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Medical Forum / Diseases and Disorders / Prostate Cancer / February 2006When did you 1st get tested for PSA post RP and become undetectable?
Curious as most you know my recent post RP PSA (7 weeks) was 0.5. My Sloan surgeon recommended I see a Radiloogy Oncologist. My brother had his RP at Johns Hoplkins around 4 years ago and was not tested until 3 months. I am wondering whether this is just residual or whether there is a difference of opinion as to when to initate PSA testing? - When do most people get tested post-RP? - Wondering what the average timeframe is that most RP patients PSA scores become undetachable? Last March, when I had my open RP, I was told to get a blood draw in 4 weeks. It was undetectable. As was the next one 6 months later. Another is due THIS April. Best of health, Ron B. Chicago > Curious as most you know my recent post RP PSA (7 weeks) was 0.5. My > Sloan surgeon recommended I see a Radiloogy Oncologist. My brother had [quoted text clipped - 8 lines] > - Wondering what the average timeframe is that most RP patients PSA > scores become undetachable? I seem to remember getting test very shortly after my RP, and it was undetectable.  Signature"Don't get me wrong... I'm SNARKY" JK Sinrod Sinrod Stained Glass Studios www.sinrodstudios.com Coney Island Memories www.sinrodstudios.com/coneymemories My PSA at three weeks was <.1 and at three months <.1. I'm not sure what qualifies as undetectable. Tom > My PSA at three weeks was <.1 and at three months <.1. I'm not sure > what qualifies as undetectable. > According to Strum & Pogliano, undetectable PSA is any value of <0.05 ng/mL *while on ADT*. (_A Primer on Prostate Cancer_ , page 144) Someone else (I disremember who) wrote of beginning intermittent ADT after a relatively short period of undetectable PSA. Strum & Pogliano recommend a record of undetectable PSA for at least one year before beginning an "off-phase." (ibid, page 145 et seq.) Regards, Steve J "We must tailor the treatment to the nature of the disease. We must listen to the biology." -- Stephen B. Strum, MD One study showed the mean half-life of PSA after open RRP was 1.416 ± 0.723 days for free PSA and 2.43 ± 0.688 days for total PSA. i.e., total PSA should drop by 50% every 2-1/2 days post-op, or by 99.9% in about 25 days. IOW, if it was 10 pre-op, it should be unmeasurable (less than .006) within a month or so. If not, there is still a PSA source there. I.P. > Curious as most you know my recent post RP PSA (7 weeks) was 0.5. My > Sloan surgeon recommended I see a Radiloogy Oncologist. My brother had [quoted text clipped - 8 lines] > - Wondering what the average timeframe is that most RP patients PSA > scores become undetachable? My urologist told me not to get a PSA test until 3 months after an RRP as the results could be mis-leading. The results were: 3 mo = 0.03, 9 mo = 0.07, 12 mo = 0.08, 18 mo = 0.05. I was worried about the upward trend until the last reading. i got my first psa 3 weeks after rp go 3-2-6 for second test first was 0 rp 10-7-5 psa 3.9 gleason 3+3 Good luck....hope you stay that way! A point to keep in mind is that additional PSA can be released into the system during the handling and cutting of the prostate that occurs during the surgical process. Hence your "starting" PSA may be higher than your pre-op PSA...Ron Based on that, then Dominic, 4.2 12/13 2.1 2½ days later 1.05 12/18 0.5 2½ days later 0.25 12/23 That would explain your doc's concern. SignaturePSA 16 10/17/2000 @ 46 Biopsy 11/01/2000 G7 (3+4), T2c RRP 12/15/2000 G7 (3+4), T3cN0M0 Neg margins PSA .1 .1 .1 .27 .37 .75 EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 Lupron 07/03 (1 mo) 8/03 (4 mo), 12/03, 4/04, 09/04, 01/05, 5/05, 10/05 PSA .07 .05 .06 .05 .08 Non Illegitimi Carborundum > One study showed the mean half-life of PSA after open RRP was 1.416 ± > 0.723 days for free PSA and 2.43 ± 0.688 days for total PSA. i.e., total [quoted text clipped - 16 lines] >> - Wondering what the average timeframe is that most RP patients PSA >> scores become undetachable? > - Wondering what the average timeframe is that most RP patients PSA > scores become undetachable? Depends on the test maker if http://www.prostatepointers.org/prostate/ed-pip/psa.html is to be believed: Detection limits are one measure of the reproducibility of the PSA assay near zero PSA concentration. Detection limits of some of the assays used in the United States are given in Table 3. This information was obtained from phone calls and postings on the PPML. Table 3. Detection Limit Assay Name Company Name 0.1 ng/ml Tandem-R Hybritech, Inc. 0.1 ng/ml Tandem-E if automated, Hybritech 0.3 ng/ml Tandem-E if run manually, Hybritech 0.05 ng/ml Tosoh Tosoh Medics 0.1 ng/ml IMX Abbott Lab 0.1 ng/ml ACS-1 Ciba-Corning Diagnostics 0.05 ng/ml ACS-2 Ciba-Corning Diagnostics 0.03 ng/ml Immulite Diagnostic Products Corp. 0.007 ng/ml ultrasensitive, Corning Nichols Institute but usually only reports >0.02 ng/ml This is a personal opinion but shared by many in the medical and academic community - if you are not getting your PSA done using an ultrasensitive assay (see Ross's post), you will NEVER know if you truly achieved undetectability. Bill Denton RP 2/12/02 PSA .67 Memphis Bill ....curious your PSA is .67 mine is .55 (or .5(different labs) yet my uro is suggesting radiation. By some of these standards you are detectable too? If I may get nosy.... what does your Dr say to you? Dominic....I think you are doing what I tend to do all the time: misread the decimal point placement. My understanding is that the convention is 0.1 or above is detectable, and 0.2 or above is recurrence. By any standard, a 0.55 or a 0.67 is detectable. I thought you generally hit lowest PSA within a month or so of RRP, but I'll defer to others on that. Fred By ANY standard I am detectable, as are you. Salvage RT is only a cure if the recurrence is local-only so the determinitive question whether the recurrence is local-only or systemic. Unfortunately there are no tests that will tell you that so you pretty much have to look at your numbers and pathologic findings. I had seminal vesicle involvement, which is a (if not THE) negative predictor for a durable response to SRT. Based primarily on that I have concluded that I most likely have systemic disease and decided to forgo SRT. All of the doctors I have seen, rad-onc, med-onc, and uro, have concurred w/ my assessment but recommended SRT anyway since it is the only chance of cure. On the other hand, Dr. Strum via e-mail figured I had a 96% probability of systemic disease, and is staunchly anti-SRT in circumstances like that. The reason I advocate the ultrasensitive assay is that whether or not you ever achieved true undectability becomes an important diagnostic factor if you later recur, and will figure into the determination of salvage Tx. Ron, per their website, the Beckman-Coulter test is sensitive to <.0008, which is about as close to 0 as you can get. The report to you of "0" is actually the dumbed down number - I suspect that the actual test result was was <.0008. Bill Denton RP 2/12/02 PSA .67 Memphis > the determinitive question whether > the recurrence is local-only or systemic. Unfortunately there are no > tests that will tell you that so you pretty much have to look at your > numbers and pathologic findings. You and I are getting dramatically different data. Do you have some reason to ignore the relatively new but now FDA-approved combined CT/PET scans for detecting small mets? > I had seminal vesicle involvement, which is a (if not THE) > negative predictor for a durable response to SRT. Research by Amling et.al. shows the primary negative predictors are PSA dynamics -- especially DT -- and Gleason 8-10. (I haven't bought the $19 trials result yet, but will). My onc knows Amling and respects his work. > Based primarily on that I have concluded that I most likely have > systemic disease and decided to forgo SRT. All of the doctors I have > seen, rad-onc, med-onc, and uro, have concurred w/ my assessment but > recommended SRT anyway since it is the only chance of cure. On the > other hand, Dr. Strum via e-mail figured I had a 96% probability of > systemic disease, and is staunchly anti-SRT in circumstances like that. Did he say why? The obvious (SEs), or just useless for your case? The only decision I reach from disagreements like these, and they're common, is this: Keep clicking and reading until we reach one of three end points: 1. Eureka! This resolves the dispute. 