady,

I am probably the best example on this site for having a low PSA and mets (.09). Given that, it is still used as a marker, but with several grains of salt. Other markers are used in conjunction with PSA to monitor moving forward.

Before RP it was 4 at age 44. .75 at age 40. The more I type this the more I get upset. Because I fell into the trap of listening to the media, etc. that said that PSA testing causes more harm than good. I also believed someone that said to check back at 45 since I established a baseline. What a load of crap.

I' m generally over my anger and deal with the cards I' 've been dealt the best I know how.

PSA not perfect, true. But, it is valuable to most PC guys in varying degrees, even me.

Sorry for the little rant there.

Jerry L.

---

11/09 Dx at Age 44 ----------- 4.03
12/09 DaVinci Surgery
1/10 T3b, G9 ------------------ <.05
2/10 Adj. Radiation ----------- <.05
3/11 PSA Rise/Scans/Spot ---- .09
on Pelvic Bone
4/11 HT / XGEVA --------------- .06
5/11 Spot Radiation ----------- <.05
12/11 - 12/12 ------------ <.01
On IET (Intermittent Everything Therapy)

Be part of something good; Leave something good behind.

---

AGE 72
BIOPSY AND TEST DONE AT MAYO, ROCHESTER, MN
STAGE T1C
GLEASON 3 + 3 in 5% of 1 core out of 13 biopsied
PSA 164
BONE AND CT SCANS NEGATIVE
CYSTOSCOPY NEGATIVE
ACTIVE SURVEILLANE

Special Lady....As has been said PSA is not a determinant, but can be a very good indicator, particularly as it changes.    However there are the variants, usually very aggressive, that don't express PSA.   A friend passed away a year ago after a seven year PCa fight during which absolutely everything was thrown at him.  Finally, the small cell cancer in the lungs prevailed....his PSA was never as high as 10.   My brother's brother-in-law has been treated for ten years with surgery, SRT, and two periods on HT....he was PSA 1 and G9 at diagnosis and has been consistently below PSA 1 for ten years, but is fighting an aggressive strain.