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Medical Forum / Diseases and Disorders / Prostate Cancer / February 2006Miniscule PSA rise after RP and radiation
I'd be interested to hear from anyone who has followed a similar path to this: In 2000 I had a radical prostatectomy. PSA had gotten up to 4.7, and was doubling in about 6 months, in retrospect. Gleason was 7. Two years later, PSA rose from undetectable to 0.17, with a similar doubling time, using the standard PSA test. I went through a course of radiation combined with hormone therapy (Lupron and Casodex for 6 months, radiation during the middle 2 months), a the advice of Dr. D'Amico of Dana-Farber. Three years went by, with "less than 0.01" quarterly PSA results on the hyper-sensitive test. Now for the first time I have a result of 0.02. I realize that the only thing to do at this point is wait three months and retest, etc. I also realize this may just be a fluke result. But, I would be interested to hear from others with a similar history, any experience with PSAs at these barely detectable levels. Thanks Martin Martin: What was your pathology after the RP in 2000? B.A. I'm at work and haven't got it handy. Will post later. Generally good. Martin: What was your pathology after the RP in 2000? B.A. Bob: Gleason was 3+4=7 (though D'Amico later looked at the slides and thought it was 3+5). 10% of both right and left lobes involved. High grade PIN, Perineural invasion present. Tumor confined to prostatic parenchyma. Seminal vesicles negative, no regional lymph node metastasis, surgical margins negative. > Martin: > [quoted text clipped - 8 lines] > vesicles negative, no regional lymph node metastasis, surgical margins > negative. This sounds like a very positive report. Hopefully the trivial increase in PSA is of no consequence - perhaps just something to do with calibration of the instruments. A change in the least significant digit is not always a real change. If the machines were accurate enough (which they're not) your .01 might really have been .01499, and your .02 might have been .01500, a real difference of only .00001. If they're not that accurate, then both your .01 and your .02 might have actually been .015. In other words, even if the test worked perfectly, there still isn't enough information yet to know for sure that the PSA really went up at all. Alan > Martin: > [quoted text clipped - 4 lines] > Bob: Gleason was 3+4=7 (though D'Amico later looked at the slides and > thought it was 3+5). Ahhhhhh. That might explain the aggressive treatment of 0.16 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 .09 .08 Non Illegitimi Carborundum On February 17, Martin wrote, in pertinent part: (snip) > Three years went by, with "less than 0.01" > quarterly PSA results on the hyper-sensitive test. Now for the first [quoted text clipped - 4 lines] > detectable levels. > I am presently in the same situation. For just over a year, I have had monthly ultrasensitive PSA tests with results generally <0.0l ng/ml. Last month, I clocked 0.03. Granted that it was three times the previous score, it was only two hundredths of a nanogram per milliliter. Standing alone, it is meaningless, though I have to confess that it rattled me just a bit. It's difficult to be philosophical and objective when *I'm* the patient. That's why we need well-trained medics as advisers. What we must look for is a pattern. It's hard to wait -- how well I know, next report not for two weeks -- but there's no help for it. Regards, Steve J "The thing is to expect nothing in particular, but be aware of the lack of enforceable guarantees or enforceable contracts with nature/god/entropy as to the condition or durability of our bodies." -- Brian Brunner, PCa survivor, December 12, 2005 on The Prostate Problems Mailing List Thank you, Brian. Mine fluctuates between .05 and .08 and I'm very happy about that. .02 is fantastic. 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 > I'd be interested to hear from anyone who has followed a similar path > to this: [quoted text clipped - 13 lines] > Thanks > Martin Hi Martin... I am 6 yrs behind you and awaiting opinions from docs (med onc from Hopkins and one from Sloan and also a rad onc from Sloan all within next 12 days) on how to proceed after detectable PSA post RP. Here are my stats: 1/04 - 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 (two different labs - last one was at Sloan Kettering was it probably more accurate) . I view these as just the margin as error between labs. My next PSA will be telling. Just curious how soon after RP did you begin treatment? My uro is suggesting that radiating prostate bed. But a Gleason 8 concerns me. How bad were the SE's with your combined treatment?? Good luck to you . Continued success. A 0.02 is very good I believe. I am 6 yrs behind you but curious how your treatment progressed as I am waiting to talk to drs at Sloan and Hopkins. Hi Martin... I am 6 yrs behind you and awaiting appts with med onc & rad onc on how to proceed after detectable PSA post RP. Here are my stats: Age 49 2003- PSA 2.0 1/04 - 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 (two different labs - last one was at Sloan Kettering was it probably more accurate) . I view these some within the margin of error between labs. My