Low PSA, high % free PSA, Large Tumor

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reinhartdm
Regular Member


Date Joined Feb 2005
Total Posts : 20
   Posted 4/20/2009 1:54 PM (GMT -6)   
My case appears most unusual, so I am looking for others who may have similar characteristics. 
 
I am 64 with family history of prostate cancer.  I religiously had yearly PSA testing and DRE by a top Washington urologist.  Over the last 14 years, my PSA has slowly bounced up from 1.0 ng to 1.6 ng (about 28 months ago), then down to 1.3 ng (16 months ago), and then to 2.1 ng (3 months ago).  After antibiotics, PSA increaed to 2.6 ng (free PSA was at 26% and PSAD = .05).  My urologist said he didn't think I had cancer.  
I SAID DO A BIOPSY!  PSA velocity trumps everything.
 
A 15 core biopsy (47cc prostate) revealed 7 positive cores (80%, 60%, 60%, 50%, 40%, 5%, 2%); all rated Gleason 6, and three cores with evidence of perineural invasion (5 weeks ago).  The tumor appears to occupy over half the left side of prostate, and 2% of one core from right side.
 
I am currently queued for Da Vinci robotic RP at NCI (guided by e-coil MRI imagining), but the wait is still over two months, and that is frustrating.  Does anybody else know of such an extensive tumor with such a low PSA and high free PSA %?  Is my tumor fast growing or did it just not produce much PSA for a long time?
 
Dan  (4/20/09)
 
 
 

LV-TX
Veteran Member


Date Joined Jul 2008
Total Posts : 966
   Posted 4/20/2009 2:58 PM (GMT -6)   
Welcome to HealingWell reinhartdm...sorry you had to be here. I don't have a specific answer to give you to your question. The gleason 6 would make this a moderately aggressive cancer and the rise in PSA would be about right (I think) with the size of prostate you have.

I know that it is impossible to make you not worry, but the wait for a couple of months is normal anyway after a biopsy. The prostate is inflammed right now and needs to cool down before surgery. So in the mean time, keep reading and researching about the type of treatment you have chosen. I do hope that you also considered other treatment options...if not while waiting look at the other treatments. Surgery isn't the only option available to you with your stats.

Again...welcome to this forum
You are beating back cancer, so hold your head up with dignity
 
Les
 
Age 58 at Diagnosis
Oct 2006 - PSA 2.6 - DRE Normal
May 2008 - PSA 4.6 - DRE Normal / TRUS normal
July 2008 - Biopsy 4 of 12 Positive 5 - 30% Involved Bilateral - Gleason (3+3)6 Stage T1C
Robotic Surgery Sept 18, 2008
Pathology October 1, 2008 - Gleason 7 (3+4) Staged pT2c NO MX - Gland 50 cc
Seminal Vesicles and Lymph Nodes clear
Positive Margins Right Posterior Lobe
PSA 5 week Oct 2008 <.05
                   3 month Jan 2009 .06
                   6 month April 2009 .06


cvc
Regular Member


Date Joined Jun 2008
Total Posts : 440
   Posted 4/20/2009 3:01 PM (GMT -6)   

This is the kind of stuff that scares the jeepers outa me. My PSA is 1 and I am 50 yrs old with enlarged prostate. My URO said "dont worry with a gland as big as yours im surprised your psa isnt higher"

 

 So... I try not to worry then I see this.. My psa was .55 6 yrs ago. It seems as though its heading the wrong way.  Keep us posted on how you make out . I wish you good luck and I bet you will come out fine !

 

Cvc


will be 50 years old this year ( 2009 )
 
Uro said enlarged prostate 
 
DRE Negitive
 
Psa  2003- .55
 
     2007 - .99
 
     2008 -  1.01
 
watchfull worrier , lol


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4226
   Posted 4/20/2009 3:21 PM (GMT -6)   
Dan,
Those stats sound unusual and don't corrolate. Any time something doesn't make sense it's prudent to dig deeper. There are some tools on the Prostate Cancer Research Institute's web site in which you can calculate PSA and tumor volume. They may be worth looking at.
Just to be on the safe side I would contact Dr Stephen Strum in Ashland Ore., Charles Meyers in VA or Mark Sholtz in Marina Del Rey. They may be able to give you some insight with a phone call.
JohnT

64 years old.