2. Crap! Not even the latest knowledge resolves the dispute. 3. Screw it. I'm choosing based on some other factor. I.P. "You and I are getting dramatically different data. Do you have some reason to ignore the relatively new but now FDA-approved combined CT/PET scans for detecting small mets?" I.P., I'm not so much ignoring it as being unaware of it - I believe you are the only one who has mentioned it. I did a quick Google search and found nothing on any study in which CT/PET has been demonstrated to identify "small mets" respecting recurrent PCa. Some articles on lung, head & neck, and rectal cancer but none on PCa. Now, a met is a met and I assume if it can pick up lung cancer mets it can pick up PCa mets, but the question would be how sensitive it is - i.e. how small can the mets be and at what level of PSA do they become detectable. As far as FDA approval is concerned, that only means that the equipment is safe - there is no implication that it is the greatest thing since sliced bread, as you seem to think. I hope you are right - where are you getting your data? "I had seminal vesicle involvement, which is a (if not THE) negative predictor for a durable response to SRT." "Research by Amling et.al. shows the primary negative predictors are PSA dynamics -- especially DT -- and Gleason 8-10. (I haven't bought the $19 trials result yet, but will). My onc knows Amling and respects his work." Some excerpts: "The initial response to sRT was more frequently achieved in men who had lower PSA levels before RRP and sRT. The only predictor for early recurrence following sRT was seminal vesicle invasion." "By multivariable analysis, predictors of progression were Gleason score of 8 to 10 (hazard ratio [HR], 2.6; 95% CI, 1.7-4.1; P<.001), preradiotherapy PSA level greater than 2.0 ng/mL (HR, 2.3; 95% CI, 1.7-3.2; P<.001), negative surgical margins (HR, 1.9; 95% CI, 1.4-2.5; P<.001), PSA doubling time (PSADT) of 10 months or less (HR, 1.7; 95% CI, 1.2-2.2; P = .001), and seminal vesicle invasion (HR, 1.4; 95% CI, 1.1-1.9; P = .02). . . . Conclusions Gleason score, preradiotherapy PSA level, surgical margins, PSADT, and seminal vesicle invasion are prognostic variables for a durable response to salvage radiotherapy." [The Stephenson, Sloan-Kettering study] "Univariate analysis demonstrated two factors that significantly predicted for successful salvage treatment: the absence of seminal vesicle invasion and the absence of lymphovascular invasion. A pretreatment PSA level less than 0.425 ng/mL trended toward statistical significance (P = 0.059). Only seminal vesicle invasion maintained significance on multivariate analysis. The RT was well tolerated, and the gastrointestinal and genitourinary toxicity was largely Radiation Therapy Oncology Group grade 1. CONCLUSIONS: Salvage RT is moderately effective in treating patients with locally persistent or recurrent prostate adenocarcinoma. Seminal vesicle invasion and lymphovascular invasion predicted for unsuccessful treatment." "In this cohort, a Gleason score [tumor grade] of 8 to 10, pre radiotherapy PSA level greater than 2.0 ng/mL, negative surgical margins [no evidence of cancer cells in the edges of the removed tissue], PSA doubling time (PSADT) of 10 months or less, and seminal vesicle invasion [cancer spreading to structures near the urinary bladder of males] were significant predictors of disease progression despite salvage radiotherapy." "That early treatment is better than late treatment should come as no surprise, as this is a fundamental principal of oncology. In the pre-PSA era, factors were identified that predicted for a high risk of local recurrence after radical prostatectomy, most notably positive surgical margins and the absence of seminal vesicle invasion, and these also are among the strongest predictors of success of salvage radiotherapy in the present study," Dr. Anscher writes "High Gleason scores of 8-10, seminal vesicle