next PSA will be telling. Just curious how soon after RP did you begin treatment? My uro is suggesting that radiating prostate bed. But a Gleason 8 concerns me. How bad were the SE's with your combined treatment?? Good luck to you . Continued success. A 0.02 is very good I believe. Dominic Dominic: After RP 4/00, I had PSA <0.1 until 6/02. Then, 12/02 0.11, 3/03 0.15, 6/03 0.15, 9/03 0.16. Went to Boston where D'Amico suggested the combined treatment. SE? sorry, unfamiliar with some of the abbrevs here. The radiation was a little tiring; hormones killed off any sex drive for about 9 months, but everything has bounced back. A few residual bowel problems but that's finally getting back to normal. Hi, Martin. You're the first "Martin" here in a couple of years. "SE" has come to mean "side effects" here. I don't know if it's used as such elsewhere. I find it interesting that you were given a "combined" treatment after your PSA went up only to 0.16 3½ years after surgery. The normal routine seems to be a course of radiation treatment (RT) if the RP doesnt' work. And usually they wait until the PSA gets up to 0.8. But, I'm not sure what you went through. When you say "combined" do you mean RP and RT or RT and hormone treatment (HT or ADT)? 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 .09 .08 Non Illegitimi Carborundum > Dominic: > After RP 4/00, I had PSA <0.1 until 6/02. Then, 12/02 0.11, 3/03 0.15, [quoted text clipped - 3 lines] > drive for about 9 months, but everything has bounced back. A few > residual bowel problems but that's finally getting back to normal. >But, I'm not sure what you went through. When you say "combined" do you >mean RP and RT or RT and hormone treatment (HT or ADT)? Combined, meaning radiation plus hormone (Lupron+Casodex). This was at the time of D'Amico's later published study on the efficacy of 6 months of hormone combine with radiation. (http://www.dfci.harvard.edu/abo/news/pressarchive/081704b.asp ) While the (IMHO arbitrary) threshhold of 0.2 had not been reached, the factors considered were (1) reexamination of slides showed the original Gleason at 3+5, and (2), the PSA sequence, quarterly, was <0.1, 0.11, 0.15, 0.15, 0.16, clearly an upward trend. Correcting my original post's doubling times, both pre RP and pre RT were > 12 months. Still, my philosophy was, don't wait, hit it with everything that's available. So far so good, totally undetectable PSA except for the recent 0.02 which we'll hope and assume for now is a fluke. > I'd be interested to hear from anyone who has followed a similar path > to this: [quoted text clipped - 13 lines] > Thanks > Martin From what I understand, many urologists don't really trust the ultrasensitive PSA tests at the very low levels. I guess there are a number of variables that can affect the results at those low levels, including tiny differences in reagents used in the tests. As Steve Jordan says below, the pattern is the important thing, and your results at those extremely low levels are not a pattern.. In a way, I'm glad that my uro doesnt use the ultra-sensitive test. I take his word when he says "undetectable" and stop being concerned until the next test. When it gets to 0.1, it will register, and then I can start to wrestle with what I'm going to do, if anything. . Doesnt Walsh say you don't need to do anything until it gets to 0.2.? Claude > In a way, I'm glad that my uro doesnt use the ultra-sensitive test. I > take his word when he says "undetectable" and stop being concerned until > the next test. When it gets to 0.1, it will register, and then I can > start to wrestle with what I'm going to do, if anything. . My onc and I agree that just because my ultra-sensitive PSA has doubled each of the last two quarters (.006, .006, .006, .012, .023) is no cause for alarm. BUT ... it does have me paying more attention, and sometimes dragging comments into my PCa folder for future reference, when I see useful RT and ADT data and authoritative opinions on my screen. It takes minimal time, and can be simply discarded if my PSA stays low, but it's there if I need it some day and want to study them seriously. Being prepared can pay huge dividends when a complex scenario presents an urgent decision point or even just a good opportunity. The key to avoiding wasting time on unneeded research is recognizing which decisions we're most likely to face. I can think of many big -- some huge -- and valid decisions my family made because a) we knew they would arise some day and b) we had been watching the options for months or years. Think how often it can pay off -- in dollars, satisfaction, opportunities snapped up, or just avoiding unnecessary urgency -- in obvious, likely, complex decisions such as choosing our next car, dog, maybe town or job or home if we move now and then, appliances, and, of course, our next PC tx. (I get the general impression that most of us have simply stalled the beast.) An incurable worrier may be better off living in a vacuum until forced to act, but the rest of us can gain immensely with preparation. If my PSA happens to continue at its present doubling rate, I'll go from 0.2 to 0.4 just three months, and I'm TIRED of having to drop everything else when foreseeable urgencies gobble up my time. For example, I've spent only an hour