I had an initial PSA test in 1999 of 4.4. PSA increased every 6 months reaching 40 in 5-08. PSA free ranged from 16% to 10%. Over this time period I had a total of 13 biopsies and an endorectal MRIS all negative and have seen doctors at Long Beach, UCLA, UCSF and UCI. DX has always been BPH and continue to get biopsies every year.

In 10-08 I had a 25 core biopsy that showed 2 cores positive, gleason 6 at less than 5%. Surgery was recommended and I was in the process of interviewing surgeons when my wife's oncologist recommended I get a 2nd opinion from a prostate oncologist.

I saw Dr Sholtz, in Marina Del Rey, and he said that the path reports indicated no tumor, but indolant cancer clusters that didn't need any treatment. He was concerned that my PSA history indicated that I had a large amount of PC somewhere that had yet to be uncovered and put me through several more tests.

A color doppler targeted biopsy in 11-08 found a large tumor in the transition zone, gleason 6 and 7. Because of my high PSA Dr. suspected lymph node involvement, 30% chance, and sent me to Holland for a Combidex MRI, even though bone and CT scans were clear.

Combidex MRI showed clear lymph nodes and a 2,5 cm tumor in the anterior. I was his 1st patient to come up clear on the Combidex which has a 96% accuracy,

I've been on a no meat and dairy diet since 12-08 and PSA reduce to 30 while I awaited the Combidex MRI.

The location of the tumor in the anterior apex next to the urethea makes a good surgical margin very unlikely. Currently on Casodex and Proscar for 8 weeks to shrink my 60 mm prostate. Treatment will be seeds followed by 5 weeks of IMRT while continuing on Casodex and Proscar. So far no side affects from the Casodex.

As of April 10 and 7 weeks on Casodex and Proscar PSA has gone from 30 to 0.62 and protate from 60mm to 32mm. Very minor side affects. Doc says all this indicates tumor is not aggessive

Awaiting schedule for seed impants

 


Ed C. (Old67)
Veteran Member


Date Joined Jan 2009
Total Posts : 2458
   Posted 4/20/2009 4:29 PM (GMT -6)   
Dan,
As you can see from my stats below, My PSA was under 4 yet I was diagnosed with aggressive PC. I think you are correct about PSA velocity which is whet triggered my biopsy and consequent Dx.
Age: 67
PSA 9/05 1.15; 8/06 1.45; 12/07 2.41; 8/08 3.9; 11/08 3.5 free PSA 11%
Dx 12/30/08
2 cores out of 12 were positive Gleason (4+4) and (4+5)
Negative CT scan and bone scan done on 1/16
Robotic surgery performed 2/9/09
Surgeon: Dr. Randy Fagin, Austin TX.
Pathology report:
Prostate weighed 57 grams size:5.2 x 5.0 x 4.9 cm
Bilateral 10-20% involved
Gleason 4+4
both nerve bundles removed,
pT3a Nx Mx
Negative margins
seminal vesicles clean
Lymph nodes: not dissected
1st PSA test 4/7/09 result <0.1


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4226
   Posted 4/21/2009 6:16 PM (GMT -6)   
Dan,
I just read paper by Dr Stephen Strum that goes through all the calculations in determining tumor volume using psa, gleason ect. If you go on the Prostate Cancer Research Institutes web site and search for the article by Strum.

64 years old.

I had an initial PSA test in 1999 of 4.4. PSA increased every 6 months reaching 40 in 5-08. PSA free ranged from 16% to 10%. Over this time period I had a total of 13 biopsies and an endorectal MRIS all negative and have seen doctors at Long Beach, UCLA, UCSF and UCI. DX has always been BPH and continue to get biopsies every year.

In 10-08 I had a 25 core biopsy that showed 2 cores positive, gleason 6 at less than 5%. Surgery was recommended and I was in the process of interviewing surgeons when my wife's oncologist recommended I get a 2nd opinion from a prostate oncologist.

I saw Dr Sholtz, in Marina Del Rey, and he said that the path reports indicated no tumor, but indolant cancer clusters that didn't need any treatment. He was concerned that my PSA history indicated that I had a large amount of PC somewhere that had yet to be uncovered and put me through several more tests.

A color doppler targeted biopsy in 11-08 found a large tumor in the transition zone, gleason 6 and 7. Because of my high PSA Dr. suspected lymph node involvement, 30% chance, and sent me to Holland for a Combidex MRI, even though bone and CT scans were clear.