involvement and a short PSA doubling time are adverse prognostic factors." "Cox regression analysis of bNED as a function of pathological and biochemical parameters showed that only Gleason's score was a significant predictor of bNED. On univariate analysis, seminal vesicle involvement was also found to be a significant predictor. . . . CONCLUSIONS: Gleason's score and seminal vesicle involvement predicted bNED after post-RRP radiation therapy in our cohort." "Peschel et al reporting on a series of 52 men who had either adjuvant or salvage EBRT found the preoperative PSA level and seminal vesicle involvement were significant risk factors for biochemical recurrence after postoperative radiotherapy." "PSA remained at undetectable levels for 2 or greater years in no patients with Gleason score 8 or greater (12 cases), positive seminal vesicles (12) . . . Conclusions: Patients with Gleason score 8 or greater, positive seminal vesicles or lymph nodes, or a PSA recurrence within the first year following surgery rarely benefit from radiation therapy." [Partin, Walsh, et al]) "Dr. Strum via e-mail figured I had a 96% probability of systemic disease, and is staunchly anti-SRT in circumstances like that." "Did he say why? The obvious (SEs), or just useless for your case?" Why? Isn't it obvious? On one side we have all the SEs including probable end of erectile function, a big radiation dose over 7 weeks, uncomfortable simulation, cost (to someone) of $40,000 - $60,000, etc. On the other side we have at best a 4% chance of cure. Bill Denton RP 2/12/02 PSA .67 Memphis Wow. Bill and Ron and Steve and Dave have given me a lot to digest and consider re SRT and CT/PET. Thanks. You guys are already ahead of my SRT and CT/PET reading, so ... Ah'll be baaak! The only bolus that came right back up was the paragraph on >> (hazard ratio [HR], 2.6; 95% CI, 1.7-4.1; P<.001) ... What do those terms mean? The only one I understand is the 95% CI. I.P. > Some articles on lung, > head & neck, and rectal cancer but none on PCa. Now, a met is a met and > I assume if it can pick up lung cancer mets it can pick up PCa mets > but the question would be how sensitive it is - i.e. how small can the > mets be and at what level of PSA do they become detectable. Walsh, I believe it was, says PC is PC is PC, and readily and uniquely identifiable as such whether it's in a toe or an earlobe. So we're back to the question of whether CT/PET can spot a PC met, and how early. I haven't researched that yet. > As far as > FDA approval is concerned, that only means that the equipment is safe - > there is no implication that it is the greatest thing since sliced > bread, as you seem to think. I hope you are right - where are you > getting your data? What I have so far is not data. It's a general impression based on scanning several of hundreds of heavy Google hits on combined CT/PET scan, triggered by someone's (Curtis?) post about it a few weeks ago. He, and I, are just trying to alert people to another prospective weapon in our arsenal. > "I had seminal vesicle involvement, which is a (if not THE) negative > predictor for a durable response to SRT." [quoted text clipped - 6 lines] > > Some excerpts [to the contrary] : SNIP Duly noted, and will be examined at length along with anything else that I can find when my PSA warrants it. I don't know yet how they stack up to Amling's research. Sounds like there's no hurry in my case (G8, SVI). And as of yet no one has explained the meanings of "(hazard ratio [HR], 2.6; 1.7-4.1; P<.001" from those snipped references. I.P. I.P. Freely wrote...snip... > You and I are getting dramatically different data. Do you have some reason > to ignore the relatively new but now FDA-approved combined CT/PET scans for > detecting small mets? I.P...I mentioned in an earlier thread that such scans, at least in the past, have not worked well for PCa. Because of PCa's slow rate of growth, uptake of the radiopharmaceutical has been at such a low level that imaging is not very well defined. Is this a new advance that has been said to work for PCa?..Ron "ron" wrote> > I.P...I mentioned in an earlier thread that such scans, at least in