PSA INCREASE SINCE SURGERY

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skapod
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Date Joined Nov 2008
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   Posted 9/21/2010 6:44 AM (GMT -6)   
Hi Everyone,
 
Haven't been here in a while, hope all is well with everyone.  Question, my husband had RPS 2 years ago.  His PSA levels have been .01 since surgery.  He took his current 6 month test and it came back .05.  I know that is still undetectable but we're still concerned that it rose at all.  I've requested he be retested in 3 months instead of 6 months.  Has anyone had this happen and if so what was the outcome?
 
Thanks in advance

Kongo
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Date Joined May 2010
Total Posts : 36
   Posted 9/21/2010 7:31 AM (GMT -6)   
Hi, skapod.

It may just be a lab glitch and you might want to have it redone to be sure. about a third of men who have RP will see a measurable recurrence of prostate cancer even if there were negative surgical margins and the doctor happily pronounced "we got it all" after surgery.

If the PSA is rising and its not a lab error, your doctors will look at the PSA velocity and doubling time to determine if they should follow additional courses of action. If it is very slow growing, like most PCa inside the prostate, they may just keep an eye on it. Or they may suggest radiation treatment, hormone treatment, or a combination of the two.

When PCa moves beyond the prostate, even at the microscopic level, it grows faster and doubles quicker than it did inside the prostate.

Hopefully, this is all just a lab error. Good luck to you.
============================
Age:  59
Dx:  March 2010
PSA @ Dx:  4.3 (Latest PSA = 2.8 after elimination of dairy)
Gleason:  3+3=6 (confirmed by second pathologist)
Biopsy:  1 of 12 cores contained adenocarcinoma at 15% involvement and no evidence of perineural invasion
DRE: Normal
Stage:  T1c
Bone scan and chest x-rays:  Negative
Prostate Volume: 47 cc
PSA Velocity:  0.19 ng/ml/yr
PSA Density:  0.092 ng/ml/ccm
PSA Doubling Time:  > 10 Years
Treatment Decision:  CyberKnife radiation treatment in June 2010.  Side effects:  None
 
 
 

skapod
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Date Joined Nov 2008
Total Posts : 35
   Posted 9/21/2010 7:55 AM (GMT -6)   
Thanks for your response. What concerns me is that when the biopsy was done post surgery we were told that 75% of the prostate was diseased and that it was a very aggressive cancer, so seeing even a slight increase is scary. He just went for his 2 year post op checkup and typically if results were good they only want to see you once every year from that point on. Our Dr. told us since the percentage was as high as it was he wants to see him every six months. We will have the test re-done in three months and take it from there. God Bless everyone, I'll keep you all in my prayers.

Purgatory
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Total Posts : 25380
   Posted 9/21/2010 9:59 AM (GMT -6)   
with that information, very surprised his doctors wants to wait every six months. if it were me, i would have tests done every 3 months for sure.
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.

skapod
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Date Joined Nov 2008
Total Posts : 35
   Posted 9/21/2010 10:06 AM (GMT -6)   
My feeling exactly, that's why I requested that he be tested every three months. In the Dr's defense, we just got the results back, haven't spoken to the Dr. yet, waiting for call back. I'm sure he'll feel the same way.

Fairwind
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Date Joined Jul 2010
Total Posts : 3738
   Posted 9/21/2010 10:07 AM (GMT -6)   
You might want to review Pat Walsh's book, 2007 edition, pages 377-384...

skapod
Regular Member


Date Joined Nov 2008
Total Posts : 35
   Posted 9/21/2010 10:13 AM (GMT -6)   
I will look into it. Is there a specific title?

Red Nighthawk
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Date Joined Oct 2009
Total Posts : 289
   Posted 9/21/2010 10:19 AM (GMT -6)   
"Surviving Prostate Cancer", by Dr. Patrick Walsh

Fairwind
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Date Joined Jul 2010
Total Posts : 3738
   Posted 9/21/2010 10:19 AM (GMT -6)   
"Guide to surviving Prostate Cancer" by Dr. Patrick Walsh. Revised edition, 2007.

It's the bible of PC..Any bookstore, library, eBay, ...

