PCa predictions from PSA Velocity

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kbota
Regular Member


Date Joined Aug 2010
Total Posts : 486
   Posted 11/18/2010 7:29 PM (GMT -6)   
The information below is a copy/paste from a (free) Johns Hopkins e-newsletter.
(to the mods: I hope I haven't broken any rules by posting it. If I have, then please delete or adjust as necessary.)

I found the information very interesting.

k


What Is PSA Velocity and How Is It Used to Screen for Early Prostate Cancer?


The prostate-specific antigen (PSA) test measures an enzyme produced almost exclusively by the glandular cells of the prostate. It is secreted during ejaculation into the prostatic ducts that empty into the urethra. PSA liquefies semen after ejaculation, promoting the release of sperm. Normally, only very small amounts of PSA are present in the blood. But an abnormality of the prostate can disrupt the normal architecture of the gland and create an opening for PSA to pass into the bloodstream. Thus, high blood levels of PSA can indicate prostate problems, including cancer. PSA blood levels are expressed as nanograms per milliliter (ng/mL).

PSA velocity is a measurement that takes into account annual changes in PSA values, which rise more rapidly in men with prostate cancer than in men without prostate cancer. A study from Johns Hopkins and the National Institute on Aging found that an increase in PSA level of more than 0.75 ng/mL per year was an early predictor of prostate cancer in men with PSA levels between 4 ng/mL and 10 ng/mL.

PSA velocity is especially helpful in detecting early cancer in men with mildly elevated PSA levels and a normal digital rectal exam. It is most useful in predicting the presence of cancer when changes in PSA are evaluated over at least one to two years. In a study reported in The New England Journal of Medicine, a rapid rise in PSA level (more than 2 ng/mL) in the year before prostate cancer diagnosis and surgical treatment predicted a higher likelihood that a man would die of his cancer over the next seven years.

Moreover, a Johns Hopkins study published in the Journal of the National Cancer Institute found that a man's PSA velocity 10 to 15 years before he was diagnosed with prostate cancer predicted his survival from the disease 25 years later. In the study, 92% of men with an earlier PSA velocity of 0.35 ng/mL or less per year had survived, compared with 54% of men whose PSA velocity was greater than 0.35 ng/mL.
Age 57 at Dx
5/09 PSA 2.26
6/2010 PSA 3.07 FPSA 18% DRE +
Biopsy, 7 of 18+, >60%, 4+5=9
7/21/2010 - RRP
Nodes neg, Ves neg
tumor contained, still 4+5=9
pni ext.
9/3, 2010 PSA - 0.04
9/3/2010, I'm 99% continent
10/14/10, PSA still 0.04, and lupron #1, now 99.9% continent
Total ED, 3 caverject failed
10/20/10 OD'd .5cc trimix, after 3hrs, neo synephrine shot
tried .15 & .17 cc neg, next .2

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 11/18/2010 7:55 PM (GMT -6)   
you are preaching to the choir on the subject of PSA velocity with me. My PSA nearly tripled in the year before surgery, and in the 2 months between treatment choice and waiting for surgery, my PSA rose another 33%. Some scary stuff, considering that I never had any infections, no UTI's, a string of negative DRE's, and no urinary symptons prior to my PC dx.

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

goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2691
   Posted 11/18/2010 8:18 PM (GMT -6)   
K

Wonder if Gleason trumps the rate ?
Goodlife
 
Age 58, PSA 4.47 Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09   Nerves spared, but carved up a little.
0/23 lymph nodes involved  pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks .
Neg Margins, bladder neck negative
Living the Good Life, cancer free  6 week PSA  <.03
3 month PSA <.01 (different lab)
5 month PSA <.03 (undetectable)
6 Month PSA <.01
1 pad a day, no progress on ED.  Trimix injection
No pads, 1/1/10,  9 month PSA < .01
1 year psa (364 days) .01
15 month PSA <.01

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3744
   Posted 11/18/2010 8:25 PM (GMT -6)   
Same here..Just another envelope full of bad news..

These studies seem to overlap..I read about this over a year ago..

This is just a wild unscientific guess: When the cancer breaches the capsule wall, the PSA measured in the blood takes off..Good a guess as any..

Many men are taking Proscar or Avodart for BPH..They get a PSA test, looks good, but maybe not..Most doctors compensate and double the numbers but some slip through the cracks, the doctor unaware the patient is taking the BPH drug...That can be a costly error..

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4227
   Posted 11/18/2010 8:46 PM (GMT -6)   
Gleason always trumps psa until psa gets over 20, which indicates a high probability of matastisis. There is a very specific relation between gleason and psa. The higher the gleason the lower the psa the tumor will generate. Psa kenetics, velocity and doubling time, are a good indicator of how fast the tumor is growing. There is also a mathamatical relationship in which you can determine tumor size by gleason and psa.
Since tumor size is a very important factor in both surgical and radiation cure rates I don't know why more doctors don't use these established formulas in coming up with their treatment recommendations.
JT
65 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, no side affects and psa .1 at 1.5 years.