Combidex MRI showed clear lymph nodes and a 2,5 cm tumor in the anterior. I was his 1st patient to come up clear on the Combidex which has a 96% accuracy,

I've been on a no meat and dairy diet since 12-08 and PSA reduce to 30 while I awaited the Combidex MRI.

The location of the tumor in the anterior apex next to the urethea makes a good surgical margin very unlikely. Currently on Casodex and Proscar for 8 weeks to shrink my 60 mm prostate. Treatment will be seeds followed by 5 weeks of IMRT while continuing on Casodex and Proscar. So far no side affects from the Casodex.

As of April 10 and 7 weeks on Casodex and Proscar PSA has gone from 30 to 0.62 and protate from 60mm to 32mm. Very minor side affects. Doc says all this indicates tumor is not aggessive

Awaiting schedule for seed impants

 


Pelahatchie
Regular Member


Date Joined Jul 2007
Total Posts : 86
   Posted 4/22/2009 7:38 AM (GMT -6)   
My dad had a low PSA all his life and all of his brothers have had prostate cancer and none have died from it with all going past the 80 year mark, my father will turn 80 in July.  After I was diagnosed my dad insisted on a biopsy and it was confirmed that his entire prostate was full of cancer and that it probably had escaped.  He was a gleason 7 3+4, this was three years ago.  He underwent external beam, hormones, and seeds and is undetectable today. 
 
My PSA score was low as well but my tumor was also pretty small, hopefully low psa means less aggressive but I don't know if there is any evidence to support that, good luck.
Age 45 at DX
 
DX 8/05 Gleason 5, Mayo clinic Second Opinion Gleason 6, PSA 2.8
 
Da Vinci surgery Dr. Dasari, Centennial Nashville 9/24/05
 
Pathology Report Gleason 6, 15 % on left side only very near to the edge of capsule, too close to call on margins, doc's said to watch it very closely, final decision T2A
 
PSA's have basically ranged from <.04 to .05 for two years.
 
no E.D. and no Incontinence, feel very blessed
 
PSA Nov 07 = .06
 
PSA Dec 10th 07 =.07
 
PSA Jan 4th 2008= .1
 
Started Guided IMRT on January 7th, 2008 to treat prostate bed and lymph nodes, completed on March 6th, 2008
 
PSA April 18th 2008 =.03
 
PSA August 18th 2008 = .01 or less, test only goes down to .01


Shad
New Member


Date Joined Apr 2009
Total Posts : 5
   Posted 4/22/2009 9:00 AM (GMT -6)   

reinhartdm,  You are not alone. My highest PSA was 3.0.  At dx (age 65) I had all the prostate involved.  I had cancer in the seminal vessels and positive margins.  My gleason was 9.

After surgery, radiation and hormones my PSA began to rise at 18 months and is doubling at 2.5 months.  And I have no family history of prostate cancer. 

In short, most people with low PSA do not have cancer.  But I am proof that it is possible to have a very aggressive version with a relatively low PSA.  

Good luck to you.

mjluke
Regular Member


Date Joined Jan 2009
Total Posts : 189
   Posted 4/22/2009 10:10 AM (GMT -6)   
Welcome Reinhartdm:
Similar situation- tumor found on DRE- biopsy dec 08- 12 samples- 4 positive- 5, 15, 80 and 90 percent- all on right side- PSA 3.5 at time of biopsy- 2.5 in Feb 07-- Gleason 6--prostate 30 cc.
Brachytherapy consult scheduled for end of the month.
 
63 years old-tumor discovered on digital exam- biopsy December 2008-
4 of 12 samples positive-all on right side
Gleason 3+3=6
PSA-3
Otherwise excellent health.
 
  "There may come a day when the courage of men will fail, but it will not be this day."


Steve n Dallas
Veteran Member


Date Joined Mar 2008
Total Posts : 4829
   Posted 4/22/2009 11:49 AM (GMT -6)   
My PSA never got over 1.3 ....but the "nodules" that could be felt via a DRE prompted the biopsy..Thte rest is history.

Age 54   - 5'11"   205lbs
Overall Heath Condition - Good
PSA - July 2007 & Jan 2008 -> 1.3
Biopsy - 03/04/08 -> Gleason 6 
 
06/25/08 - Da Vinci robotic laparoscopy
Catheter in for five weeks.
Dry after 3 months.
 
