Persistent PSA after RALP-next steps

I recently discovered this Forum--this is my first post.

A routine physical exam late August 2015, PSA of 6.3 and a nodule felt on the left side of my prostate during a DRE was followed by a biopsy in October (results in signature) and dx of prostate cancer. I decided for RALP which was performed just before New Year's Eve--surgeon spared one nerve, but removed the other. Should mention that my urologist was trained in urological surgery at Mass General, and oncology training at City of Hope.

Recovery from RALP has been relatively smooth, although frustrated that the return of continence has been slow--but it is returning.

Five weeks after surgery, my urologist/surgeon ordered PSA test--results was 0.2 ng/ml. He was not too concerned at the time, and indicated would take another test in 3 months. On May 12, I received the news that my PSA was 0.4, my urologist contacted me, and scheduled an appointment for the next day. The next week I met with a radiation oncologist to discuss options. RO would like to schedule a 6660 cGy in 37 fractions. The radiation would be 3D conformal radiation

Just before Memorial Day weekend, I met again with my urologist. He has suggested the following plan: another PSA at the end of June, if PSA is unchanged, then watch and measure again in two months. If the PSA continues to rise wants to start ADT immediately for 3 months, followed by salvage RT as described above, and maintained on ADT for 12-18 months. Then remove ADT and follow testosterone and PSA thereafter.

After the firs PSA at five weeks, I was not too concerned (neither was my urologist), but everything seems to have jumped into high gear since May 12.

I have tried to read as much as possible, which at times has really depressed me (especially concerns about mets), but I found this forum, and the individual stories and experience are more hopeful.

I know there are many experienced people on this forum and your thoughts on the above are appreciated. I am particularly nervous about ADT--I am a pretty active guy (about four weeks ago started cycling again 60-100 miles per week and do resistance training 3 x per week)--everything I have read about ADT has me concerned--but my urologist said to continue exercising, and that this approach is my best chance for a cure-- Thoughts?

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Age 61 @ DX
08/30/2015 PSA 6.3, DRE nodule left side, biopsy= Gleason 4+3 =7

RALP- Dec 30, 2015, PSA 7.2
Staging: pT2c, pN0.
Gleason: 4 + 3 = 7; focus suggestive of 5 representing much less than 5%.
Bilateral, Largest focus left side 1.6 CM, Largest focus right side, 0.2 CM.
Neg surgical margins.
Extraprostatic extension: not identified.
Seminal vesicles: negative for tumor.
Prostatic intraepithelial neoplasia high grade: present
Perineural invasion: present.
Angiolympahtic invasion: not identified
Lymph Node, right pelvic excision: neg 0/9
Lymph Node, left pelvic excision: neg 0/8

Post RALP PSA Feb 5, 2016 = 0.2
PSA May 13, 2016 =0.4

JWH -

I would certainly do another PSA test to confirm the 0.4-

You can figure, because the PSA has a long 1/2 life, the first test was too soon - Patrick Walsh says to wait at least 12 weeks - if I remember correctly-

Nothing is glaring in your post op pathology-

Labs do make mistakes!

Bobby Mac

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Age: 69, 69 at PC dx, PSA 6.7 Avodart (6.7 x 2.3 = 15.5)
Biopsy: 2/16 13 of 14 Positive, 2-99%, GL 8, 2nd look GL 7 (4+3)
RALP 4/20/16
Post OP Pathology:
Non-Focal EPE, 2 positive margins, Gleason 4+3=7, involving 50% of gland, prostate weight 31.5 g, Stage pT3a N1 Lymph node involvement: 2/10, right side positive, Diameter of largest N Metastisis 2 mm

Welcome to HW. I think your URO has a plan there. Get the .4 confirmed and then do the treatment. The ADT isn't fun and the side effects can be difficult to deal with, but the combo therapy does give the best chance of a cure.

