I've Made Myself a Victim of PSA Anxiety

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Heavy Leaker
Regular Member


Date Joined Feb 2010
Total Posts : 63
   Posted 5/11/2010 6:31 AM (GMT -6)   
Just when I thought my life was getting back to normal, I have disovered the famous PSA anxiety.  The last 4 & 1/2 years have been an interesting journey, but other than severe incontinence for 4 months post surgery, I've been much luckier than a lot of guys here.  I did deal with 4 biopsies over 4 years with a PSA that kept rising till it reached 18 shortly before the last biopsy found cancer.  I chose surgery over radiation since my biopsy results of Gleason 6 in only 5% of one core (after 3 negative biopsies) just didn't correlate in my mind with such a high PSA.  The pathology report after surgery found clear margins & no lymph node involvement.
 
My first PSA 6 weeks post-op was <.1 but last week, at 6 months post-op was .1.  My surgeon says we are going to monitor my PSA every 6 weeks now & that if it rises to .3 I will need radiation.  In addition, he says that since I've had pretty bad incontinence (5 to 7 pads a day) until a month ago when it went down to 2 to 3 pads a day), I will need hormones first.  The reason is that radiation stops all progress on incontinece & that the hormones will pause cancer growth until I am 1 year post surgery when it is likely that there will be no more improvement in incontinence.  He did say though, that there is a good chance that my PSA will not rise further.  He says that with my clear margins, it is unlikely that there is cancer left.  He also said that my prostate was stuck to the rectal wall pretty badly as a result of the 4 biopsies & that it took him an extra hour to peel the prostate away & that some benign prostate tissue could have been left behind.  So here are my questions:
 
1.  Has anyone else had a similar situation?
2.  Has anyone else had their second PSA be .1 then stay under .3?
3.  How high can PSA go from residual benign tissue?
 
Thanks in advance for any help.  I had started feeling really good about this journey as my pad usuage has been reduced almost overnight & now I am dwelling on this PSA situation.  Also, thanks for all the help you guys have given me!
4 biopsies over 4 years starting in 2006, 4th biopsy showed 5% of one core Gleason 3+3=6.  PSA in 2005 6.0, rose to PSA 18 shortly before surgery.  Chose surgery over radiation due to conflicts in PSA versus biopsies.  PSA 18, Gleason 3+3+6, Age 58, Rising PSA since 1999, Biopsy 5% of one core
Robotic surgery 10/26/09  T2B Tumor 30% of prostate  involving left & right lobes  NOMX Gleason 3+4=7  Urethral Resection margins &  resection surface clean Seminal vessicles clean.


Sephie
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Date Joined Jun 2008
Total Posts : 1804
   Posted 5/11/2010 7:42 AM (GMT -6)   
HL, take a look at my signature and you'll see that my husband had a very similar situation. The difference in his case was that his final path report showed EPE but negative margins. When his PSA began to climb last summer, we all assumed that the single focus of EPE was coming back to haunt us. As you can see, his PSA went back down - and has stayed there - but we were ready to pull the trigger on SRT.

In my husband's case, after the first detectable PSA (which was in August), the urologist chose to do another test in 1 month. The September test came back at 0.3, which was when we met with a radiation oncologist. My husband, the urologist and the radiation oncologist all advised for waiting for the 3rd PSA test (which was 1 month after that) before starting treatment. On a Saturday afternoon, the urologist called us at home to tell us the wonderful news that John's PSA was back down to undetectable. We were cautiously optimistic. Doc said come in for another PSA test in 6 weeks - that too came back at zero.

The only major difference I can see between your situation and John's is that your PSA became detectable 6 months after surgery whereas John's took 17 months. I suggest you stay on top of your PSA and watch it closely. Hopefully your doctor is correct and you won't see any further elevation.
Husband diagnosed in 2/2008 at age 57 with stage T1c. Robotic surgery performed 3/2008. Stage upgraded to T3a (solitary focus of extraprostatic extension). Perineural tumor infiltration present. Apex margin, bladder neck and SVs negative. Final Gleason 3+4. PSA: 0.0 til July 2009. August 2009 - 0.1, September 0.3, October back to 0.0, December 0.0, March 2010 0.0. Next PSA in 6 months. Thank you God!


Tim-from-Maine
Regular Member


Date Joined Apr 2010
Total Posts : 83
   Posted 5/11/2010 7:48 AM (GMT -6)   
I had my fourth PSA at .16 with a retest of .17 and am doing radiation as we speak - one year from surgery.