10/03/08 - 1st Quarter PSA -> less then .01
01/16/09 - 2nd Quarter PSA -> less then .01
Surgeon - Keith A. Waguespack, M.D.
 


reinhartdm
Regular Member


Date Joined Feb 2005
Total Posts : 20
   Posted 4/22/2009 12:54 PM (GMT -6)   
From: Reinhartdm 4/22/09
Update from above:

It is very easy to get paranoid, especially when your disease appears so atypical. My latest fear is that my cancer has metastasized to my bones. (My positive biopsy was only 5 weeks ago.) With a PSA of only 2.6 (free PSA = 26%) my urologist did not think I needed a bone scan, but I have been experiencing mild hip pain on the left side (where my tumor is located) for several weeks now. I keep hoping it is only arthritis. I'm meeting with my urologist tomorrow. I plan to have a bone scan and PAP test conducted. The doctor says PAP is too variable, and has recommended against it. Any suggestions?
Dan

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4226
   Posted 4/22/2009 3:16 PM (GMT -6)   

Dan,

The following link will take you to some papers written by some of the best practioners, and researchers in the PC world. These are on staging and diagonistic techniques. After reading them I garentee you will know more than your doctor about the next steps you must take.

PAP is a simple blood test that is an indicator of PC spread. It is unlikely your PC has spread to the bone.

 
JohnT

64 years old.

I had an initial PSA test in 1999 of 4.4. PSA increased every 6 months reaching 40 in 5-08. PSA free ranged from 16% to 10%. Over this time period I had a total of 13 biopsies and an endorectal MRIS all negative and have seen doctors at Long Beach, UCLA, UCSF and UCI. DX has always been BPH and continue to get biopsies every year.

In 10-08 I had a 25 core biopsy that showed 2 cores positive, gleason 6 at less than 5%. Surgery was recommended and I was in the process of interviewing surgeons when my wife's oncologist recommended I get a 2nd opinion from a prostate oncologist.

I saw Dr Sholtz, in Marina Del Rey, and he said that the path reports indicated no tumor, but indolant cancer clusters that didn't need any treatment. He was concerned that my PSA history indicated that I had a large amount of PC somewhere that had yet to be uncovered and put me through several more tests.

A color doppler targeted biopsy in 11-08 found a large tumor in the transition zone, gleason 6 and 7. Because of my high PSA Dr. suspected lymph node involvement, 30% chance, and sent me to Holland for a Combidex MRI, even though bone and CT scans were clear.

Combidex MRI showed clear lymph nodes and a 2,5 cm tumor in the anterior. I was his 1st patient to come up clear on the Combidex which has a 96% accuracy,

I've been on a no meat and dairy diet since 12-08 and PSA reduce to 30 while I awaited the Combidex MRI.

The location of the tumor in the anterior apex next to the urethea makes a good surgical margin very unlikely. Currently on Casodex and Proscar for 8 weeks to shrink my 60 mm prostate. Treatment will be seeds followed by 5 weeks of IMRT while continuing on Casodex and Proscar. So far no side affects from the Casodex.

As of April 10 and 7 weeks on Casodex and Proscar PSA has gone from 30 to 0.62 and protate from 60mm to 32mm. Very minor side affects. Doc says all this indicates tumor is not aggessive

Awaiting schedule for seed impants

 


reinhartdm
Regular Member


Date Joined Feb 2005
Total Posts : 20
   Posted 4/22/2009 9:03 PM (GMT -6)   
On 4/20, JohnT noted that my stats (PSA = 2.6, larger tumor, GS = 6 on seven positive cores, free PSA= 26%) didn't "corrolate". I appreciate that he noted this, because this strange combination stats has befuddled me and my urologist. From my readings, it sounds like I may have a large neuroendocrine component (androgen independent PC). This, of course, will be bad news. Tomorrow, I will undergo bone scan and PAP test (although my urologist says the PAP is quite variable and may only distress me). There will probably be other tests to follow. I really appreciate all the feedback that everybody has provided. I have read so much about PC I don't recall everything I have already read. It is so overwhelming.