Carlos
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Date Joined Nov 2009
Total Posts : 486
   Posted 9/21/2010 10:32 AM (GMT -6)   
Skapod,  Another good source of info is a paper recently published by Dr. Choo, Mayo Clinic.  He covers many of the issues dealing with recurrence after RP.  He has an informative section on PSA and some of the issues presented by the ultra sensitive test.  The article may give you some good insight on your situation.  This is the link:
 
 
Hope this helps.
Carlos

Diagnosed 2/2008 at age 71, PSA 9.1, Gleason score 5+3, stage T1c.
Robotic surgery 5/2008, LFPF at 6 wks.,nerves spared, stg. pT2c, N0, MX, R0, Gleason 5+3
PSA <0.1 at 26 months and at all tests since surgery.

skapod
Regular Member


Date Joined Nov 2008
Total Posts : 35
   Posted 9/21/2010 10:55 AM (GMT -6)   
Thank you all for your help. I will be going to the library today and checking out that site now. : )

Casey59
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Date Joined Sep 2009
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   Posted 9/21/2010 11:10 AM (GMT -6)   
skapod said...
His PSA levels have been .01 since surgery.  He took his current 6 month test and it came back .05.  I know that is still undetectable but we're still concerned that it rose at all. 
 
 
Hi scapod,
 
Well, the results you've reported here are not undetectable; they are indeed detectable, but they are very low and maybe still too low to worry about them very much.
 
An undetectable result using an ultrasensitive PSA test with two decimal points would have been reported as "less than" 0.01 ng/mL, or >0.01 ng/mL.  If you didn't inadvertantly leave of the ">" (less than) sign, then your husband's initial results were at the lower detection limit of the test, but not below the lower limit (i.e., not undetectable).  That's some fine details, but I added it here for your clarity and hopefully to make your discussion with your doctor more meaningful. 
 
The more important point is the most recent result of 0.05 ng.mL, and what it might mean.
 
The first thing to recognize is that there are some differences in how different labs analyze & report results, and sometimes doctors switch sending their blood results from one lab to another.  So, firstly verify that the recent and older tests were analyzed & reported by the same lab.  If by chance there was a change, then a re-baselining with several data points from the new lab will be appropriate before drawing any conclusions.
 
The next thing to recognize is that benign (non-cancerous) prostatic tissue left behind after surgery may be contributing to PSA in the bloodstream.  There will be small variations in the measured PSA as a result of the other various sources of PSA.  The prostate is (was) the main source of PSA, but other sources can contribute a very small but detectable level of PSA when the ultrasensitive PSA test is used.
 
Lastly, the increase may be due to the multiplication of cancerous cells which might have been left behind after surgery.  It's possible that there was a small amount which has finally become detectable via the PSA test.  The reference to Dr Patrick Walsh's book points to a section titled (from memory) "What to do when PSA rises after RP?"  Be aware that the American Urological Association defines biochemical recurrence (BCR) as two consecutive measurements above 0.20 ng/mL, but with your husband's ultrasensitive test sensitivity, he may see a recurrence coming...maybe, maybe not.
 
You didn't mention whether he had any positive surgical margins (PSM) or not; PSMs are more likely to have BCR.  Even if he had PSM, a small PSM is less likely to have BCR than a large PSM.  Also, the pathological Gleason result at the PSM is a strong progosticator of BCR; with low Gleason at the PSM to a strong indicator of no BCR.  Did he have positive surgical margins, and what was his final Gleason score?
 
hope that this helps have a meaningful discussion with the doctor...

skapod
Regular Member


Date Joined Nov 2008
Total Posts : 35
   Posted 9/21/2010 11:31 AM (GMT -6)   
Wow, you have been very informative and have given me food for thought and questions to discuss with his Dr. The one question I can answer now is that all test have been done in the same lab.

The "less than" sign that you used is actually the "greater than" sign, did you mean to say "greater than" 0.01?

When I have answers I will let you guys know. Thanks for all your help.

Sephie
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Date Joined Jun 2008
Total Posts : 1804
   Posted 9/21/2010 11:32 AM (GMT -6)   
Casey, are you sure about this?  My research indicates that there is only one definition of undectable...a PSA of less than 0.1.  Anything below this is often considered "background noise."  I have never heard about there being a difference in what constitutes undectable based on what PSA assay is used - not that this means it isn't true just trying to clarify since there is so much controversy over which assay should be used. 
 
Scapod, while I understand your concern for your husband (especially in light of his pathology), I wouldn't be too quick to jump the gun with a PSA of 0.05...regardless of what the original post op PSA result was.  See my signature below to understand why I am saying this. 
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!

Purgatory
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Date Joined Oct 2008
Total Posts : 25380
   Posted 9/21/2010 11:41 AM (GMT -6)   
Sephie, I agree with you. Post-surgery in particular, any thing <.10 is considered a technical zero. Not .01.

On the BCR issue, I am more comfortable with the standards they use in my area, that BCR is considered a fact when you have 3 consecutive rises above .10, not .20 as stated in Casey's post.

