On February 5, Annie wrote:

(snip history)

Everyone reacts differently. Below I have referred Annie and her husband
(what's his name?) to the Prostate Cancer Research Institute for
reliable information.

If the cancer (PCa) had moved outside the gland, it could have been
settling elsewhere even before the brachytherapy, which is at best a
local tx.

Since the seeds are permanently implanted, I would suspect a rising PSA
is from another source.

Often, brachytherapy is performed either immediately before or
immediately after external radiation such as IMRT.

And there are other txs on the menu, so I think it depends upon what
other tx is contemplated.

However, I believe that radiation therapy does take time to reach full
effectiveness. Perhaps five months is not enough time.

Here is the PCRI site, which can be searched for relevant information:

http://prostate-cancer.org/index.html

Lastly, unless the uro is very unusual, I recommend consultation with a
real cancer specialist, an oncologist. Preferably one who specializes in
tx of PCa.

Anything beyond surgery, which is the uro's specialty, is IMO beyond
him. I'm uncomfortable with the implication that the uro performed the
brachytherapy. It is normally done by a radiation oncologist.

There are many tests that can be done to obtain information on the state
of the case. They include CGA, PAP (though some might say it's late for
that), CEA, and so on. They are explained on the PCRI site.

Good luck.

Regards,

Steve J

Annie,

The best person to ask these questions of is the radiation
oncologist.  He or she may know a lot more about what to expect
than will a urologist, who may or may not know much at all about
radiation.

I'm not a radiation oncologist, and the answers I provide below
are given from the perspective of a layman who had brachytherapy,
but is by no means an expert.

It varies considerably from invidividual to individual.  In my
own case, it took about two years to settle down to its current
low value.

Brachytherapy does not kill the cancer all at once.  It damages
the DNA in the prostate cells so that when the cells divide -
which cancer cells do - the molecular machinery they require for
successful division is damaged and the cells die.  This process
can take months or years to complete.

If the radiation was successful (i.e., no areas of cancer were
missed by the seed placements and the dose to all areas was
adequate), I believe there should be no metastasis.  To
metastasize the cells must divide and that's precisely when the
radiation damage kills them.

However it is possible that mets developed before brachytherapy
but were too small to detect, or that the seed placement didn't
cover all of the cancer.

The second condition (failure to cover the whole area properly)
can be detected by the radiation oncologist if he does some
imaging to test the current position of the seeds vis a vis his
original plan.  If that is the case, he could put in another one
or a few seeds to get the spot(s) he didn't cover as well as he
hoped.  It's something to ask him about.

It is possible, but I don't think you have enough information to
say that it has.  See below.

I believe that the standard answer to that question is to wait
for at least three consecutive rises in PSA in a nine month
period.  This is important because brachytherapy very frequently
causes the PSA to bounce up and down and it is only a long term
trend upward that indicates failure.

I'll tell you my own experience.  I had a combination of high
dose rate brachytherapy, external beam therapy, and Lupron for a
Gleason 4+3 cancer.  My pretreatment PSA was between 8 and 10,
though I think the real PSA was closer to 8 and the 10+ reading I
got may have been due to some prostatitis that I had at the same
time as the cancer.

My PSA was initially undetectable because of the Lupron.  After
the Lupron wore off, it shot up to .8.  Then it began bouncing
all around.  It went down to .6, up to .9, down to .8, up to 1.8
(about a year after treatment), and then gradually trended down
(but still with another bounce up) to the present low value of
.2.

"PSA bounce" is fairly common with brachytherapy.  It is thought
to be caused by radiation induced stress on the prostate cells
which put out sometimes more and sometimes less PSA in response
to the stress.  For men who experience bounces, they commonly
occur in the first three years after treatment, but can sometimes
occur even later than that.

If I were you, I would not accept hormone therapy at this time.
If your husband gets hormone therapy it will lower his PSA
dramatically and you won't know what's going on.  He could stay
on Lupron for two or three years, suffering the side effects of
Lupron, and never know whether his low PSA was solely due to
Lupron, or whether in fact the radiation killed his cancer and he
never needed Lupron at all.

If I remember correctly from the reading I did when my own PSA
went up to 1.8, PSA bounces in the 1, 2, 3, maybe even 4 or 5
range were common.  But at least one bounce up to 15 was recorded
in the literature.

I got my brachytherapy in a clinical trial at the National Cancer
Institute.  Of the fourteen men in the trail, I think about five
of us experienced PSA bounce.  One guy panicked, dropped out of
the trial, and went on Lupron when his PSA went up to 2.4.  The
rest of us all opted to wait and see.  All of the rest of us had
our PSA settle back down again with no Lupron.  I suspect that
the guy who dropped out and is probably still on Lupron also had
a bounce and didn't need the Lupron.  None of the rest of us did.
But he'll never know for sure.

I know that your husband's condition is scary.  It is possible
that he does have a continuation or recurrence of the cancer.
But, surprisingly, it turns out that the rate of cures for men
who have PSA bounce is actually higher than those who don't.
And brachytherapy has an excellent track record for men with PSA
below 10, which is what your husband had.  The numbers I've seen
indicate a 90% or better chance of long term elimination of the
cancer.

So my advice is to hang in there.  Ask about getting tested every
3-4 months for another 9-12 months.  Don't panic.  Don't accept
hormone therapy unless and until treatment failure is clearly and
unambiguously confirmed.  Even if it is a treatment failure,
there is likely to be little harm in waiting to be sure.  Also
ask the radiation oncologist if he can test the seed placement to
be sure everything is okay and fix it if it is not.

Best of luck to you both.

   Alan

Annie,

My husband had brachytherapy 4 July 2006 his PSA pre implant was 19.7,
six weeks after implant 4. 6, then a three months later it dropped to
1.1, his oncologist thought it should have been lower, but he had an
infection and this had a bearing on the reading.

We were told that it takes up to 12 months for full efficacy with the
implant, after that the seeds have done the job.

I know if they think some of thePCa has escaped the capsule they
recommend brachytherapy with ERBT to get the lot.  Kent's Tumour was a
T2b, Gleason 4+3.

Kent has stated he will not have ERBT ever and hormone therapy is also
not an option.

Of course ERBT is not as refined over here as it is in the States and
ADT is one size fits all.  Treatment for cancer over here is a post
code lottery.

His oncologist specialises in PCa only so we have utmost faith in his
opinions.  I don't think the urologists are specialised enough.  This
is just my opinion, but read up on other treatment options before
making a decision.

Did you husband have his PSA done at the same lab?   This also can
cause a variation in readings.

Good luchk and please keep us posted.

Phillipa

Hopefully, someone more knowledgeable about brachy has or will answer this,
but let me start off by calming you down.  I suspect the experts will tell
you that 1.4 PSA just 3 months after treatment is not a bad PSA.  I will
also tell you, as much as I love my urologist, you should be talking to a
radiation oncologyst or medical oncologyst, not a urologist.