the > past, have not worked well for PCa. Because of PCa's slow rate of > growth, uptake of the radiopharmaceutical has been at such a low level > that imaging is not very well defined. Is this a new advance that has > been said to work for PCa? I don't know ... haven't gotten that far yet. I.P. Bill, zerospam@midsouth.rr.com noted: "This is a personal opinion but shared by many in the medical and academic community - if you are not getting your PSA done using an ultrasensitive assay you will NEVER know if you truly achieved undetectability." I've heard this also and it makes sense but my doc uses the Beckman-Coulter test and the results come back as "0". Maybe "0.0" They consider this undetectable...but I understand the thinking behind the ultrasensitive tests. Maybe they feel that until it's ".2 " they wouldn't do anything ANYWAY...so just let it be. I don't know. The thinking may also be that it decreases PSA Anxiety. And boy, do I know THAT one...along with all OTHER anxieties. Good health, Ron B. Chicago DominicM, Top of the evening, I had RPP at Emory University Atlanta Ga August 99. The surgeon did not order a PSA until after 90-days. His reasoning was that the wait was to insure a more accurate reading. Hope this helps. Lomax > Curious as most you know my recent post RP PSA (7 weeks) was 0.5. My > Sloan surgeon recommended I see a Radiloogy Oncologist. My brother had [quoted text clipped - 8 lines] > - Wondering what the average timeframe is that most RP patients PSA > scores become undetachable? Just answering my experience. My RRP was Dec 15, 2000. My next PSA was March 2001; two months later than yours. But, I don't know what to make of that. I do know that you have to take that Gleason 8 seriously. But, then, we all know that a pattern requires three readings. I wish I could tell you. I think I would make the appointment and see what he has to say. It take long enough to set up EBRT (or IMRT) that you will have time for another PSA before sllipping benethat the particle accelerator gun. SignaturePSA 16 10/17/2000 @ 46 Biopsy 11/01/2000 G7 (3+4), T2c RRP 12/15/2000 G7 (3+4), T3cN0M0 Neg margins PSA .1 .1 .1 .27 .37 .75 EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 Lupron 07/03 (1 mo) 8/03 (4 mo), 12/03, 4/04, 09/04, 01/05, 5/05, 10/05 PSA .07 .05 .06 .05 .08 Non Illegitimi Carborundum > Curious as most you know my recent post RP PSA (7 weeks) was 0.5. My > Sloan surgeon recommended I see a Radiloogy Oncologist. My brother had [quoted text clipped - 8 lines] > - Wondering what the average timeframe is that most RP patients PSA > scores become undetachable? Well just got off the phone with my brother's surgeon from Hopkins ..nice guy. Normally he waits to 3 months for PSA when he does a post op to check out ED etc. Given the damn Gleason 8 he definitely feels that I should see and medical oncologist as well as the radiological oncologist that my MSK uro advocated. Looks like I may need to hit this with both guns (Adjuvant & RT) as there could be microscopic metastasis. "DominicM" wrote. > Looks like I may need to hit this > with both guns (Adjuvant & RT) as there could be microscopic > metastasis. You've confused us. "Adjuvant" in this world means "second PC treatment", as in adjuvant RT, adjuvant ADT (adjuvant hormone therapy), or adjuvant wing and a prayer. Did you mean "adjuvant RT" or "ADT and RT"? I.P. My naivete. I meant ADT & RT. A. I think think you might end up wtih ADT and RT B. But, don't do it without researching it, I implore you. Just as you had time for your RRP decision, you have time for the rest of your treatment and, more importantly, another PSA. SignaturePSA 16 10/17/2000 @ 46 Biopsy 11/01/2000 G7 (3+4), T2c RRP 12/15/2000 G7 (3+4), T3cN0M0 Neg margins PSA .1 .1 .1 .27 .37 .75 EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 Lupron 07/03 (1 mo) 8/03 (4 mo), 12/03, 4/04, 09/04, 01/05, 5/05, 10/05 PSA .07 .05 .06 .05 .08 Non Illegitimi Carborundum > Well just got off the phone with my brother's surgeon from Hopkins > ..nice guy. Normally he waits to 3 months for PSA when he does a post [quoted text clipped - 3 lines] > with both guns (Adjuvant & RT) as there