PSA has started to rise 2 1/2 years after RP

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Carlos
Regular Member


Date Joined Nov 2009
Total Posts : 486
   Posted 11/10/2010 11:02 AM (GMT -6)   
My latest PSA took a little jump to 0.12  at the 2 1/2 year mark.  Will meet with my onc next week to put our plans in motion.   Is there a normal time frame for waiting between rechecks?  Have there been any improvements in imaging that might help determine if a recurrence is local or systemic?  My onc previously mentioned that Prostascint had not proven very reliable but MRI might be usefull.  Oh well, here we go again.
 
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 .12 at 2.5 years. All prior tests <0.1.

Galileo
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Date Joined Nov 2008
Total Posts : 696
   Posted 11/10/2010 11:38 AM (GMT -6)   
Hi.
Even if MRI indicated something in the area of the prostate bed, that would not mean you were clear of distant spread. And if MRI didn't show anything, that wouldn't necessarily mean the PSA was coming from distant spread--it still might be local.
As far as I know, the best tool is the Stephenson nomogram, which you can find in the form of an online calculator at www.mskcc.org/applications/nomograms/prostate/SalvageRadiationTherapy.aspx (a site from Memorial Sloan-Kettering Cancer Center). It takes into account margin status, amount of time you were free of recurrence, pre-RT PSA (a very important factor, btw), Gleason, seminal vesicle and lymph node status, etc. What you get is a statistical probability of success for men with your medical history. Not a crystal ball.

You might find the article by Nathan Roundy, "Nine Decisions Before Choosing Radiation Therapy After Prostatectomy" in PCRI Insights helpful. I thought it was very well done. You can find it here:

www.prostate-cancer.org/pcricms/sites/default/files/PDFs/Is13-2_p8-17.pdf
Galileo

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T2c, NX MX, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) Jan-Mar 2007
PSA 9/2007 and thereafter <0.1
pcabefore50.blogspot.com

pattersson
Regular Member


Date Joined Apr 2010
Total Posts : 97
   Posted 11/10/2010 11:40 AM (GMT -6)   
I had .14 but then it went down again. I had a retest at 3 months. From what Ive heard it is highly unlikely that any imaging technique would be able to spot the source of the psa, be it cancer or something more benign.
Radical prostactemy 10/2006 @42, PSA 3.9, Gleason 3+4
PSA <0.2 2006-2009

PSA 0.14 01/2010
0.07 05/2010
0.06 10/2010

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25364
   Posted 11/10/2010 11:45 AM (GMT -6)   
I dont think any kind of scan would show anything with a PSA of .12, so you might want to save the money and trouble. Also, I am assuming its your first reading above .10. The usual is to check in 3 months, then 3 months again, to see if you have 3 rises above .1 before calling it BCR.

Wouldn't hurt to talk to a good radiation oncologist at this point, just to have the basics of a game plan in place if you need it

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 Not taking it
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/23/10

Galileo
Veteran Member


Date Joined Nov 2008
Total Posts : 696
   Posted 11/10/2010 11:48 AM (GMT -6)   
I also don't think it would hurt to wait 90 days. However, if you show another rise, and you are considering salvage, at that point you should "start the clock" because you're best off starting SRT at or before 0.5. Optimally you would want to start then. If you miss that point, then you'd want to get started before 1.0, although there is no clear delineation of PSA readings when SRT would be guaranteed to fail. The pre-radiation PSA level has been shown, in multiple studies, to be a predicting factor for success.
On the other hand, you don't want to pull the trigger unnecessarily, as the other poster indicated.