Dan 4/22/09

reinhartdm
Regular Member


Date Joined Feb 2005
Total Posts : 20
   Posted 4/26/2009 8:33 AM (GMT -6)   
Hello to all,

Tomorrow I get the results of my PAP test and I undergo a bone scan. (Minor, but troubling pain in left hip.) I also plan to ask for neuron-specific enolase (NSE) and chromogranin A (CGA) tests. I figure these will be necessary if my worst fears are true and I seek experimental or palliative care for Neuroendocrine Carcinoma.

Immediately after getting my biopsy results almost 6 weeks ago, I read in Walsh's book that a large prostatic tumor such as mine with a very low PSA 2.1, 2.6, 2.4) suggested small-cell. I immediately contacted the pathology lab and spoke with the pathologist who evaluated my biopsy samples (all 7/15 positive samples = GS 6). He reviewed the slides and said he saw no evidence of small-cell anywhere which relieved me at the time. But, did the lab do the appropriate preparation of biopsy samples to distinguish NEC/small-cell)? Now, my reading suggests it is much more difficult to distinguish NEC from the Adeno.

My questions:
Are there any cases (other than Neuroendocrine) where a tumor greater than 10cc can generate such a low PSA (most recent PSA = 2.4)?
If I do have Neuroendocrine carcinoma, where can I turn for experimental and/or palliative treatment? My urologist seems to be in denial that this outcome is very real possibility.

Thanks for any help.
Dan

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4226
   Posted 4/26/2009 8:29 PM (GMT -6)   
Dan,
The best advice I can give is to see a top prostate oncologist. Your urologist is over his head on this issue. Don't panic or jump to any conclusions on what you have or don't have based on what you have read.
The only thing you know is that that your numbers don't make sense. A large Gleason 6 tumor should be generating more PSA. There may be a few explainations for your situation.

The only one with the skill level to do good dective work on the biological level is an oncologist who specealizes in prostate cancer.
JohnT

64 years old.

I had an initial PSA test in 1999 of 4.4. PSA increased every 6 months reaching 40 in 5-08. PSA free ranged from 16% to 10%. Over this time period I had a total of 13 biopsies and an endorectal MRIS all negative and have seen doctors at Long Beach, UCLA, UCSF and UCI. DX has always been BPH and continue to get biopsies every year.

In 10-08 I had a 25 core biopsy that showed 2 cores positive, gleason 6 at less than 5%. Surgery was recommended and I was in the process of interviewing surgeons when my wife's oncologist recommended I get a 2nd opinion from a prostate oncologist.

I saw Dr Sholtz, in Marina Del Rey, and he said that the path reports indicated no tumor, but indolant cancer clusters that didn't need any treatment. He was concerned that my PSA history indicated that I had a large amount of PC somewhere that had yet to be uncovered and put me through several more tests.

A color doppler targeted biopsy in 11-08 found a large tumor in the transition zone, gleason 6 and 7. Because of my high PSA Dr. suspected lymph node involvement, 30% chance, and sent me to Holland for a Combidex MRI, even though bone and CT scans were clear.

Combidex MRI showed clear lymph nodes and a 2,5 cm tumor in the anterior. I was his 1st patient to come up clear on the Combidex which has a 96% accuracy,

I've been on a no meat and dairy diet since 12-08 and PSA reduce to 30 while I awaited the Combidex MRI.

The location of the tumor in the anterior apex next to the urethea makes a good surgical margin very unlikely. Currently on Casodex and Proscar for 8 weeks to shrink my 60 mm prostate. Treatment will be seeds followed by 5 weeks of IMRT while continuing on Casodex and Proscar. So far no side affects from the Casodex.

As of April 10 and 7 weeks on Casodex and Proscar PSA has gone from 30 to 0.62 and protate from 60mm to 32mm. Very minor side affects. Doc says all this indicates tumor is not aggessive

Awaiting schedule for seed impants

 


reinhartdm
Regular Member


Date Joined Feb 2005
Total Posts : 20
   Posted 4/27/2009 9:09 AM (GMT -6)   
JohnT,
I greatly appreciate your direct, level-headed advice.  My urologist left a message that my PAP measurement was 1.4 (with PSA = 2.4 from the same blood sample).  I know this is not a good sign, but I will certainly attempt to find a good prostate cancer oncologist.
Thanks for everything.
Dan

ahiinc
Regular Member


Date Joined Aug 2010
Total Posts : 23
   Posted 9/7/2010 10:20 AM (GMT -6)   
Dan,
Checking in on you as my conditions were similar to yours and it helps to watch and learn sometimes from each other. What has changed (good or bad) and how are you being treated?

