Question about the Zero club...

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Kmac
Regular Member


Date Joined Mar 2010
Total Posts : 58
   Posted 4/11/2010 8:10 AM (GMT -6)   
 
Hello all,
I guess I've gotten to the acceptance stage and understand some of the technicalities of psa - well as much as you can without being a dr or statistician! However I am still confused about the psa measuremnts.
 
Firstly - I thought that only the prostate gland can produce psa, so why when the gland is removed is psa still produced? Or is the cancer cells that still produce it?
 
Secondly - does being 'zero' mean anything under 0.1? ie 0.09 and so forth....
 
Thirdly - I read that a psa level of under 10 is ok when doing the initial tests for psa?
 
And fourthly...(sorry for so many questions), but what level of psa post surgery usually will determine the need for raditiation treatment?
 
Thankyou wink

142
Forum Moderator


Date Joined Jan 2010
Total Posts : 7082
   Posted 4/11/2010 11:27 AM (GMT -6)   
Kmac,
Not being the expert, I can only offer some guidance based on what I've learned.
1) psa is produced by the cancerous material, which may have gotten outside the prostate before removal, and that is why we live from one PSA test to the next. After treatment, each "undetectable" is a sort of "free pass" to try to forget about PCa until the next periodic test.
2) Zero is subjective, in some ways. Different labs have different tests and measures for "undetectable". You could search here and find many variations. Dr. Walsh's book (p.369) says less than 0.1 ng/ml is "undetectable", although a lot of the results posted here have been from ultra-sensitive tests, and seem to focus around 0.04 as "zero".
3) A total PSA of 10 is high. I had two tests to recheck the numbers, both at 7.+, and my GP sent me immediately to the urologist. Only 4% of men in the 50-59 group (mine) have PSA of 4.1 or higher, again, quoting Walsh.
4) It isn't just the initial post-surgery level (although that counts). It is more the time it takes to double. Mine post-surgery is still "undetectable", but my pathology was bad, so we will do radiation anyway.

So, no clear answers, I am afraid. PCa is unpredictable.

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4268
   Posted 4/11/2010 11:55 AM (GMT -6)   
Psa is produced by other parts of the body, but the amounts are so small they are meaningless.
There is always some prostate tisssue left after surgery. Depending on how much is left, it will produce small amounts of psa. This type of psa should remain stable at a very low level.
Any cancer cells that have escaped the prostate will produce psa that will continue to rise as the cancer grows.
After any treatment, low and stable is what you are looking for. Any increases over time are indicative of a reoccurance.
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


Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 4/11/2010 4:03 PM (GMT -6)   

All good questions, kmac.

The "Zero Club" is a misnomer which can causes unnecessary anxiety and/or disappointment in some patients whose expectation is that after radical treatment for PC their PSA will truly be "zero", and their results come back at something greater than zero.

Addressing your questions in the order asked:

  1. After a radical prostatectomy, a patient continues to have PSA testing to see if prostate cancer cells were left behind or spread.  PC cells outside the prostate (if present) will continue to produce PSA in the bloodstream.  Continuously and consistently low levels (or undetectible levels) of PSA indicate that the surgery has "cured" the prostate cancer (in other words, that the cancer was truly "organ-contained, and the organ with all the cancer has been removed).  Similarly, if one chooses radiation therapy as first-line treatment (or has radiation as a secondary treatment), ongoing PSA tests measure the effectiveness of cure.
  2. As previously clarified "zero" PSA is a misnomer.  Every living, breathing man with or without a prostate has some level of PSA in his bloodstream.  There are different measurement technologies which are accurate to different levels of detection.  For men in the low risk category before surgery who end up with no extraprostatic extension and negative surgical margins, most commonly their doctors will prescribe the "standard" PSA test with lower detection limits (LDL) down to 0.1 ng/mL.  In cases that should be watched more closely, there is an "ultra-sensitive" PSA test (most commonly with one more digit of significance).
  3. A PSA result of 10 ng/mL in an untreated patient (or a treated patient) is considered outside of a normal range.  Generally, 4 ng/mL is the upper threshold for looking further at the root cause of the elevated PSA result, although there are also age-adjusted thresholds.  Younger men should not be at 4, and 4 might be ok for older men.
  4. The American Urological Association (AUA) has defined biochemical recurrence as an initial PSA value equal to or greater than 0.2 ng/mL followed by a subsequent confirmatory PSA value also at equal to or greater than 0.2 ng/mL.

With so many good questions about PSA, I recommend visiting this link to the AUA's free online document "Prostate-Specific Antigen Best Practice Statement:  2009 Update."  Go here: http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-reports/psa09.pdf

best wishes...