My surgeron also said he had to peel the prostate away from the surrounding tissue - and it was an extra hour or so.

I wonder if radiation kills the residual tissue?? I will be interested in others response to this thread.
PSA Feb 09 - 9
Dx age 62 - March 2009 - Gleason 7
Surgery - da-vinci RP on April 29, 2009 Gleason upgraded to 9
Started VEGAN diet June 2009
3 month PSA - <.04
6 month PSA <.04
9 month PSA .05
12 Month PSA  .16
SRT began May 3, 2010 - will do about 41 treatments
 
 


STW
Regular Member


Date Joined Jun 2009
Total Posts : 292
   Posted 5/11/2010 11:40 AM (GMT -6)   
My father had some benign tissue left after his RP.
25 years later he developed cancer in that bit that was left and was treated with proton beam radiation. I don't know his PSA progression over that time but it suggests where there's tissue there's a risk.
Diagnosed at 54
PSA 8.7 Biopsy 1/7/09
4 of 6 cores positive, one at 90%
Gleason 3+4=7 Neg bone scan 1/15/09
One shot Lupron Depot 1/27/09 Tax Season
RP 4/29/09
Neg lymph nodes, postive seminal vesicle, 1 positive margin
Gleason 3+4=7 with tertiary 5 T3b
Catheter out at 2 weeks no nighttime incontinence Pad free week 5
PSA 6/6/09 <0.1; 9/10/09 <0.1; 3/11/10 <0.1


Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 5/11/2010 9:42 PM (GMT -6)   
Heavy Leaker said...
...He also said that my prostate was stuck to the rectal wall pretty badly as a result of the 4 biopsies & that it took him an extra hour to peel the prostate away & that some benign prostate tissue could have been left behind...
 
 
3.  How high can PSA go from residual benign tissue?
 
Hi, and first of all I'm glad to hear of recent improvements in continence.  Keep working at it.
 
To your question above, the situation your surgeon described ("peel the prostate away") gives a potentially plausible scenario to extra-ordinarily high amount of benign tissue remaining behind yielding detectible PSA (with "standard PSA" test). 
 
Normally, the remaining benign tissue would be below the LDL (lower detection limit) of the standard PSA test (one decimal place of significance), although it might register in the hundredths place of the ultra-sensitive PSA test (two decimal places of significance).  The more commonly seen variation in the hundredths position is where the original "PSA Anxiety" term comes from.  (see the article in yellow, at the bottom of this web page:  http://www.phoenix5.org/Basics/psaPostSurgery.html)
 
I think you are on the right path to monitor more frequently now.  You may also consider a switch to the ultra-sensitive test, now that you've had this "yellow flag" go up...but do keep in mind that by switching tests you will want several data points with the new method (because you cannot compare one method's results to the other method's results).
 
Hoping that this works out for you and your results drop back below 0.1 ng/mL going forward.
 
-------------------------------
 
Regarding Tim-from-Maine's question:  "I wonder if radiation kills the residual tissue??"
 
Salvage Radiation Therapy (SRT) is intended to kill the cancerous cells that were left behind in the prostate bed during surgery, but it will also affect normal cells in the area as well...it simply is not focused enough to get only the cancerous cells.   Does this answer your question?
 
-------------------------------
 
Regarding STW's comment "My father had some benign tissue left after his RP.  25 years later he developed cancer in that bit that was left...".  
 
Unfortunately, but obviously, there was also some cancercous cells left behind after his RP.  Since 25 years went by, it would have been only a small amount and it took years for the slowly growing PC cells to multiply enough times to become detectible in a PSA test (thereby leading to his SRT).  Sounds like his SRT cleaned things up, as it usually will.
 
 

41diagnosed
Regular Member


Date Joined Jun 2007
Total Posts : 176
   Posted 5/11/2010 11:18 PM (GMT -6)   
Regarding post above: your last statement regarding STW's comment regarding have a recurrence at 25 years...you are suggesting the only way he had a recurrence was that cancer was left behind 25 years earlier. I do not believe you are correct about this. Actually, I believe STW is the one who is correct. Non-cancerous prostate tissue left behind absolutely can turn cancerous later. It is one of the inherent risks of radiation as a primary form of treatment...with radiation, benign prostate tissue remains which is why there is still a PSA level. Recurrence can happen when benign tissue left behind from radiation again goes haywire and becomes cancerous. So same would be true for missed tissue post surgery.

Regarding STW's comment "My father had some benign tissue left after his RP. 25 years later he developed cancer in that bit that was left...".

Unfortunately, but obviously, there was also some cancercous cells left behind after his RP. Since 25 years went by, it would have been only a small amount and it took years for the slowly growing PC cells to multiply enough times to become detectible in a PSA test (thereby leading to his SRT). Sounds like his SRT cleaned things up, as it usually will.
 
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 5/12/2010 6:41 AM (GMT -6)   
41diagnosed said...
Non-cancerous prostate tissue left behind absolutely can turn cancerous later. It is one of the inherent risks of radiation as a primary form of treatment...with radiation, benign prostate tissue remains which is why there is still a PSA level.
Respectfully disagree with how you have extended a situation following Radiation Therapy (with a fully intact prostate) to a very different situation after Radical Prostatectomy.  Quite simply, the feeding of prostate cancer cells does not work that way.
 
Please do refer to Dr Patrick Walsh's book "Guide to Surviving Prostate Cancer", Chapter 10 "How Successful is Treatment of Localized Prostate Cancer", subsection "Cancer Control after Radical Prostatectomy."
 
You are correct about RT; but it is not the same after RP.
 
 
 
By the way, the longer the amount of time that goes by after RP before those pesky residual PC cells show themselves in a PSA test, the better the likelihood for favorable outcome of Salvage Radiation Therapy (SRT).  Twenty-five years is not unheard of, but is atypical.
 
 
 

edit:  typo

Post Edited (Casey59) : 5/12/2010 7:58:37 AM (GMT-6)


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4268
   Posted 5/12/2010 11:32 AM (GMT -6)   
The reason radiation sometime fails is that the dose was not high enough to kill all the cancer or that there were dead spots in delivering the radiation. Getting PC in tissues that have been previously radiatied is extremely rare. The radiated tissue becomes fallow. The newer forms of radiation deliver 81 gy' vs the old 65gy protocols and and much more effective. A seed and external combination deliver 140gy and unlikely to leave any living PC within the prostate. In rare cases some PC cells can develop a resistance to radiation, using two different types of radiation can eliminate this.
There is always some prostate tissue left behind in a surgery, good surgeons leave less. If these contain cancer cells reoccurranc may occurr.
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


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4268
   Posted 5/12/2010 1:08 PM (GMT -6)   
Leaker,
As I recall you had a large transition zone tumor. These are difficult to operate on and invaribly leave some prostate tissue behind. You can image or rebiopsy the area before you get salvage RT to confirm if it is still local or is benign prostate tissue that was left.
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


Heavy Leaker
Regular Member


Date Joined Feb 2010
Total Posts : 63
   Posted 5/12/2010 1:18 PM (GMT -6)   
John T said...
Leaker,
As I recall you had a large transition zone tumor. These are difficult to operate on and invaribly leave some prostate tissue behind. You can image or rebiopsy the area before you get salvage RT to confirm if it is still local or is benign prostate tissue that was left.
JT

John T,

 

I don't ever ecall that terminology (large transition tuymor) being used.  My pathology report is summarrized in my signature.  Is it possible that this amount of PSA is coming from benign tissue?  How much PSA does benign tissue generate & is there anything else that can generate PSA other than benign or cancerous prostate tissue?


4 biopsies over 4 years starting in 2006, 4th biopsy showed 5% of one core Gleason 3+3=6.  PSA in 2005 6.0, rose to PSA 18 shortly before surgery.  Chose surgery over radiation due to conflicts in PSA versus biopsies.  PSA 18, Gleason 3+3+6, Age 58, Rising PSA since 1999, Biopsy 5% of one core
Robotic surgery 10/26/09  T2B Tumor 30% of prostate  involving left & right lobes  NOMX Gleason 3+4=7  Urethral Resection margins &  resection surface clean Seminal vessicles clean.


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4268
   Posted 5/12/2010 4:08 PM (GMT -6)   
Other organs produce psa, but not in measurable amounts. It's either PC or benign prostate cells. If it is benign psa will stabalize while pc will keep rising. The only way to tell early on is with scans like Color Doppler or MRIS and a biopsy of the suspected area.
When post surgery psa reaches .2 it is commonly called a reoccurrance and salvage radiation is recommended. There is evidence that salvage radiation works better at the .2 level than waiting for it to go higher. There is also evidence that three succesive rises on the ultrasensitive psa test indicate a reoccurrance much earlier than waiting until it hits .2. The earlier salvage radiation is given the higher the chances for a cure.
JohnT

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

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