Stevec

Age:47 diagnosed 34 PSA Gleason 4.5 + 4.5 = 9
Prostate removed and started HT
HT 2005 to current (Lupron/Casodex) PSA between .02 and .08
4/2010: PSA at .08 Tumor discover (pain in left hip) at 3.5" dia.
4/2010 - 8/2010 Cho treatment (no improvement)
8/2010 RT 12 treatments
9/2010: To start Clinical Trials???

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4226
   Posted 9/7/2010 11:50 AM (GMT -6)   
The last I heard Dan had surgery and his doctors felt everything was OK. He did some futher reasearch and found some obscure studies about large tumors and low psa. He visited Dr Myers and was DXed as having a very agressive varient and was sent to Holland for a Combidex which confirmed the DX. The last I heard he was being treated at the Dattoli Cancer center. That was about a year ago.
JT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


proscapt
Veteran Member


Date Joined Aug 2010
Total Posts : 644
   Posted 9/7/2010 3:08 PM (GMT -6)   
A doctor friend once said to me that "an uncommon presentation of a common disease is more likely than a common presentation of an uncommon disease."

Meaning, don't torture yourself with the fear of small-cell PC unless/until you have data that says you have it.

John T is right; see a specialist. You can retrieve your slides from whoever did the biopsy analysis initially and have the slides re-examined by a specialist. Then you'll know a lot more about what's going on.

Others have had good experience with color doppler ultrasound giving a way to look at the size/position of the tumor. This could confirm what the biopsy is telling you, or could indicate something else going on.

salva
New Member


Date Joined Sep 2010
Total Posts : 5
   Posted 9/7/2010 9:57 PM (GMT -6)   
These are the stories that frighten someone like me; low PSAs and aggressive cancers. Even though these are uncommon situations, who is to say that the atypical case won't apply to oneself?  By the way, if velocity trumps everything, then I am certainly worried.  Apparently, there are 2 schools of thought on this, those that believe velocity has clinical significance and those that argue velocity does not confer any diagnostic advantage over and above PSA cut offs.  I wonder what the majority here think?

proscapt
Veteran Member


Date Joined Aug 2010
Total Posts : 644
   Posted 9/7/2010 10:39 PM (GMT -6)   
hi, Salva -

Velocity is important, to be sure, but I wouldn't necessarily agree that it trumps everything. I would say it trumps pre-operatively if the evidence otherwise is ambiguous.

I did a lot of research on the velocity question, because it affects me personally. In the three months between the PSA test that sent me to biopsy (3.6) and the RP, my PSA jumped up to 5.6. Now, many people don't bother to get another PSA after the diagosisis and before treatment, but I wanted to see if a radical improvement in nutrition might help. Obviously it didn't The jump in PSA freaked me out and started me reading the journals and talking to people. I asked my surgeon whether I should seek adjuvant treatment, given the high pre-op PSAV and short PSADT. He said no, given that my pathology (EPE-, SM-, SV-) was favorable. He said the path report trumps the pre-operative PSAV and PSADT. I said, "so what does it mean that my PSA moved up so quickly just before surgery" and his answer was "it means it's good that we got it out when we did. That's about it." Another well respected doc said essentially the same thing.

Still, I was bothered by the publications by D'Amico and Catalona et. al. around 2004 and 2005. And at the same time, I was encouraged by the nomograms (Stephenson, et. al.) Those authors said that they tested PSAV and PSADT and it didn't add any explanatory or predictive power once other factors were taken into consideration. Then finally, there was another article (Catalona also one of the authors) that said that PSA kinetics are predictive of a worse pathology report after surgery, but after pathology is taken into consideration they are NOT predictive of a worse overall outcome.

So, I am still trying to make sense of it all. The jury is still out on this. There is clearly a controversy raging in the literature; I found one "letters to the editor" exchange where Kattan and other challenge D'Amico's findings and D'Amico defends his work. I am thinking of seeking out D'Amico or Catalona for a consultation, just so I hear their views in my particular case.

Each stage of the process brings different information and different decisions to make. Which information is most important depends on the where someone is in the process of diagnosis and treatment. To stay sane, I try to keep my focus on the decision at hand.

Best wishes, and please share what you discover.
DX at age 54 12/2009
Initial clinical profile: PSA 5.6, DRE-, high pre-op PSAV. Clinical stage T1c
Biopsy: Gleason 3+4 with PNI / 6 of 14 cores + / 10% of total length + / worst 45% +
TX: Robotic assisted RP 2/2010
Pathology: pT2cNx / Gleason 3+4 / PNI+ / SM- / SV- / EPE- / Tumor vol 7% / vol 40cc / 63 Grams
PSA - post-op 0.01

Post Edited (proscapt) : 9/7/2010 10:48:43 PM (GMT-6)


salva
New Member


Date Joined Sep 2010
Total Posts : 5
   Posted 9/8/2010 10:52 PM (GMT -6)   
proscapt,
 
I hear you.  How does one make sense of this business when the experts disagree?  Unfortunately, while the odds of having aggresive cancer with low PSAs are low, the odds of winning the lottery are much lower and someone wins the lotto every week, it seems.
 
I can see where the path report trumps everything else because these data are more reliable.  By the way, I have been to Catalona's website a few times.  Good info at that site, although it is quite obvious he is very opposed to WW or AS and very proactive when it comes to biopsies. 
 
After your readings, have you come to the conclusion that pre-op velocity is not necessarily indicative of a poor prognosis, then? Let me know how things turn out for you.

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 9/9/2010 7:36 AM (GMT -6)   
I am a big beliver in the pre-op PSA velocity theory. My own case makes proof of it. At the time of my PC dx, my PSA went to 12.3 from an already high of 5.8 the year before. In the 2 months from dx to surgery, it had further climbed to over 16.

I had open surgery, Stage II, still a Gleason 7. Within 9 months of surgery, I had confirmed recurrance, thus creating the need for SRT

I have had 3 PSA readings since the SRT last November. 1st one went down, 2nd went down to under .1, but the 3rd one, increased by 50%.
We are waiting for my next reading in November. Hoping it stays steady or goes down again, though with my PSA numbers, there is usually no going back down, mine have never trended up and down. If it is up again, then the SRT has failed within a year.

My urolologist said from the beginning, that my PSA velocity was going to be a problem, so far, it is working that way. He said, that a fast velocity case, can be more dangerous than the average Gleason 8-10 case.

BTW, I never had any evidence of any inflamation or infections in my prostate, or any kind of prostate related problems prior to PC dx.

David in SC
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 11/10 ?
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, on Catheter #21, will be having Ileal Conduit Surgery in Sept.

proscapt
Veteran Member


Date Joined Aug 2010
Total Posts : 644
   Posted 9/9/2010 4:15 PM (GMT -6)   
To Purgatory -

Sorry to hear of your situation. Your urologist clearly saw the high risk nature of your PC early on. Did he discuss with you any options for adjuvant treatment, or did he tell you to wait and see if the PSA stays down, and not treat further until/if it came back? I am asking because my situation is similar in some respects, and in my scan for potential trials for adjuvant therapy I didn't see any trials for which I qualified. (All the adjuvant trials had higher risk thresholds than my situation)

To Salva -

It seem very clear that high PSAV is predictive of greater odds of having a not-so-good pathology report. As for the rest, I'm undecided. I would sure LIKE to believe that if your pathology is clear then you're in good shape. I think also that a lot of the researchers and MD's would like to believe PSAV can be ignored since the data is not uniformly collected and if they have to limit studies to those with PSAV tracked in a specified manner then they lose a lot of potential research subjects. But wanting to believe and believing are different. The experts continue to duke it out in the literature and I'm not even close to being an expert on this stuff. So all I can do is monitor closely and ask the experts.

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 9/9/2010 4:29 PM (GMT -6)   
pro

my uro discussed both methods with me, but he's a strong believer of waiting to see if recurrance is happening first, because sometimes, even with bad pathology, some men do well for a period of time before ever having recurrance, that extra time helps in dealing with incontinence and ED issues. He also knew, that I had a terrible experience with RT 10 years before for a different type of cancer, and knew that I did not want to undergo any ki
nd of RT unless it was absolutley needed.

because of the velocity, my rad. oncologist only gave it roughly a 20% chance of working, but i took the risk, knowing that the radiation might do a lot of damage to me, and unfortunately, for me, it has. most men here have gone through RT or SRT without too much difficulty, so my situation is not typical.

good luck, i know its a tough decision to make
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 11/10 ?
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, on Catheter #21, will be having Ileal Conduit Surgery in Sept.
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