Nerve Sparing and PSA

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Bob D
Regular Member


Date Joined Mar 2008
Total Posts : 199
   Posted 2/20/2010 2:11 AM (GMT -6)   
I know the post op PSA topic has been talked about here many times. However when it
"hits home" it takes on even more urgency. My details are below but as a summary, I had
my surgery in 3/08. My recovery has been nothing short of amazing. I am continent, erections
are as good as pre op as well as orgasms. Except for the lack of the "fluid", all is normal.
My PSAs have been .04 until my last which was .06. Still in the zero range but the rise concerned me.
My Uro said it can fluctuate some. I did have sex the day before the test which I am not sure if this would
affect my PSA. I had read somewhere that when the nerves are spared there can still be some PSA present.
Has anyone else heard of this? Perhaps I should not be so anxious about my PSA but I am. Any input is appreciated.
    1. Age 59, psa 4.7 in Jan. 08. Biopsy: one positive sample out of 13. 1% of one sample cancer. Prostate removed on 3/5/08. Open Surgery. Northeast Georgia Medical Center, Gainesville Ga. Nerves spared. Cath out 12 days later. Continence good. No pads needed since 6/10/08. First PSA: Less than 0.1 on 6/17/08. First erection five days post op and have been improving well since then. Full erection now possible (less than four months post op) with the assistance of Cialis.  Post Op Biopsy : No malignant cells in lymph node. Gleason 3=4=7. Tumor on both lobes. Urethral margins/apex free of neoplasia. Right and left seminal vesicles free of neoplasia. No invasion of prostatic capsule of the resection margins are noted by the tumor. Tumor occupies 10 to15% of the prostate gland. Path staging T2c, NO, MX- Group staging II.  Focal areas of perineural invasion by tumor are noted. 80% natural erections and full erections with 10mg Cialis. 9/22/08-Took 10mg Cialis on Monday night, had very usable full hard erection at night, the next morning, and the following Thursday morning, 60 hours after original dose !! Orgasm quality Excellent.!!!!! I am pleased with the progress so far. Married to same wonderful woman for 39 years. She is still beautiful and sexy as ever. A great help in my recovery !!: 3/12/09: Full natural erections with penetration. 10mg Cialis makes them easier to maintain but I have had several med free full erections lately, Yipieeee !!!!!!!  3/24/09: One year PSA <0.1.  3/28 & 3/29: had sex with full naturals with no meds. Erections are gained and maintained with very little manipulation. Getting more like pre op every day. 5/30/09, I take only 5mg Cialis every 2 or 3 days. This greatly assists my full naturals and provides great staying power and no manipulation required and allows sex anytime !! Lenght and girth are back to pre op size due to regular "workouts". 11/10/09: Full naturals without meds. I will sometimes take 5mg of Cialis if my wife and I have a big weekend or evening planned, but spontanous erections are fine even without.
    1.  


      Steve n Dallas
      Veteran Member


      Date Joined Mar 2008
      Total Posts : 4833
         Posted 2/20/2010 6:21 AM (GMT -6)   
      Take a deep breath.....
       
      What helps me a bit...Your original PSA was 4.7 when converted to my little unoffical formula is 4 dollars and 70 cents...aka 470 pennies....
       
      Your recent PSA's have been (.04)  4 pennies....and just went up to 6 pennies...You're still a real poor man when it comes to PSAyeah
      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
      05/14/09  - 4th Quarter PSA -> less then .01
      11/20/09 - 18 Month PSA -> less then .01
      Surgeon - Keith A. Waguespack, M.D.


      Casey59
      Veteran Member


      Date Joined Sep 2009
      Total Posts : 3172
         Posted 2/20/2010 8:33 AM (GMT -6)   

      Hello Bob D,

       

      Perhaps you missed it, but just yesterday another HW member (41diagnosed) posted an almost identical question about the presence and fluctuation of very low levels of PSA. 

       

      As you hopefully know, there is no such thing as “zero” PSA in a living, breathing male.  The notion of a “zero club” is somewhat of a misnomer, which causes anxiety in some men when their PSA is reported at something other that “zero”, and especially when some variation exists.  Nerve-sparing RP is probably the best known and most significant source of PSA for surgical PC patients with no prostate.

       

      I’ve copied/pasted the bulk of my informative reply to 41diagnosed’s question (posted yesterday morning) here:

       

      Some surgeons specifically tell their patients to get only the “standard” PSA test after surgery specifically to avoid what is called “PSA Anxiety.” 