Hang in there,
Andrew

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I'll be in the shop.
Age 56, 52 at DX
PSA:
4.2 10/11, 1.9 6/12, 1.2 12/12, 1.0 5/13, .6 11/13,
.7 5/14, .5 10/14, .5 4/15, .3 10/15, .3 4/16
G 3+4
Stage T1C
2 out of 14 cores positive
Treatment IGRT - 2/2012
My latest blog post

Welcome to HealingWell. Sorry you find yourself here but glad you found us. Hope we can help.

Nine out of ten times the advice we give here on the forum is to slow down, take your time, do your homework and then decide what to do. Good advice, that. But...

It seems to me that your urologist is dragging his feet a bit. PSA has a half-life and five weeks is too early... but... 0.2 is pretty high and 0.4 is higher. I can see another PSA test next month to verify the 0.4 but, if I were you I'd look to pull the trigger pretty quickly if the 0.4 level holds up.

A Gleason score of 4+3 -- with the pathologist muttering about focal bits that look like grade 5 -- puts you in a pretty high risk category. Unfortunately that sort of cancer seems to respond best to prompt, aggressive treatment.

As for being nervous about the ADT I very very much understand. One of my first postings here was about being scared at the prospect.

Hormone Therapy, the Pod Person and the Plan

But the advantage of ADT as a part of an attempt to salvage a cure is that it is temporary. If the salvage is successful then there will come a time when the shots will stop with you still on the green side of the sod. That's worth something.

Update: I see that the Tall One and I were typing at the same time again. That always makes me nervous since he is sooo much better at this than I am. But I am pleased to see that he and I are mostly in agreement on this one. Whew! (wipes brow.)

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63 Slow PSA rise 2007-2012: 1.4=>8
4 bxs 2010-2012: 1&2 neg, 3 pos 1/14 6(3+3) 3-4% (2^nd opn. 7(3+4)), 4 neg
DaVinci 6/14/12. "some" nerve sparing on left
Path: pT3a pN0 R1 GS9(4+5) Pos margins on rt
24 mo ADT3 7/12 - 7/14
Adj IMRT 66.6 Gy 10/17/12-12/13/12
8/2012-3/2015: Incont., Trimix, VED, PSA<0.015.
AUS & IPP installed 3/5/2015
Forum Moderator - Not a medical professional

Post Edited (PeterDisAbelard.) : 5/30/2016 1:07:23 PM (GMT-6)

They typically wait 2 months after ADT begins before starting SRT. That gives it time to radio-sensitize the nasty critters. Two months should be plenty time to meet with other ROs who use more up-to-date equipment. D'Amico questions the effectiveness of ADT on radio-sensitizing Gleason pattern 5 (but I question his analysis). So, while it's likely that the ADT will hold it in check, no one can guarantee that waiting for the Fall will be a good strategy.

I'm not familiar with ROs in Orange County, unfortunately. I know UC San Diego has a good RO department, and of course, UCLA and Cedars-Sinai do. USC is experimenting with shorter treatment times for SRT:

/clinicaltrials.gov/ct2/show/NCT02446366

JWH, you can take TA's advise to the bank...Find a new R.O. one that has access to a newer LINAC. That's the machine that will be treating you.. You want to be treated on a Varian RapidArc or newer. 40 fractions, 1.8 - 1.9 Gy per fraction for a total of 72 to 76 Grays..Also, and this is just my opinion, you should try to get one of the newer full body scans that can spot prostate cancer at a very early stage. If they can spot the source of your rapidly rising PSA they can treat it much more effectively...

I would try to hold off on the radiation until the incontinence issue is resolved..Radiation will freeze progress in that regard right where it is when treatment starts..Starting the ADT now is fine, it will stop the spread of your cancer and put it into remission until you are ready to start the radiation..

One more thing....If you have never consulted with a Medical Oncologist now would be a good time to do so...They have seen it all and a good one will have valuable insights as to how your treatment should progress. They will know and recommend an RO that uses modern equipment and has a good track record..