What I find interesting too, is that in my post-SRT world now, the doctors here consider .05 as evidence that there is still active PSA after radiation. What they want, is when it settles down, your PSA to<.05, to consider the SRT successful. That's why when my third reading went from .04 (the lowest it ever went) to .06 in 3 months, there is concern, and why I am waiting patiently for my November reading. Any upward movement now, from the .06 would not be a good thing. Unlike RT as a primary treatment, there isn't any PSA bounce with SRT, it should go down and down, and bottom out, and then stay there. That was the consensus of opinion with all the radiation oncologists and the medical oncologist that I have had dealings with say.

Like all things PC, different answers from different doctors in different areas

LV-TX
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Date Joined Jul 2008
Total Posts : 966
   Posted 9/21/2010 12:28 PM (GMT -6)   
David...interesting that your area is different than the standards set forth by the American Urologist Association and the European Association of Urology which put forth the guideline that PSA equal or greater than 0.2 with a subsequent test of greater than 0.2 as the definition of biochemical recurrence. It was also noted that failure of SRT was defined as anything above 0.3.

That would seem to contrary to what is used in your area. Do you know why they use a different standard? No wonder folks get so confused when doctors all use a different standards to advise patients from.
You are beating back cancer, so hold your head up with dignity

Les

Signature details in Sticky Post above - page 2

skapod
Regular Member


Date Joined Nov 2008
Total Posts : 35
   Posted 9/21/2010 12:58 PM (GMT -6)   
Sephie,

That's very encouraging news. Our plan is to get him tested again in three months, see what the results are and take it from there. Not jumping the gun just want to stay on top of it. I'm curious though, why was your husband tested every month?

skapod
Regular Member


Date Joined Nov 2008
Total Posts : 35
   Posted 9/21/2010 1:02 PM (GMT -6)   
By the way, these are my husband's stats:

Diagnosed: 8/24/08, age-47
Father died of prostate cancer at age 72
PSA 1.5 early 2007, 4.5 mid 2008, all remedies tried & reduced to only 3.2, uh oh.
Biop - 2 positives of 20 samples
Gleason - 3+3
RRP - 11/13/08 via Da Vinci method
Post op biopsy - 75% of samples positive for cancer, Post op Gleason 3+4
some lymph Nodes tested, all negative
all nerves spared - I'm told

Sephie
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Date Joined Jun 2008
Total Posts : 1804
   Posted 9/21/2010 1:52 PM (GMT -6)   
Skapod, my husband's PSA was checked every 3 months for the first 2 years because his surgical stage was upgraded to a T3a (there was extraprostectic extension) and the surgeon wanted to be extra careful...which we had absolutely no problem with.  The surgeon's guess as to why his PSA jumped up a year ago was that there was benign prostatetic tissue left (usually around the nerve bundles).  It is not uncommon with the nerve sparing procedures - at least according to our surgeon.  When my husband's PSA started to creep up, the uro/surgeon strongly cautioned us to not "jump the gun" with SRT until we had a confirmed upward trend.  Got real nervous when that second PSA came in a 0.3...it's been stead at 0.0 since October 2010.

142
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Date Joined Jan 2010
Total Posts : 6945
   Posted 9/21/2010 2:08 PM (GMT -6)   
Skapod,
 
Looks like Casey got his "less than" mixed up. He does have a good point on the pathology report. It should tell you about any "margins" - you want all negative, and either "Extra Capsular Extensions" or "Extra Prostatic Extensions". If they say positive margin(s) or ECE/EPE, then there is the possibility that cancerous tissue remained in the prostate bed.
 
I had a G 4+4 (in 7 of 12 samples) at biopsy, and was told that at that level, the surgeon did not want to save the nerves, as they very well could harbor cancerous tissue. That is a risk of nerve sparing. In fact he was right, path report showed extensions and G 4+5.
 
Just for peace of mind (or perhaps only certainty), if it were me, and the cost was not an issue, I would ask for a retest now.

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 9/21/2010 2:32 PM (GMT -6)   
les,

can't answer that question. only repeating what has been taught to me by my local area experts. i'm not the doctor, just the messenger.
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.

Casey59
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Date Joined Sep 2009
Total Posts : 3172
   Posted 9/21/2010 2:32 PM (GMT -6)   
skapod said...
Wow, you have been very informative and have given me food for thought and questions to discuss with his Dr. The one question I can answer now is that all test have been done in the same lab.

The "less than" sign that you used is actually the "greater than" sign, did you mean to say "greater than" 0.01?