      As you have already pointed out, Dr Catalona is (in your words) “dismissive of anything below .1.”  Why is this?  One reason is that unilateral or bilateral nerve-sparing surgery will leave benign tissue behind which produces PSA at a level detectable by the “ultra-sensitive” PSA tests.

      (reference:  http://www.prostate-cancer.org/education/preclin/McDermed_Using_PSA_Intelligently2.html)

       

      Additionally, there is also normal day-to-day variation of PSA results which are evident only with the detection levels of the “ultra-sensitive” PSA test.  This article “The Downside of Ultra-Sensitive Tests” reports normal variation within the range of what you are seeing:

      (reference:  http://www.phoenix5.org/Basics/psaPostSurgery.html)

       

      The concluding sentence in the article reads:

      ''It's important that we don't assume anything or take action on a very low level of PSA. In routine practice, because of these analytical variations from day to day, if it's less than 0. 1, we assume it's the same as nondetectable...''

       

       

       

       

      Or, to read 41diagnosed’s entire thread, go here:  http://www.healingwell.com/community/default.aspx?f=35&m=1724435

       

       

      Hope this helps ease your mind...


      James C.
      Veteran Member


      Date Joined Aug 2007
      Total Posts : 4462
         Posted 2/20/2010 4:21 PM (GMT -6)   
      Bob, you will hear it several different ways, but a zero is anything under .10, or as was said 10 pennies. 4 pennies, 6 pennies, or 3 pennies, it's still statistically a zero. I guess we probably could start using the term "zero (<.1) " to reduce the confusion. I wouldn't worry about it until there's a definite visible and chartable rise, consistent over time. Two points in reference is a start.
      James C. Age 62
      Co-Moderator- Prostate Cancer Forum
      4/07 PSA 7.6, referred to Urologist, recheck 6.7
      7/07 Biopsy: 3 of 16 PCa, 5% involved, left lobe, GS 3/3=6
      9/07 Nerve sparing open RRP 110gms.- Path Report: GS 3+3=6 Stg. pT2c, 110gms, margins clear
      32 mts: PSA's: .04 each test since surgery, ED Continues-Bimix .3ml PRN or Trimix .15ml PRN


      Purgatory
      Elite Member


      Date Joined Oct 2008
      Total Posts : 25380
         Posted 2/20/2010 4:27 PM (GMT -6)   
      Bob, you are still pulling a solid zero.
      Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
      3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
      Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
      Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
      Incontinence:  1 Month     ED:  Non issue at any point post surgery
      Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
      Post SRT PSA: 1/10 .12
      Latest: 7/9 met 2 rad. oncl, 7/9 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 out 38 days, 9/9 - met 3rd rad. oncl., mapped  9/9, 10/1 - 3rd corr. surgery - SP cath/hard dialation, 10/5 - 11/27 IMRT SRT 39 sess/72 gys ,cath #8 33 days, Cath #9 35 days, 12/7 - Cath #10 43 days, 1/19 - Corr Surgery #4,  Caths #11 and #12 in at the same time, 2/8-Cath #11 out - 21 days


      Bob D
      Regular Member


      Date Joined Mar 2008
      Total Posts : 199
         Posted 2/21/2010 1:13 AM (GMT -6)   
      Thanks for your replies. You all echo what my wife tells me. "don't worrry be happy".
      I will certainly try. I appreciate the links, they were real helpful. I was not aware that
      nerve sparing does leave some prostate tissue behind. My Uro did say that the area will
      produce a small amount of PSA.
        1. Age 59, psa 4.7 in Jan. 08. Biopsy: one positive sample out of 13. 1% of one sample cancer. Prostate removed on 3/5/08. Open Surgery. Northeast Georgia Medical Center, Gainesville Ga. Nerves spared. Cath out 12 days later. Continence good. No pads needed since 6/10/08. First PSA: Less than 0.1 on 6/17/08. First erection five days post op and have been improving well since then. Full erection now possible (less than four months post op) with the assistance of Cialis.  Post Op Biopsy : No malignant cells in lymph node. Gleason 3=4=7. Tumor on both lobes. Urethral margins/apex free of neoplasia. Right and left seminal vesicles free of neoplasia. No invasion of prostatic capsule of the resection margins are noted by the tumor. Tumor occupies 10 to15% of the prostate gland. Path staging T2c, NO, MX- Group staging II.  Focal areas of perineural invasion by tumor are noted. 80% natural erections and full erections with 10mg Cialis. 9/22/08-Took 10mg Cialis on Monday night, had very usable full hard erection at night, the next morning, and the following Thursday morning, 60 hours after original dose !! Orgasm quality Excellent.!!!!! I am pleased with the progress so far. Married to same wonderful woman for 39 years. She is still beautiful and sexy as ever. A great help in my recovery !!: 3/12/09: Full natural erections with penetration. 10mg Cialis makes them easier to maintain but I have had several med free full erections lately, Yipieeee !!!!!!!  3/24/09: One year PSA <0.1.  3/28 & 3/29: had sex with full naturals with no meds. Erections are gained and maintained with very little manipulation. Getting more like pre op every day. 5/30/09, I take only 5mg Cialis every 2 or 3 days. This greatly assists my full naturals and provides great staying power and no manipulation required and allows sex anytime !! Lenght and girth are back to pre op size due to regular "workouts". 9/09 PSA <0.1. 11/10/09: Full naturals without meds. I will sometimes take 5mg of Cialis if my wife and I have a big weekend or evening planned, but spontanous erections are fine even without.
      1.  


        Pelahatchie
        Regular Member


        Date Joined Jul 2007
        Total Posts : 86
           Posted 2/22/2010 2:22 PM (GMT -6)   
        Bob,
         
        Your story sounds very similar to mine.  There is no doubt in my mind that sex raises the psa level so I would abstain for four or five days before any psa test.  I elected to be very aggressive with my situation and only time will tell if that was the right decision.  As of now I have no ed or continence issues and the radiation appears to have done its job on the cancer. 
         
        I am the type person that worries too much so that is what drove me to do whatever I could do stop dancing with the PSA bear, hopefully I won't have to dance again and neither will you.
         
        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
         
        PSA August 21st 2009 = .01 or less
         


        Bootheel
        Regular Member


        Date Joined Oct 2007
        Total Posts : 300
           Posted 2/22/2010 6:03 PM (GMT -6)   
        Bob,
        With no positive margins or capsular penetration, I woulldn't be too concerned. Anything less than .1 is considered a zero in my book. get well.
        Age 65
        Diagnosed 10/12/07
        PSA 6.3
        Biopsy 18 core samples, 2 positive <5%
        Stage T1a Gleason 6 (3+3)
        LRP  1/29/08
        Post-op
        Gleason 7 (3+4)
        1 positive margin (.3cm)
        T2C
        4/16/08- Started Bi-mix injections 
        5/15/08- 1st Post-Op PSA 0.07 Undetectable
        8/11/08 -2nd Post-OP PSA 0.02 Undetectable
        8/15/08- No more pads as of today  Whoopee!!!
        11/13/08- 3rd post-op PSA 0.02 Undetectable
        03/02/09- 1 yr. post-op PSA .09 Undetectable
        05/13/09   PSA .18 (ouch)
        Started IMRT June 13, 2009
        Completed 37 treatments July 31, 2009 (66.6gy)
        11/23/09 Post IMRT PSA .18
        2/12/10   Post IMRT PSA 0.00


        goodlife
        Veteran Member


        Date Joined May 2009
        Total Posts : 2691
           Posted 2/22/2010 6:56 PM (GMT -6)   
        I know statistically you guys are right. I also know that sometimes there is residual prostate tissue that is not removed during the surgery, and may be able to produce small amounts PSA.

        All that being said, if there was no value in knowing PSA to the .01, I doubt there would be any reason to do those tests. It is easy for us to say, don't worry, it's less than .1. Since .5 is commonly acknowledged here as the decision point for reoccurence, why not say less than .5 is zero, or of no consequence?

        I agree there is no reason to take any action. But, in my own PSA's, I am certainly going to look carefully at the next PSA is 90 days. What I am looking for is a trend. I have decided that 3 increases in PSA, no matter whether it is .01 increments or .1 increments, I say a trend is a trend.

        I guess what I'm saying is that I think we are a little too quick to dismiss these small increases. I know that in a large number of cases, they do go back down. I still say it is like a yellow warning light on the dash. It goes off for a reason.
        Goodlife
         
        Age 58, PSA 4.47 Biopsy - 2/12 cores , Gleason 4 + 5 = 9
        Da Vinci, Cleveland Clinic  4/14/09   Nerves spared, but carved up a little.
        0/23 lymph nodes involved  pT3a NO MX
        Catheter and 2 stints in ureters for 2 weeks .
        Neg Margins, bladder neck negative
        Living the Good Life, cancer free  6 week PSA  <.03
        3 month PSA <.01 (different lab)
        5 month PSA <.03 (undetectable)
        6 Month PSA <.01
        1 pad a day, no progress on ED.  Trimix injection
        No pads, 1/1/10,  9 month PSA < .01


        41diagnosed
        Regular Member


        Date Joined Jun 2007
        Total Posts : 176
           Posted 2/22/2010 10:09 PM (GMT -6)   
        You've heard it all.  I'm going through the same thing.  Basically, the bottom line is that the magic number for being considered a recurrence is .1, below which it's an uncertain thing.  So though I still have concern, I manage it by staying active and thinking positively, because honestly there is nothing to be done other than wait an see. 
         