Best--
Galileo

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T2c, NX MX, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) Jan-Mar 2007
PSA 9/2007 and thereafter <0.1
pcabefore50.blogspot.com

F8
Veteran Member


Date Joined Feb 2010
Total Posts : 3778
   Posted 11/10/2010 11:51 AM (GMT -6)   
i'd err on the side of caution and make arrangements with a radiation oncologist.
 
ed
age: 55
PSA on 12/09: 6.8
no symptoms, no prostate enlargement
12/12 cores positive....gleason 3+4 = 7
HT, BT and IGRT
received 3rd and last lupron shot 9/14/10

Carlos
Regular Member


Date Joined Nov 2009
Total Posts : 486
   Posted 11/10/2010 1:23 PM (GMT -6)   
Galileo,  Thanks for the reply.   The MSK nomograms indicate that PSADT has a significant impact on my probabilities.   The nomogram also suggests that adding neoadjuvant HT to SRT will significantly improve my odds of success.  For me, I think the most difficult part of the decision process will be whether or not to do SRT if the odds of success are low.  F8(ed), I have an experienced rad onc lined up just in case.   My pre surgery PSA had a 3 month doubling time and am not sure I can hold out for 90 days.  Patterson,  what did your doc say about your PSA rise, just lab error?
 
Carlos

julios
Regular Member


Date Joined Jun 2010
Total Posts : 38
   Posted 11/10/2010 2:45 PM (GMT -6)   
Ask a medical oncologist to consider a standard ductal and acinar adenocarcinomaPET scan. Recent research has shown it's efficacy in detecting local and distant PCa. The Choline C type PET scan is not yet available clinically, which is even better, but the common PET/CS has shown to detect high Gleason cancer. It was used on me recently and showed clearly some tumor in both the prostate bed and in 3 lymph nodes. The plan is to radiate next month. I'm on ADT now in hopes of shrinking the tumors first.

All the best
Age 52

At Diagnosis of PCa, had Gleason 9 and normal PSA

Radical Prostatectomy on July 7th, 2010 by Dr. Fagin using daVinci

25% to 50% nerves spared on left, 100% spared on right.

Continent from day one.

Pathology showed postive margins and extension beyond gland, including seminal vesicals and lymph nodes. Stage upgraded to T3b.

pattersson
Regular Member


Date Joined Apr 2010
Total Posts : 97
   Posted 11/10/2010 2:49 PM (GMT -6)   
I just discussed my case with the doc today. He says that one possibility for my numbers could be just measurement error and other random variation. Basically, i could have stationary psa but the measurement varies depending on random factors. The good news is that it does not appear to be increasing. The negative is that it is a bit elevated. I hopefully only have some relatively benign stuff left down there.
By the way, i am not sure that the nomogram should be interpreted in such a way that adjuvant HT is good. This is something that you should discuss with the doctor.
Radical prostactemy 10/2006 @42, PSA 3.9, Gleason 3+4
PSA <0.2 2006-2009

PSA 0.14 01/2010
0.07 05/2010
0.06 10/2010

Galileo
Veteran Member


Date Joined Nov 2008
Total Posts : 696
   Posted 11/10/2010 9:25 PM (GMT -6)   
Carlos, you hit the nail on the head--what to do if your odds of success are low?  Because the other way, your decision is almost made for you.
 
In my case, my odds of success in the short time frame provided by the nomogram are 38%.  So far, it looks like I'm in the 38%.  But you should be aware that Catalona and others have shown that at 10 years out from SRT, the overall odds of being progression free are 25%.  The odds are better if you have a complete response (i.e. PSA falls below 0.1).   Complete responders have a 35% chance of being progression free 10 years after SRT.  So the odds are almost certainly against all of us SRT guys, given enough time.   Of course, having PSA progression later on does not mean one will die from prostate cancer, but it is something I think about, especially given my age.  If my PSA starts rising in the next few years, there's a better than even chance prostate cancer will be the end of me.
 
Another way to look at it is that the gamble is (generally--there are always exceptions) not a bad one.  Usually the side effects from SRT are mild, especially compared to what men have already gone through from the surgery.  That was my experience, and that of some others here, though not all.   So that's the downside of the gamble--the risk it won't work and the person ends up with a lower quality of life.   The upside is tremendous, however--a second chance at a cure.  And even failing a cure, SRT can buy years of life free from the side effects of hormone therapy and chemo.
 