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Age now 73 . Diagnosed G-9 6/2010
RALP Sept 3 2010, pos margin, one pos vesicle nodes neg. Post Op PSA 0.9 SRT, HT. 2-15-'11 PSA <0.1 10/'11, <0.1 2/12, <0.1, 4/12 <0.1, 9/12, 0.8 3/13, 0.5 6/13, 1.1, back on HT. 5/16 stay the course, Lupron, Zytiga, PSA <0.1

There have been a few most about elevated PSA and cycling. As a Triathlete, I am concerned about this factor as I too have my taint pressed upon 6 to 8 hours a week and I'm due for a post hdr Brachy treatment PSA in 4 months. I'm a little intimidated to get back in saddle. Has there been any discussion about the amount of cycling you do and elevated PSA?. I dont know if there are any studies substantiating a correlation but it is a good discussion that can't hurt.

Best of luck

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51 engaged. PSA 1/15, 4.3 6/15, 3.1, 12/16 4.1
prostate biopsy 1/27/2016, G=7 (3+4). 48 grams positive in 2 cores. 0 cores right. 2 positive left. Cores > 30% cancer.
Review Biopsy JHU 03/01/2016, RALPH HRUBAN, M.D.
A) benign prostatic tissue, B) left mid: prostatic adenocarcinoma, 3+4=7 (grade Group 2) involving two of two cores (30%, 40%), (30% pattern 4.) C-F benign prostatic ti

JWH-

Do not know if this is applicable to you?

Antibodies interference with PSA testing

http://www.ncbi.nlm.nih.gov/pubmed/19264827

http://jco.ascopubs.org/content/30/5/e62.extract

http://www.clinchem.org/content/51/1/208.full

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Age: 69, 69 at PC dx, PSA 6.7 Avodart (6.7 x 2.3 = 15.5)
Biopsy: 2/16 13 of 14 Positive, 2-99%, GL 8, 2nd look GL 7 (4+3)
RALP 4/20/16
Post OP Pathology:
Non-Focal EPE, 2 positive margins, Gleason 4+3=7, involving 50% of gland, prostate weight 31.5 g, Stage pT3a N1 Lymph node involvement: 2/10, right side positive, Diameter of largest N Metastisis 2 mm

Bobby Mac--thanks for the links--this is news to me. My only comment is that most of my career, I have worked around laboratory animals (mice). To be through, I should probably have a PSA tested at another facility, but using a different assay or have my sample pretreated with heterophilic blocking agents-not even sure how to go about this---guess the first thing to do when I go in this week for a new PSA test is to ask the lab tech what kind of analytical instrument they use and raise this issue.

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Age 61 @ DX
08/30/2015 PSA 6.3, DRE nodule left side, biopsy= Gleason 4+3 =7

RALP- Dec 30, 2015, PSA 7.2
Staging: pT2c, pN0.
Gleason: 4 + 3 = 7; focus suggestive of 5 representing much less than 5%.
Bilateral, Largest focus left side 1.6 CM, Largest focus right side, 0.2 CM.
Neg surgical margins.
Extraprostatic extension: not identified.
Seminal vesicles: negative for tumor.
Prostatic intraepithelial neoplasia high grade: present
Perineural invasion: present.
Angiolympahtic invasion: not identified
Lymph Node, right pelvic excision: neg 0/9
Lymph Node, left pelvic excision: neg 0/8

Post RALP PSA Feb 5, 2016 = 0.2
PSA May 13, 2016 =0.4

Just thought I would post an update since my May 31 post. I have now had a bone scan and CT scan, both negative. I have a new Radiation Oncologist, who focuses on prostate cancer. He has spent a lot of time reviewing my case and also talking with colleagues. He is worried that I may have, micrometastasis and as several of you have indicated, does not want to wait too much longer to start ADT and SRT. He will use Volumetric Arc Therapy (VMAT) --I am meeting with him again this week, so I will report the exact protocol. Due to my continence issues (slow to recover but there are signs of recovery), he said he would be ok with waiting up to two months after we start ADT (I will start in the next couple of days), but advised not to wait longer. So I am looking at end of July or August to start SRT. I will stay on ADT for 6 months, then we will follow testosterone and PSA. He indicated to me that I probably only have a 20% chance that the cancer will be located in the fossa, but I am convinced it is worth a try as it is my only shot at a cure, although not a great shot.