When I have answers I will let you guys know. Thanks for all your help.
You are welcome; glad to help.  And you are absolutely correct that I mistakenly flipped the sign.  [This is the same reason that on a check you have to both write out the numbers and the words; whenever they are in conflict, the words overrule.  The thought being that the quick writing of the numbers (or in this case the sign) might be more prone to error than the writing out of the words.]  Thank you for pointing out my mistake; often these posts are re-read by others later, and I wouldn't want that to be uncorrected.
 
When the PSA result is less than the test's lower detection limit, it is undetectible....just let those words sink in for a minute, they are sort-of redundant.  (This is also answering Stephie's question.)  When it is below the detection limit of the test, it gets written out as less than the lower detection limit (LDL). 
 
So, if you had the "standard" PSA test which has a lower detection limit (LDL) of 0.1 ng/mL (just one figure to the right of the decimal point), and your test result was less than 0.1 ng/mL, it would be reported as "undetectable" or <0.1ng/mL (I got the sign correct that time).
 
On the other hand, your husband appears to have had what's known as the "ultrasensitive" PSA test which typically has a LDL of 0.01ng/mL.  [I say "typically" because there are more than one ultrasensitive PSA tests, with slightly different LDLs; the most common ultrasensitive PSA test has a LDL of 0.01 ng/mL, and the second most common has a LDL of 0.008ng/mL.]  Since his results were reported with two figures to the right of the decimal point, your husband's test was one of the ultrasensitive PSA tests.
 
Some doctors prescribe the standard test after RP, others prescribe the ultrasensitive test after RP.  In general, if the pathology report shows no positive surgical margins (PSM) or extraprostaic extension (EPE), and the final Gleason was 3+4 or less (maybe some other factors, too), then most doctors prescribe the standard PSA test because it is a low probability that the patient will have biochemical recurrence (BCR).  If, on the other hand, the patient had PSMs, EPE or 4+3 or greater, there starts to be a decent chance of BCR, and in these cases are best-suited for the ultrasensitive test in order to monitor more closely the early possible progression.  These, however, are just general rules; some doctors only prescribe, for example, the ultrasensitive test no matter what, and the opposite might also be true...but I've detailed out the most commonly accepted rules of thumb.
 
So, without putting words into Stephie's mouth, I think was she was saying was that even if someone has a detectible level of 0.05 ng/mL from an ultrasensitive test (as your husband did), that low level would have been undetectible if the standard test had been performed instead.  It is detectible from the test that was performed, but would likely have been undetectible on the standard test.
 
I hope that after all those words I have reduced, rather than increased, any confusion there might have been...
 
 
 
edit:  fixed typos

Post Edited (Casey59) : 9/21/2010 2:48:44 PM (GMT-6)


skapod
Regular Member


Date Joined Nov 2008
Total Posts : 35
   Posted 9/21/2010 3:54 PM (GMT -6)   
You have, and I truly appreciate you taking the time to explain them to me. We were told when he was diagnosed, and after surgery that this was not a cure, that there was a chance he could have a recurrence. The decisions to go the RP route was for several reasons, his is a very young man, 49 as of this date, 47 when diagnosed, saving the nerves, getting as much of, if not all of the cancer out if it was contained in the prostate, which according to the tests done on the lymphnodes it was, and also in case it did come back that he would then have the other options such as radiation etc. My hope is that this was a fluke or lab error, but my fear and rational thinking is kicking in so I want to take every precaution possible to nip it before it goes any further. Thank you ALL for your responses and support, they really mean alot. Please keep my husband in your prayers as I will keep all of you. Have a great night!

BillyMac
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Date Joined Feb 2008
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   Posted 9/21/2010 4:23 PM (GMT -6)   
Casey has explained very clearly the meaning of "undetectable" in relation to the different levels of sensitivity of the PSA test. I am a fan of the ultrasensitive test for this very reason, especially for those with higher BCR risk factors. I do not believe you can truly claim "undetectable" unless you set the bar as low as possible. Perhaps that's just the engineer side of me coming into play. Currently the lowest limit of detection is 0.003ng/mL ........ using the Diagnostic Products Corporation's "Immulite 2000" ......... but given the same sample can deliver a 20% variation at this level of detection (i.e. below 0.01) most labs will report only that it is somewhere less than 0.01 despite the fact the actual test reading obtained may have been say, 0.007ng/mL. On a side note there is no reason for the ultrasensitve test to cost any more than the standard test.
Bill

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 9/21/2010 4:26 PM (GMT -6)   
Billy - probably the old "supply and demand" trick at play once more on the cost, I agree with you
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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