could be microscopic > metastasis. "DominicM" wrote Looks like I may need to hit this > with both guns (ADT& RT) as there could be microscopic > metastasis. One doesn't just casually "hit" ANYTHING with ADT. ADT can be, and often is, the biggest nightmare in people's lives to that point. I might have undetected micro mets, too, but there's no way in hell I'm taking a 98% chance of sacrificing the most important things in my life beginning virtually immediately in the chance it MIGHT add a few months to my life several years in the future, especially considering the fact that ADT never cures PC. If that broad statement intrigues you, you need to do a TON of research into ADT before just "hitting" anything with it. You'll find many links to it and many long discussions of it starting back in late Dec '04in the forum archives ... way, WAY too much to try to repeat or summarize here. Go to Google Groups at http://groups.google.com/ , click on Advanced Groups Search, type alt.support.cancer.prostate into the Group box, set the starting date somewhere near early January '05, click Google Search, and start reading any threads addressing such topics as ADT, HT, SEs, adjuvant whatever, etc. Follow links to the better PC sites, too, especially Strum and the PCRI and the Androgen Deprivation Syndrome at http://rattler.cameron. edu/strum.pcri/ads.html . This is a far, FAR bigger decision than your original treatment choice was, IMO; it surely was for me and thousands of others. Even the people who say it is no big deal often reveal some pretty serious SEs when pressed for details, so Do Your Homework. Sample starting point is the thread beginning at http://groups.google.com/group/alt.support.cancer.prostate/browse_frm/thread/3f1 d8a711a85cb37/6f49b29750f1e0c2?lnk=st&q=pcri+ADS+strum&rnum=2#6f49b29750f1e0c2 You'll notice I didn't even mention RT. Hell, all it MIGHT do beyond RP is mess up your bowels permanently some day and/or give you bowel cancer 20 years from now ... piece 'o cake compared to what ADT is LIKELY to do you starting immediately. Start Reading. I.P. I.P. Freely wrote...snip... > One doesn't just casually "hit" ANYTHING with ADT. ADT can be, and often > is, the biggest nightmare in people's lives to that point. I might have [quoted text clipped - 3 lines] > several years in the future, especially considering the fact that ADT never > cures PC. I.P...You mean " add a few years to my life" right? See J Urol. 2004 Apr;171(4):1525-8; Survival of patients with hormone refractory prostate cancer in the prostate specific antigen era; Oefelein MG, Agarwal PK, Resnick MI. BJU Int. 2005 Nov;96(7):985-9; A retrospective study of the time to clinical endpoints for advanced prostate cancer; Sharifi N, Dahut WL, Steinberg SM, Figg WD, Tarassoff C, Arlen P, Gulley JL. Gentlemen: I thought after my RP I'd be free of cancer. We'll that not my case. I am starting realize the gravity of the disease and future treatment options. I do not want to jump in to something without serious due diligence and consideration. I hope to see med onc's from Hopkins & MSKCC and a RT from MSKCC for starters. I am hoping that after those appointments in next 2-3 weeks that I may have some concensus of opinion (if that's possible w PC). I will continue to read and research etc. Thanks for all you guys share. This site to me is worth more than owning Google stock! ps.... I have thick skin so if I say something stupid like "I'll need hit this with RP & ADT" you can set me straight. I fully realize it's not trivial. 6/03 - PSA 2.0, 6/04 - PSA 2.5, 8/05 - PSA 4.2 BIOPSY 8/16/05, T2A, 3+5 = 8 RP 12/13/05 PATHOLOGY GLEASON 3+5=8 TERTIARY 4, SEMINAL & LYMPH - NEG T2A, EXTRACAPSULAR EXTENSION UPTO MARGIN PSA POST RP 1/26/06 = 0.5, 2/1/06 = 0.55 "ron" wrote> > I.P...You mean " add a few years to my life" right? Nope. 6-8 months on average, which doesn't even make up for the extra sack time demanded by the 26 months of ADT required to achieve it. I'll click on your references, but my whole team of oncologists agreed with my number, derived from every reference I could find on the subject. I.P. |
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