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Medical Forum / Diseases and Disorders / Prostate Cancer / March 2007having a ,3 PSA level after surgery 5 years ago, this July 18
He was 64 at this time, great physical shape, now 68 and in good shape but tired. PSA was 0.01 for 3 years + and then .2 and now .3. The doctor is sending us to a oncologist to set up 7 weeks, 5 x week for radiation treatments in that particular area only. He had a bone scan, clear 9 months ago at first . 2 PSA reading. I need to know if this is the right step, and if we are going in the right area. Thanks in advance. Wife of 48 years. Specimen Soource : 1. RT. Obturator Node ----2. Lt. Obturator Node. ------ 3. Prostate Gland History: CA Prosstate Microscopic Description: tumor type---------Adenocarcinoma Gleason score --------4 + 3 = 7 (moderately differentiated Tumor size/ volume------------ 1.9 x 1.2 x 1.0 cm Lobe involved--------- left capsular penetration ----------no Surgical Margins------------- negative Seminal vesicles -----------negative bilaterally Right node status # positive ------0 # examined ---- 1 Left Node Status # Positive -----0 # Examined----- --2 TNM Stage ------ T2a, NO, MX sf Diagnosis: A: Right Obturator Lymph Node: Negative for Metastatic Carcinoma. B. Left Obturator Lymp Nodes : Negative for Metastatic Carcinoma. C. Postate, Prostatectomy: Moderately Differentiated Adenocarcinoma. Margins Negative for Tumor. > He was 64 at this time, great physical shape, now 68 and in good shape > but tired. [quoted text clipped - 4 lines] > months ago at first . 2 PSA reading. I need to know if this is the > right step, and if we are going in the right area. A PSA increase like what you describe usually means that there is still some prostate cancer in your husband's body. If the cancer has spread to remote sites, radiation can't cure it, and the usual treatment is hormone therapy. That won't cure it, but it may control the cancer for an extended period of time. If the cancer is still in the prostate bed, it is possible to cure it entirely with radiation to that area. The fact that it took over two years before his PSA started rising suggests that it is in the local area. So radiation would be appropriate and there is a good chance it will take care of the cancer. Good luck. > Thanks in advance. > Wife of 48 years. [quoted text clipped - 49 lines] > Moderately Differentiated Adenocarcinoma. > Margins Negative for Tumor. >A PSA increase like what you describe usually means that there is still >some prostate cancer in your husband's body. If the cancer has spread [quoted text clipped - 5 lines] >that it is in the local area. So radiation would be appropriate and >there is a good chance it will take care of the cancer. What is the thinking here which leads to that conclusion? It's possible I'll have to make a decision on SRT sooner or later and I'm still unsure as to how this calculated guess comes about. You appear to be saying, above, that a longer period before a PSA rise points to local recurrence (I'm assuming a prostatectomy resulted in apparently organ-confined disease). >> A PSA increase like what you describe usually means that there is still >> some prostate cancer in your husband's body. If the cancer has spread [quoted text clipped - 12 lines] > local recurrence (I'm assuming a prostatectomy resulted in apparently > organ-confined disease). I'm afraid I was misremembering something from Walsh's book. He gives data there on how long a man can be expected to be metastasis free on the average if his PSA rises after surgery. The best case is a Gleason 7 or less, PSA recurrence occurred after two years and PSA doubling time was greater than 10 months. 82 percent of such men can be expected to be metastasis free after seven years. That of course is not exactly the same question as how likely it is that the cancer is still localized, but I would think it would be related. Earlier in the same chapter he says that for men with a Gleason of 7 or less and negative seminal vesicles and lymph nodes, the longer before PSA starts to rise, the better the odds that radiation therapy will be worthwhile. These things keep changing on the basis of continued research, so if the need arises, you have to rely on what a doctor you trust tells you rather than trying to get information from the internet. In this case, the best we can do is to confirm that what the doctor recommended made sense. The > >> fact that it took over two years before his PSA started rising suggests > >> that it is in the local area. So radiation would be appropriate and > >> there is a good chance it will take care of the cancer. > > > What is the thinking here which leads to that conclusion? I heard basically the same thing from my rad and my urologist. As I remember the conversations, their educated guess that my recurrence was local was based on four factors 1. Low post-operative PSA nadir (0.003) suggesting no mets at that time. 2. Slowly rising PSA suggesting that not an established tumor site;apparently established met would be expected to push PSA up more quickly. 