        The waiting can be nerve racking if that's all you focus on.  So we have to accept it and keep moving forward...hard as it may be some days.
         
        Good luck and hoping the best for you.
         
        43 yo. now
         
        5/07 PSA 4.65 at routine physical
        6/07 biopsy Gleason 7 (3+4)...diagnosed at 41 y.o.
        6/07-9/07 manic research and interviews with physicians across the country in search of the "right" decision.  I went to Mass General in Boston, Loma Linda, University of Chicago and Northwestern.
        9/17/07 - RRP at Northwestern Memorial by Dr. William Catalona.  Thankful the father of the PSA test was right here in Chicago.
        Post op path report confirmed Gleason 7 (3+4). negative margins, no seminal vesicale involvement, no lymphatic or vascular invasion, bladder and urethral free and tumor volume was 5% of 27.3g.  
        9/27/07 - catheter removal...let the games begin...
        12/31/07 - threw out the pads (I only had used 1 pad per day for protection against minor drips)
         
        I started Trimix 8 weeks after surgery with success.  I hope someday I won't need injections, but I hope more that my PSA stays at 0 forever.
         
        9/17/08 One year past surgery and doing well.  PSA less than .1 and ED continues to get better and showing reasonably good results using Levitra which for a long time did nothing. 


        Casey59
        Veteran Member


        Date Joined Sep 2009
        Total Posts : 3172
           Posted 2/24/2010 9:28 AM (GMT -6)   

        goodlife and 41diagnosed,

        I wanted to share this insight (with you, and others who may follow this thread in the future seeking similar information) before this thread disappeared off the page.  You guys each mentioned different thresholds for BCR, biochemical recurrence…goodlife mentioned that 0.5 ng/mL is “commonly acknowledged”, and 41diagnosed mentioned the “magic number for being considered a recurrence” is 01/ ng/mL.

        While it is true that any doctor (or any patient, like yourselves) may use any threshold that they wish in order to declare a biochemical recurrence after radical prostatectomy, there IS an “industry standard” that exists.  The vast majority of practitioners have adopted this standard for uniformity, but one can still find (mostly in the older studies) various other levels referenced...you have pointed out several.

        The “industry standard” I refer to is in the American Urological Association’s  (AUA) “Prostate-Specific Antigen Best Practice Statement:  2009 Update” which is available free online.  The AUA serves as a medical specialty “support system”, working to ensure that it’s members are current on the latest research and practices in urology through various means, including “Best Practice” updates such as this.  There is no AUA enforcement mechanism, however, and so members are free to use and interpret as they see fit.  I find that being an empowered patient means keeping myself abreast of the latest & greatest which is published in industry-recognized documents such as this.

        The Guideline says the following with regard to reporting biochemical relapse of PC after RP on page 38:

        The AUA defines biochemical recurrence as an initial PSA value ≥0.2 ng/mL followed by a subsequent confirmatory PSA value ≥0.2 ng/mL.

         

        The AUA PSA Guideline is available free online at:

        http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-reports/psa09.pdf


        Post Edited (Casey59) : 2/24/2010 7:55:11 AM (GMT-7)


        English Alf
        Veteran Member


        Date Joined Oct 2009
        Total Posts : 2216
           Posted 2/24/2010 10:11 AM (GMT -6)   
        It's hard to know how to deal with PSA results after treatment.

        I've been told that they will only want to give me further treatment if I go above 0.2 (and stay there of course, as one test result on its own is not enough info.)

        When the numbers are restricted to one decimal place by rounding up or down then a "0.2" can of course be a 0.16, which doesn't need to fluctuate much to be back at 0.14 and get called a 0,1)

        The use of two decimals does though help distinguish between the two extremes that can be missed when the numbers get rounded up. ie

        0.14 rising to 0.16 is a change from 0.1 to 0.2 when rounded up,
        but so is 0.06 rising to 0.24!

        My first post op PSA was 0.1; I'm due another test in March. I'm hoping it won't have gone up, but if it has and has only gone up to 0,2, then I'm simply going to ask to have another test in May or June.

        Alfred
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