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3744
   Posted 11/18/2010 9:12 PM (GMT -6)   
"I don't know why more doctors don't use these established formulas in coming up with their treatment recommendations." <JohnT>

That might have a negative outcome on surgeons and to a lesser extent R-docs annual income..

There is a lot of room for improvement in how Prostate Cancer is diagnosed and treated...

goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2691
   Posted 11/18/2010 9:35 PM (GMT -6)   
John,

I have heard you say that many times, I just found it curious that the article never mentions Gleason. Just mortality by doubling time. I guess maybe the low PSA, high gleason ratio may actually take care of that in their study, whether they considered it or not.
Goodlife
 
Age 58, PSA 4.47 Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09   Nerves spared, but carved up a little.
0/23 lymph nodes involved  pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks .
Neg Margins, bladder neck negative
Living the Good Life, cancer free  6 week PSA  <.03
3 month PSA <.01 (different lab)
5 month PSA <.03 (undetectable)
6 Month PSA <.01
1 pad a day, no progress on ED.  Trimix injection
No pads, 1/1/10,  9 month PSA < .01
1 year psa (364 days) .01
15 month PSA <.01

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 11/18/2010 9:51 PM (GMT -6)   
The most recent medical oncologist I spoke with locally, would definitely say that high velocity trumps gleason. Again, no agreement even among the experts or professionals.
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

proscapt
Veteran Member


Date Joined Aug 2010
Total Posts : 644
   Posted 11/19/2010 1:06 AM (GMT -6)   
In discussion of "x trumps y" we should probably consider whether we are talking about two pieces of data that are both prior to surgery or we are talking about a pre-surgery statistic of PSA or Gleason compared to the post surgery pathology report.

In my case, my PSA jumped 2 ng in the 3 months just prior to surgery, however, the path report came back clean. The docs I spoke with said that although the jump in PSA is generally of concern, that the favorable pathology trumps the high pre-op PSAV.

The research Kbota found said...
In a study reported in The New England Journal of Medicine, a rapid rise in PSA level (more than 2 ng/mL) in the year before prostate cancer diagnosis and surgical treatment predicted a higher likelihood that a man would die of his cancer over the next seven years.


This research was followed up by another study which said that the high PSAV was predictive of poor pathology (EPE+, SM+ etc.) but NOT of early mortality once these pathology features were taken into account.

See:

"Among the 852 consecutive patients in our series2 (1989 to 2002; median follow-up, 3.4 years [range, 0.4 to 14.6]) and who met the eligibility criteria of D'Amico et al., a PSA velocity of more than 2.0 ng per milliliter per year was associated with more advanced clinical and pathological stages, but not with recurrence of cancer or a reduction in overall survival. The probability of death from any cause at seven years was 7 percent (95 percent confidence interval, 5 to 9 percent) among those with a PSA velocity of 2.0 ng per milliliter per year or less and 7 percent (95 percent confidence interval, 2 to 13 percent) among those with a PSA velocity of more than 2.0 ng per milliliter per year.” Source: Bianco, Kattan, Scardino in JAMA www.nejm.org/doi/full/10.1056/NEJM200410213511723

and...

Pretreatment Prostate-Specific Antigen (PSA) Velocity and Doubling Time Are Associated With Outcome but Neither
Improves Prediction of Outcome Beyond Pretreatment PSA Alone in Patients TreatedWith Radical Prostatectomy

Matthew Frank O’Brien, Angel M. Cronin, Paul A. Fearn, Brandon Smith, Jason Stasi, Bertrand Guillonneau,
Peter T. Scardino, James A. Eastham, Andrew J. Vickers, and Hans Lilja

and...
Urology. 2007 May;69(5):931-5. Assessment of prostate-specific antigen doubling time in prediction of prostate cancer on needle biopsy. Spurgeon SE, Mongoue-Tchokote S, Collins L, Priest R, Hsieh YC, Peters LM, Beer TM, Mori M, Garzotto M. which found: "In contrast to its prognostic value after the diagnosis of prostate cancer has been established, PSA kinetics offer little to clinical decision making as predictors of cancer or high-grade cancer in men with a PSA level of 10 ng/mL or less."

BuiDoi
Regular Member


Date Joined Aug 2010
Total Posts : 234
   Posted 12/10/2010 11:14 PM (GMT -6)   
John T said...
Gleason always trumps psa until psa gets over 20,........... There is a very specific relation between gleason and psa. The higher the gleason the lower the psa the tumor will generate.


Whilst the comment a a little old now, are you sure of the comments.
Mechanically, I would have assumed that Gleason and Velocity would have been similar curves, for which the slope would have a factor in the PSA...