or three since my surgery in '04 considering salvage RT, but already I've seen pretty good indications from world-class experts that it may not be warranted in my case (G 8, SVI). > Doesn't Walsh say you don't need to do anything until it gets to 0.2.? Walsh takes it a step further with adjuvant ADT, all but saying we should wait 'til we have proof of mets. I.P. >> In a way, I'm glad that my uro doesnt use the ultra-sensitive test. I >> take his word when he says "undetectable" and stop being concerned until [quoted text clipped - 29 lines] > I've seen pretty good indications from world-class experts that it may not > be warranted in my case (G 8, SVI). I certainly did that when I suspected cancer. I knew I was going to have an RP and who would do it when the results came back. I was actually lurking in this forum before my diagnosis. However, I am now 68, and time becomes an important factor in my calculations. At what point do I decide that enduring the risks of radiation, especially on my rectum, are not worth it? What about other health risks that might be there at the time of recurrence? How good is my sex life at time of recurrence? How fast is my PSA going up? Depending on my age and these other variables, none of which I know right *now*, I may decide upon radiation, hormone therapy, or nothing. If I were 48, then I would be doing a whole lot more contingency planning. It doesnt seem worth it to me to plot out all the contingencies right now and waste some quality time in doing so. "Claude" wrote> > I certainly did that when I suspected cancer. I knew I was going to have > an RP and who would do it when the results came back. I was actually [quoted text clipped - 8 lines] > planning. It doesnt seem worth it to me to plot out all the contingencies > right now and waste some quality time in doing so. I'm "only" 62, and in great health unless one counts cancer squared -- neither detectable at present. But at our age we are conscious that our remaining years have "become finite", and it would take a huge increase in the salvage RT or adjuvant ADT therapeutic index to persuade me to accept either before I have clinical reoccurrence. I'd far rather "waste" 12 hours a week busting my a.s in the gym than waste 28 EXTRA hours a week lying in bed because I'm too tired to get up or many extra hours a week running to and from the bathroom. The only reason I keep paying attention is that my opinion so far is based on casual attention to SRT and intense examination of ADT; the former still needs more of my attention at some point. I.P. > (I get the general > impression that most of us have simply stalled the beast.) I.P. Do you feel that there really is no chance for a real cure no matter what the pathology was or from the treatments that we chose? It's a pretty bleak outlook for us if it's true. B.A. "Bob Anthony" wrote I.P. wrote >> (I get the general impression that most of us have simply stalled the >> beast.) > Do you feel that there really is no chance for a real cure no matter what > the pathology was or from the treatments that we chose? Oh, no, I wouldn't say that. And even if I did, it wouldn't mean squat compared to the real PC statistics. My comment hinges on three words, "us" and "general impression". Most of "us" in this forum have not been cured; if we were we'd have moved on. And that's a general impression, not a poll or tally. But while adjuvant tx benefits are debatable, initial txs are a no-brainer even including deliberate WW / AS. That first tx choice is vital on many levels, physical and psychological, and should be aimed at a cure if the pt should otherwise live for 10-15 years. The second choice, upon reoccurrence, is probably even tougher, because at that point we realize we're probably screwed and are just trying to decide how we want to spend our remaining years and how much we're willing to risk or give up to extend them. And even THAT still ranges from a general impression for RT and a much stronger conclusion for ADT, with all of it colored by our post-op pathology -- a major advantage we RP pts have, IMO. I.P. >> (I get the general impression that most of us have simply stalled the >> beast.) [quoted text clipped - 6 lines] > > B.A. Within our lifetimes, there have been several diseases for which very smart men or teams thereof have found cures. I'd bet that people who had those diseases thought there would be no cure. Currently, there is no reason to believe that a man with your numbers and surgery results is not already cured. There is no reason to believe that a man with advanced prostate cancer will be cured. And there is no reason to believe that by 2015 there will not be a cure. IP: You wrote: >My onc and I agree that just because my ultra-sensitive PSA has doubled each >of the last two quarters (.006, .006, .006, .012, .023) is no cause for >alarm. But that's a pretty steady pattern, and fast doubling. If it goes on another quarter or two, it's telling you the same thing that 0.6, 1.2, 2.3, 4.6 would be teling you: you have a problem. Based on a clear pattern, my choice was, zap it now rather than walking around with it for another year or two and potentially letting it migrate. But that's the crapshoot we are all engaged in. Martin
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