Post Edited (Casey59) : 4/11/2010 4:04:53 PM (GMT-6)


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 4/11/2010 8:37 PM (GMT -6)   
I think the term "Zero Club" here at HW is well understood, as any PSA result <.10. It has been mentioned many, many times. It has also been explained that there isn't any true .00.
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, no problem post SRT
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04
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  same time, 2/8-Cath #11 out - 21 days, 3/2- Cath #12 out - 41 days, 3/2- Corr Surgery #5, 3/6 Cath #13 out - 4 days, Cath #14 out - 27 days, Cath #15 - 3/29


Kmac
Regular Member


Date Joined Mar 2010
Total Posts : 58
   Posted 4/11/2010 9:56 PM (GMT -6)   
Thanks guys for your thorough responses on this one. I have done some more reading and getting my head around it all. I feel truly sorry for someone who has a poor GP and no access to the net or services to help them understand the disease as it can all be very confusing. I also hated maths in school - numbers blah! give me words to interpret anyday!

I know I should slow down and stop trying to look too far ahead of this unpredictable disease - dad is yet to have the surgery even! I'm sure after that with the path report I will have more questions to analyse and try and understand. I guess at this stage - knowing the basics helps the anxiety and worry right - Stage T2, localised, no speading as known, gleason 7?

I did find out that while there is no history of prostate cancer in my family, my dad's mum died of breast cancer adn that gene can be passed on and presented in sons as pca.

English Alf
Veteran Member


Date Joined Oct 2009
Total Posts : 2218
   Posted 4/12/2010 2:22 AM (GMT -6)   
Kylie,

Given you hated maths it's perhaps worth mentioning the decimal point
There have been a number of cases mentioned at HW where people got results over the phone etc where they misheard what they were told
eg they heard they were "0.1" when they were actually "0.01" which is very good, or they thought they heard they were "0.1" when they were actually "Less than 0.1" (usually written down as "<0.1"), which is much better than "0.1".

A PSA level of "<0.1" after treatment is good; that's what we regard as "Zero". And one that also stays at "<0.1" is what we all aim for.

So try to make sure your dad gets all such details on paper so he and you or your mum do not have to feel uncertain about exactly what you have been told.


Re a PSA of 10.
The lab report from my initial PSA test was part of a general health check and all the way down the report next to my own readings it listed what was the "safe" level (be that for sodium, sugar, cholesterol or whatever) and for PSA my lab marked 2.5 as being the borderline. So in Holland the rule seems to be that a PSA above 2.5 needs to be investigated further, so a PSA of 10 is too high to be ignored. (Thus my own PSA, at 8.6, was flagged up on the report with an "H" next to it)

PSA can never really be zero, some women have even been found to have very low levels in them, but what counts here is that the PSA that matters is made by prostate cells, however the problem with prostate cancer is that cancerous cells can move away from the actual prostate gland and not be removed with the gland at the operation. The biopsy report is therefore important to give an indication about what the cancer is like. In your first post you said:

I do know that it is stage 2, Gleason of 7 and localised, no spreading to bone, lymph nodes or seminal vessels.

And that is positive enough news for the doctors for them to believe that if they remove the gland they will have a good chance of removing all the cancer (a so-called curative treatment).

Thus testing the blood after the operation to see if there is still PSA in it helps the doc find out if all the prostate cells were indeed removed.
My doc said that they would want to give me additional treatment if the PSA level got above 0.2 after the op. so as it was 0.4 at the last test I am off to the hospital tomorrow to be prepared for radiotherapy.

And remember that because it takes a while for the PSA that is still in a guy's blood the day after the op to get broken down it will be a fews weeks before they test the PSA after the operation.

Alfred
(It might help everyone understand your dad's situation if you edit your profile to add a signature about his statistics)
Age at Dx 48 No Family history of Prostate Cancer
Married 25 years, and I cannot thank my wife enough for her support.
April 2009: PSA 8.6 DRE: negative. Tumour in 2 out of 12 cores. Gleason 3+3.
RALP (nerve-sparing) at AVL-NKI Hospital Amsterdam on 29th July 2009. Stay 1 night.
Partial erections on while catheter still in. Catheter out on 6th Aug 2009.
Dry at night after catheter came out
Post-op Gleason 3+4. Tumour mainly in left near neck of bladder.
Left Seminal Vesicle invaded, (=T3b!)
no perineraul invasion, no vascular invasion. clear margins,
Erection 100% on 15th Aug 2009, but lots of leaking
Stopped wearing pads on 21st Sept 2009
Pre-op style intercourse on 24th Oct 2009 !! No use of tablets, jabs, VED etc.
Nov 17th 2009 PSA = 0.1
Mar 17th 2010 PSA = 0.4!!! referred to radiation therapist

Post Edited (English Alf) : 4/12/2010 1:25:23 AM (GMT-6)

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