He indicated that although I don't exactly fit the inclusion criteria, he is basing his approach on two recently published papers in The Lancet, details in ClinicalTrial.gov (NCT00110162 and NCT00423475), Duchesne et al (2016), Lancet Oncology, http://dx.doi.org/10.1016/S1470-2045(16)00107-8 and Carrie et al (2016) Lancet Oncology, http://dx.doi.org/10.1016/S1470-2045(16)00111-X

He is meeting with a group of ROs up in LA this Wednesday and will present my case, and said if there is any additional input or insights, or suggested approaches, he would let me know.

So having a complete blood workup this week, including testosterone and another PSA, and then we will start. The only thing that would change the currently trajectory is if my PSA was lower--but he indicated that was not likely. Thanks for all of your input--it provided the directions to seek out an additional RO, and I am comfortable with the plan going forward. Any additional insights would be appreciated.

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Age 61 @ DX
08/30/2015 PSA 6.3, DRE nodule left side, biopsy= Gleason 4+3 =7

RALP- Dec 30, 2015, PSA 7.2
Staging: pT2c, pN0.
Gleason: 4 + 3 = 7; focus suggestive of 5 representing much less than 5%.
Bilateral, Largest focus left side 1.6 CM, Largest focus right side, 0.2 CM.
Neg surgical margins.
Extraprostatic extension: not identified.
Seminal vesicles: negative for tumor.
Prostatic intraepithelial neoplasia high grade: present
Perineural invasion: present.
Angiolympahtic invasion: not identified
Lymph Node, right pelvic excision: neg 0/9
Lymph Node, left pelvic excision: neg 0/8

Post RALP PSA Feb 5, 2016 = 0.2
PSA May 13, 2016 =0.4

JWH

You may have pic but your mind is where it needed to be. I congratulate you for seeking out knowledgable information, not be frozen with fear, and getting on with the program that has the possibility of success. Proud of you and your actions- they were correct. Praying for death to those destructive little pic cells.

Just another quick update: my testosterone was 18 ng/dL (pre-lupron, July 1, 2016; 717 ng/dL). PSA <0.1 ng/ml.

RO decided to also do a CBC and put off Lupron injection until this week. Just received my CBC results and my hematocrit was down to 39 (pre-Lupron 46.6) and my hemoglobin was down, 13.1g/dL (pre-Lupron 15.7 g/dL) all other blood values (WBC, platelets, etc lower, but still within normal range).

As indicated in my messages above, I continue to cycle and go to the gym on a regular basis--every weekend since May, I am cycling with my friends (25-30 miles per ride), I don't experience shortness of breath when exercising and I am not wiped out afterwards.

Have not had the second Lupron injection yet--waiting to hear from RO, as I just had the CBC on Monday.

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Age 61 @ DX
08/30/2015 PSA 6.3, DRE nodule left side, biopsy= Gleason 4+3 =7

RALP- Dec 30, 2015, PSA 7.2
Staging: pT2c, pN0.
Gleason: 4 + 3 = 7; focus suggestive of 5 representing much less than 5%.
Bilateral, Largest focus left side 1.6 CM, Largest focus right side, 0.2 CM.
Neg surgical margins.
Extraprostatic extension: not identified.
Seminal vesicles: negative for tumor.
Prostatic intraepithelial neoplasia high grade: present
Perineural invasion: present.
Angiolympahtic invasion: not identified
Lymph Node, right pelvic excision: neg 0/9
Lymph Node, left pelvic excision: neg 0/8

Post RALP PSA Feb 5, 2016 = 0.2
PSA May 13, 2016 =0.4

Great news on your improving continence. I hope the trend continues.

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Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
•SBRT 9 yr onc. results •SBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog