Impact of rapid PSA rise before surgery

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Veteran Member

Date Joined Aug 2010
Total Posts : 644
   Posted 8/22/2010 6:33 PM (GMT -6)   
Hi -

I'm new to this board. It looks like a great community!!

I'm a bit unsure what to do at this point and would appreciate hearing from anyone with similar experience.

Last fall my PSA hit 3.6, sending me off to urologist for biopsy which found cancer, leading to robotic assisted surgery in Feb 2010. For the three years prior, my PSA was moving up about 30-35% per year. I'm 55 years old. While waiting for surgery I tried to radically improve my diet and exercise, thinking it might reverse or at least slow things, and I had a PSA test again just the week before the surgery. PSA at that point was 5.6, up 2 points in 3 months.

There's a journal article which says that a rapid PSA rise pre-op signals much greater chance for problems later on: Preoperative PSA Velocity and the Risk of Death from Prostate Cancer after Radical Prostatectomy, NEJM July 8 2004, Anthony V. D’Amico, M.D., Ph.D., Ming-Hui Chen, Ph.D., Kimberly A. Roehl, M.P.H., and William J. Catalona, M.D.

This 2004 article said "Men whose PSA level increases by more than 2.0 ng per milliliter during the year before the diagnosis of prostate cancer may have a relatively high risk of death from prostate cancer despite undergoing radical prostatectomy." It recommended that men with > 2.0 increase in PSA per year prior to surgery should seek to get into a trial for adjuvant therapy in such cases.

So then I had the surgery by a well-respected doc with extensive experience at a major medical center, and the pathology report was pretty favorable: Gleeson 3+4, total tumor volume 3 cc, margins clear, seminal vesicles clear, no extracapsular extension. pT2cNx. Lymph nodes weren't tested and no bone scans or other scans were done. The doc said that no adjuvant therapy was warranted due to the relatively good pathology report. 3 month followup PSA was <.01. 6 month was 0.01. So biochemically I'm in good shape.

Recovery has been good generally in terms of urinary and erectile function. I'm in very good health generally other than the PC. But I'm concerned whether to seek further treatment at this point, or just keep an eye on the PSA every quarter.

Any suggestions?
Robotic assisted RP 2/2010
Path report: pT2c / Gleeson 3+4 / margins neg. / seminal ves neg. / capsule confined /
PSA - Pre-op 3.6 / last post-op 0.01

Tony Crispino
Veteran Member

Date Joined Dec 2006
Total Posts : 8128
   Posted 8/22/2010 6:43 PM (GMT -6)   
Hi proscapt,
Welcome to our site.

Now take it easy... Lot's of studies are out there, and few should affect your feeling that you did the right things. It sounds like you did well with the procedure. As time goes on, it will best help you to learn as you can about this disease and a study in 2004 is old news. Most will do quite well with your statistics. And biochemical numbers, while scary, don't mean as much as you might think. After surgery you have great options, but that's getting ahead of where you are. The best option is healing well, and getting back to normal. Again, welcome to HealingWell.

Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog :

Elite Member

Date Joined Oct 2008
Total Posts : 25393
   Posted 8/22/2010 6:46 PM (GMT -6)   
Hello and welcome:

I am going down the high PSA velocity path myself. My PSA went up nearly 300% in the year prior to my surgery. No, I never had any evidence of any kind of infection that may have made the PSA to rise. After surgery, I had recurrance within 9 months of my operation. Then I went through 39 treatments of SRT, 72 gys, which ended late November of last year. I just had my 3rd post SRT PSA recently, and though the number is small at this point, it still rose by 50%.

My uro/surgeon is a big believer in the school of thought where rapid PSA velocity is not a good thing. Its one or two readings too early in my case to call the SRT a failure, but I am preparing myself in case it does fail indeed.

I started PSA readings at age 50, and everyyear it rose and rose. All my DRE's were negative. I did not have any pre-PC prostate or urination problems, not even a UTI. And there was no known PC in my family.

I wish you luck, and hope that recurrance stays away from you. Hope you keep posting with us.

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.

Veteran Member

Date Joined Jan 2009
Total Posts : 2243
   Posted 8/22/2010 6:52 PM (GMT -6)   
Welcome aboard. At this point any addtional tx would be your call, but I have to agree with Tony that your numbers are fairly good and your recovery is going well. If more TX will bring you piece if mind, then it might be worth it, but otherwise enjoy life and wait to see if your PSA goes up and then deal with it.
Dx with PCA 12/08 2 out of 12 cores positive 4.5 psa
59 yo when diagnosed, 61 yo 2010
Robotic surgery 5/09 Atlanta, Ga
Catheter out after 10 days
Gleason upgraded to 3+5, volume less than 10%
2 pads per day, 1 depends but getting better,
 started ED tx 7/17, slow go
Post op dx of neuropathy
T2C left lateral and left posterior margins involved
3 months psa.01, 6 month psa.4, 6 1/2 month psa.5 on 11/28/10
Starting IMRT on 1/18/10, Completed 39 tx at 70 gys on 3/12/10
6 week Post IMRT PSA .44 a drop from .5 but maybe more
Great family and friends

Elite Member

Date Joined Oct 2008
Total Posts : 25393
   Posted 8/22/2010 7:18 PM (GMT -6)   
As a P.S. to my post, I would fully agree not to have any additional treatment(s) until and only if you have recurrance. Your body needs all the healing it can at this point. A rapid PSA rise is not a guarantty that you will have reucrrance, but just more likely. Because of my velocity, my radiation oncologist gave my SRT in the 20% range of working. Not great odds, but since it is a curative possibility, I went for it. Unfortantately, I did and am still having a lot of post radiation damage issues that I am working through.

Hopefully you won't have to deal with "Part II".
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.

Veteran Member

Date Joined Aug 2010
Total Posts : 644
   Posted 8/22/2010 7:45 PM (GMT -6)   
Thanks, guys, for your feedback and encouragement.

I've been continuing to check the literature, focusing on Catalona and D'Amico who did a lot of the work in this area. Interestingly, I found this, which appears to at least partially reverse the earlier finding. basically it says that pre-treatment PSAV is associated with the probability of non organ-confined disease, but not with the probability of biochemical progression.

Title: Preoperative prostate specific antigen doubling time is *not* a useful predictor of biochemical progression after radical prostatectomy.

Loeb S, Kan D, Yu X, Roehl KA, Catalona WJ., Department of Urology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.

PURPOSE: Postoperative prostate specific antigen doubling time may be used as a surrogate for prostate cancer specific mortality in patients with biochemical recurrence after radical prostatectomy. Less is known about the usefulness of preoperative prostate specific antigen doubling time for the initial prediction of prostatectomy outcomes.

MATERIALS AND METHODS: Preoperative prostate specific antigen doubling time was calculated in 1,208 men from a large prostate cancer screening study who were treated with radical prostatectomy. We examined the relationship of prostate specific antigen doubling time with tumor features and biochemical progression-free survival.

RESULTS: Overall prostate specific antigen doubling time was associated with non-organ confined disease (OR 0.996, 95% CI 0.992-0.999, p = 0.013) but not with biochemical progression (HR 1.000, 95% CI 0.998-1.001, p = 0.66). Using previously published 18 and 36-month thresholds for prostate specific antigen doubling time there was no significant relationship between doubling time and specific adverse pathological features or biochemical progression. Using the concordance index prostate specific antigen doubling time did not enhance the prediction of biochemical progression beyond that achieved by a model with prostate specific antigen, clinical stage and biopsy Gleason score.

CONCLUSIONS: In our series of men with newly diagnosed, clinically localized prostate cancer shorter preoperative prostate specific antigen doubling time was associated with nonorgan confined disease but not with biochemical progression after radical prostatectomy. All calculations of prostate specific antigen kinetics may not be equivalent. Caution should be exercised when using prostate specific antigen doubling time in the pretreatment setting.
DX 10/2009
Robotic assisted RP 2/2010
Pathology: pT2c / Gleeson 3+4 / margins neg. / seminal ves neg. / capsule confined /
PSA - Pre-op 5.6 / last post-op 0.01

Veteran Member

Date Joined Jul 2010
Total Posts : 3892
   Posted 8/22/2010 8:14 PM (GMT -6)   
That's why I have trouble with "Watchful Waiting", "Active Surveillance" and "Indolent Cancer"..

You coast along for a few years, a decade perhaps, and all of a sudden, in just a few months time, the thing explodes into a raging monster and blows you right over to the other end of the Partin table...

When I first put together my history, I really didn't know what it meant..I do now...
Age today: 68. Married, 6', 215 pounds, active, no health issues.
PSA at age 55: 3.5, DRE negative. Advice, "Keep an eye on it".
PSA at age 58: 4.5
PSA at age 61: 5.2
PSA at age 64: 7.5, DRE "Abnormal"
PSA at age 65: 8.5, DRE " normal", biopsy, 12 core, negative...
PSA at age 66 9.0 DRE "normal", BPH, Finesteride. (Proscar)
PSA at age 67 4.5 DRE "normal" second biopsy, negative.
PSA at age 67.5 5.6, DRE "normal" U-doc worried..
PSA at age 68, 7.0, third 12 core biopsy positive for cancer in 4 cores, 3 cores Gleason 6, one core Gleason 9. Finesteride discontinued, still no urinary symptoms, never had any..From age 55 to 65 I had no health insurance.

I have a date with the robo surgeon on Sept 3 but I'm keeping my options open. I'm also looking at seeds combined with IGRT which seems to be having good results with high-risk patients..

Veteran Member

Date Joined Dec 2008
Total Posts : 3149
   Posted 8/23/2010 8:57 AM (GMT -6)   
Proscapt you are an informed person. You are wise in searching and reading for your own benefit and likely you will be able to add things to discussions for others to take note on. Tony gave you a good heads up as for now.
You can get other psa test(s) on your own, use for comparisons and always re-verify anything, lab errors etc. things happen. I get psa tests at walkin basis hospital gig for $15 anytime, been great in monitoring for me. Sometimes I went monthly, looking at my stats below you will see why.
Dx-2002 total urinary blockage, bPsa 46.6 12/12 biopsies all loaded 75-95% vol.; Gleasons scores 7,8,9's (2-sets), gland size 35 normal, ct and bone scans appearing clear- ADT3 5 months prior to radiations neutron/photon 2-machines, cont'd. ADT3, quit after 2 yrs. switched to DES 1-mg, off for 1 yr., controlled so well, resumed, using intermittently, pleased with results

Post Edited (zufus) : 8/23/2010 8:01:00 AM (GMT-6)

John T
Veteran Member

Date Joined Nov 2008
Total Posts : 4269
   Posted 8/23/2010 3:52 PM (GMT -6)   
Low risk cancer just doesn't work that way. Low risk PC just doesn't go to high risk PC; it may take decades for it to mutate if it mutates at all. Agressive PC starts out as agressive and progresses very rapidily. AS is very safe for low and very low risk patients.
Prostate cancer is a family that has a lot of variation; it can range from a kitten to a tiger and all stages in between. It is critical that you know what you are dealing with as you handle a kitten differntly than you handle a tiger, and a kitten will never turn into a tiger.

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.


Veteran Member

Date Joined Mar 2010
Total Posts : 1152
   Posted 8/23/2010 10:16 PM (GMT -6)   

Many reputable prostate cancer centres do not recommend AS for younger patients. Why? Because many Gleason 6 cancers do not stay Gleason 6 over a period of more than 15 years. In many cases the kitten does not stay that way.

Secondly, we all know the limitations of screening for prostate cancer. Biopsies only give a snapshot of tiny portions of the prostate. The PSA numbers do have value and they can be read well by skilled oncologists but the numbers are not very reliable in people with prostatitis and BPH. Free PSAs, MRI's with spectroscopy, Urine tests, colour dopplers, CT scans all have problems with sensitivity or specificity or both. You may think you are dealing with a kitten but you may be dealing with a wildcat or a tiger.

There are risks and significant testing burdens associated with the approach you put forward.

Husband's age: 52. We live in Sydney Australia.
Family history:
Maternal grandfather died of prostate cancer at 72. Maternal uncle died of prostate cancer at 60. Because he is the third generation to be diagnosed he has hereditary PC.
PSA history:
Aug07 - 2.5|Feb08 - 1.7|Oct09 - 3.67 (free PSA ratio 27%)|Feb10 - 4.03 (free PSA ratio 31%) |Jun10 - 2.69
DRE normal
Biopsy 28/4/2010: results, negative for a diagnosis of PC however 3 focal ASAPs “ suspicious but not diagnostic for prostatic adenocarcinoma."
Review of biopsy by experienced pathologist, results,
1 out of 12 core diagnosed with 10% of Gleason score 3+3 cancer (left transitional)
1 out of 12 cores with ASAP (left apex), suspicious but not diagnostic of cancer

Nerve sparing RP on 20th August 2010 at St Vincent’s with Dr Stricker.
Post-op pathology
Final Gleason score: 3+4
Margin involvement: Nil
Extraprostatic extension: Nil
Multifocal, with involvement in the Peripheral, apex, fibro-muscular and transitional zones.

Regular Member

Date Joined Jul 2010
Total Posts : 161
   Posted 8/23/2010 10:30 PM (GMT -6)   
I have found JohnT to be a reliable and knowledgeable voice on these forums! Not the bottom line, but definitely knows what hes talking abound on quite a few levels! I always give him a extra listen!!!! Most would be wise to!
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