" The higher the gleason the lower the psa the tumor will generate." -- Do you recall where you got this from, because in my mind it would imply that as the cancer becomes more aggressive, it would be notionally increasing the Gleason (but you would not be aware of it) whilst the PSA would be falling.. ie. One could think that you were getting BETTER, when you were actually getting far worse.
.
.
Nov 2009 = First-PSA 5.3 @ 60yo - Asymptomatic - DRE-Non-Palpable
Jan-'10 = TRUS Bx DX - AdenoCar T1c - GS(3+3)=6 , 5 & 45% max., L-MidZone
May-'10 = RRP-Nrv-Spare
Post Op. GS(3+4)=7, 1.1cm3, Pos Margins, EPE (focal) Lateral Left
Margin-Involvement (extensive) Posterior , Grade3 x 8mm
+8week PSA<0.01, ED-85%, Incont-30%
+16W PSA<0.01, ED -85%, Cont -5%
+17W First 'DRY' day. ED -90%

BillyMac
Veteran Member


Date Joined Feb 2008
Total Posts : 1858
   Posted 12/11/2010 1:49 AM (GMT -6)   
John is right BuiDoi,
Grade 5 cells produce about half the PSA of grade 4 cells which in turn produce about half the PSA of grade 3 cells. It is for this reason that aggressive PCa can be present even when the blood PSA reading is quite low. I for example, had a maximum PSA of 4.1 prior to surgery, nothing felt on DRE, yet post surgery pathology revealed a preponderance of grade 4 cells (80%) occupying much of one side of the gland, top to bottom and about half of the other side had a separate tumour about 50% grade 4.
Bill
Biopsy

4 of 10 cores positive for Adenocarcinoma-------bummer!
Core 1 <5%, core 2----50%, core 3----60%, core 4----50%
Biopsy Pathologist's comment:
Gleason 4+3=7 (80% grade 4) Stage T2c
Neither extracapsular nor perineural invasion is identified
CT scan and Bone scan show no evidence of metastases
Da Vinci RP Aug 10th 2007

Post-op

Positive for perineural invasion and 1 small focal extension
Negative at surgical margins, negative node and negative vesicle involvement
Some 4+4=8 identified ........upgraded to Gleason 8
PSA Oct '07 <0.1 undetectable
PSA Jan '08 <0.1 undetectable
PSA April '08 <0.001 undetectable (disregarded due to lab "misreporting")
PSA August '08 <0.001 undetectable (disregarded due to lab "misreporting"-----it is not possible for any lab to get a reading of less than .003)

Post-op pathology rechecked by new lab:

Gleason downgraded to 4+3=7
Focal extension comprised of grade 3 cells
PSA September '08 <0.01 (new lab)
PSA February 09 <0.01
PSA May '10 <0.01

www.yananow.net/Mentors/BillM2.htm

Never underestimate old people ............ you don't get to be old by being stupid.

BuiDoi
Regular Member


Date Joined Aug 2010
Total Posts : 234
   Posted 12/11/2010 3:11 AM (GMT -6)   
BillyMac said...
John is right BuiDoi,
Grade 5 cells produce about half the PSA of grade 4 cells which in turn produce about half the PSA of grade 3 cells. It is for this reason that aggressive PCa can be present even when the blood PSA reading is quite low.


Bloody Hell ! So an unthinking doctor, seeing a rising and then a falling PSA and doing nothing, can be condemning the patient to misery, and alternatively an unseen rise and fall and then have a PSA reading of low value, can create a false "I'm Fine" attitude, just prior to finding full-mets.

My PSA dropped just prior to the RRP (Psa5, G6)and I chose to believe that I was controlling the cancer (Psa4.5), but when the biopsy came back (G7) after the RRP, I was worse than expected .

Buggar ! . skull

What can you believe as FACT for YOUR condition.. Are you a 5 on the rise or a 5 after the fall
.
.
Nov 2009 = First-PSA 5.3 @ 60yo - Asymptomatic - DRE-Non-Palpable
Jan-'10 = TRUS Bx DX - AdenoCar T1c - GS(3+3)=6 , 5 & 45% max., L-MidZone
May-'10 = RRP-Nrv-Spare
Post Op. GS(3+4)=7, 1.1cm3, Pos Margins, EPE (focal) Lateral Left
Margin-Involvement (extensive) Posterior , Grade3 x 8mm
+8week PSA<0.01, ED-85%, Incont-30%
+16W PSA<0.01, ED -85%, Cont -5%
+17W First 'DRY' day. ED -90%

Post Edited (BuiDoi) : 12/11/2010 2:33:14 AM (GMT-7)


montee
Regular Member


Date Joined Mar 2007
Total Posts : 315
   Posted 12/11/2010 7:40 AM (GMT -6)   
As you can see by my signature, my psa rose approx. 1 point per year for 3 years starting at 1.8 and because it was lower than 4 the uro said normal. After it got over 4 he did the biopsy, it only took me a couple min. on the internet to find psa velosity and yet this uro took no notice. So I guess I was doing watchful waiting and didn't notice, in the mean time after surgery I had 40% tumor involvement, if my uro had taken notice of the rise in psa a 3 years earlier, my volume and possibly gleason would have been a lot less.

by the way, why doesn't my signature show up any longer

Post Edited (montee) : 12/11/2010 6:43:31 AM (GMT-7)

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