For Dr. Catalona's study, see the abstract here:
 
 

Galileo

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T2c, NX MX, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) Jan-Mar 2007
PSA 9/2007 and thereafter <0.1
pcabefore50.blogspot.com

Carlos
Regular Member


Date Joined Nov 2009
Total Posts : 486
   Posted 11/11/2010 5:30 AM (GMT -6)   
Thanks for all the replies.  Julios, what was your PSA at the time of your MRI?  Just curious, since PET scans aren't generally used with PCa.  ed(F8), Did you go to Dr. Sartor in New Orleans?  Galileo, I noticed that you did not have HT along with your SRT.  Do you mind sharing your thinking?  For my stats, the MSK nomograms show a two to four fold improvement on odds of success.  I don't have any qualms about using HT if it provides that kind of benefit.  I'm 74 now and am fortunate to enjoy very good health and could easily live into my 90s were it not for the PCa.   So, unless we can rule out lab error and do confirm the recurrence, i'm ready to start.
 
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 .12 at 2.5 years. All prior tests <0.1.

Post Edited (Carlos) : 11/11/2010 5:11:08 AM (GMT-7)


Galileo
Veteran Member


Date Joined Nov 2008
Total Posts : 696
   Posted 11/11/2010 10:15 AM (GMT -6)   
Carlos, to answer your most recent question, when my PSA rose after surgery I consulted both a medical oncologist and a radiation oncologist. The medical oncologist said, basically "You've got a positive margin--go get radiation. Your PSA will probably come down. Hopefully you'll never need my services."

The radiation oncologist also did not recommend HT.

I'm aware that there are studies that show HT seems to enhance radiation. However, I'm glad that I didn't have it, because I would have wondered for a long time whether I was seeing a (possible) cure from the SRT, or just a temporary reprieve granted by the HT, or some combination. The picture gets muddied, in my opinion. So having just radiation prevented a lot of anxiety on my part, and I did not have to be bothered by the side effects of HT. I know what caused my remission.

That's just my outlook on HT, SRT, and me, and I have no argument with doctors or patients who combine HT with SRT.
Galileo

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T2c, NX MX, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) Jan-Mar 2007
PSA 9/2007 and thereafter <0.1
pcabefore50.blogspot.com

Carlos
Regular Member


Date Joined Nov 2009
Total Posts : 486
   Posted 11/15/2010 1:43 PM (GMT -6)   
Met with my uro onc this morning and he sounded as if he had been talking to pattersson and Galileo.  He said the recent increase in my PSA could well be due to some benign tissue or lab error.  We agreed to test monthly for the next few months to see if there is any trend.  If my PSA is indeed rising, he wants to start SRT well below the 0.4 level.  Since we have a new Varian Rapid Arc available, he also recommends full pelvis radiation.  He does not recommend adjuvant HT but if I really want it, I can have it. 
 
Carlos

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3624
   Posted 11/15/2010 4:57 PM (GMT -6)   
In my case, I talked with 3 different doctors, isolated from each other, different specialties, they all said "with your risk factors, Gleason 9, positive margin, positive vesicle, you need to do all 3, surgery, radiation, hormones..." Hit it as hard as you can as soon as you can..I fought having to do HT as hard as I could, they all said that's up to you but I would not recommend it..

So every case is different, we all have different doctors and we all get different treatment recommendations..

I have found the managing my treatment is just as difficult as coping with the PC itself..
Age 68.
PSA at age 55: 3.5, DRE normal. Advice, "Keep an eye on it".
age 58: 4.5
" 61: 5.2
" 64: 7.5, DRE "Abnormal"
" 65: 8.5, " normal", biopsy, 12 core, negative...
" 66 9.0 "normal", 2ed biopsy, negative, BPH, Proscar
" 67 4.5 DRE "normal"
" 68 7.0 third biopsy positive, 4 out of 12, G-6,7, 9
RRP Sept 3 2010, pos margin, one pos vesicle nodes neg. Post Op PSA 0.9 SRT, HT, Dec
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