3. Length of time before significant rise after surgery, Same reasoning as #2. 4. In my case, extracapsular extension (even with clear surgical margins) made it more likely that some cancer cells left behind in prostate bed. Intuitively, all of these seem to make some sense, But they were quick to tell me this was a guess, and there was no way to know for sure. Fred >The >> >> fact that it took over two years before his PSA started rising suggests [quoted text clipped - 25 lines] > >Fred Thanks fred, I've spotted your notes on this topic before. Of course with so little hard and fast evidence, intuition has to play a role in all this and I can see how #4 would be persuasive, but I still fail to get a reliable feel for 2 and 3. With such a low, effectively zero, post surgery PSA, I don't see why the presence of mets, undetectable at the time of surgery, couldn't just as easily explain a slow change in PSA? At least they admitted to some guesswork, that appeals to me more than a snap-on air of confidence. With such a low, effectively zero, > post surgery PSA, I don't see why the presence of mets, undetectable > at the time of surgery, couldn't just as easily explain a slow change > in PSA? I think the logic is that it is unlikely (but not impossible) to have low PSA immediately after surgery and have established mets. So let's say you have a (say) 75% chance of localized recurrent disease which could be cured by radiation, and you're in your mid fifties and in otherwise good health, I think you take your chances and run with the radiation. That made sense to me anyway. But I agree it's not a slam dunk, simply because there's no reliable way to determine whether you're dealing with mets or localized recurrence. Fred > think the logic is that it is unlikely (but not impossible) to have >low PSA immediately after surgery and have established mets. So let's >say you have a (say) 75% chance of localized recurrent disease which >could be cured by radiation, and you're in your mid fifties and in >otherwise good health, I think you take your chances and run with the >radiation. That made sense to me anyway. I'm sure I'd have done the same. My stats are slightly different from yours, so I'll have to re-appraise at the time if or when it occurs. >But I agree it's not a slam dunk, simply because there's no reliable >way to determine whether you're dealing with mets or localized >recurrence. >I'm afraid I was misremembering something from Walsh's book. He gives >data there on how long a man can be expected to be metastasis free on [quoted text clipped - 13 lines] >the best we can do is to confirm that what the doctor recommended made >sense. Thanks Leonard, I'm still trying to make this all fit together - every little helps even if so many of the pieces seem to belong to different puzzles. I take your point about the internet vs trusted doctors although it concerns me that no matter how much confidence they might inspire, they're confounded also. Fred's post hints at that. > He was 64 at this time, great physical shape, now 68 and in good shape > but tired. [quoted text clipped - 4 lines] > months ago at first . 2 PSA reading. I need to know if this is the > right step, and if we are going in the right area. We are not doctors here, but, yes, based on his history, most here would recommend a medical oncologist and probably radiation. Look at my signature. You'll see that is the course I took in 2002 when my PSA went to 0.37.  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, 2/06, 6/06 PSA .07 .05 .06 .09 .08 .132 .145 Casodex added daily 07/06 PSA <0.04, <0.05 Non Illegitimi Carborundum I agree with what Leonard and Steve have already said. As you'll see from my history below, I made the decision to go the salvage radiation route last year when my PSA started to rise again, and so far the results have been excellent. However, they will tell you that you should wait 2 years after radiation before you start celebrating. I had very few side effects (all fairly minor and very tolerable) during treatment and after, and I feel fine. However, your mileage may vary; there are certainly risks and side effects associated with salvage radiation, which a conscientious radiologist will explain to you.. I'd recommend you find a place for the radiation where they use the latest technology. Look for IGRT (Image Guided Radiation Therapy); I was treated on a Trilogy machine which I was told was the latest and greatest a year ago. So I think you're getting good advice and are on the right track. Good luck!! Fred 4/99 PSA 1.58 10/01 PSA 1.68 9/02 PSA 2.7 10/03 PSA 3.8 11/03 needle biopsy. Positive for Gleasons 6 on left side. 12/03 Radical Prostatectomy performed at the Cleveland Clinic. Gleasons 3+4 = 7, clear surgical margins, extracapsular extension established. 3/17/04 PSA 0.003 4/27/04 PSA 0.003 7/22/04 PSA <0.1 (not 3rd generation test) 11/10/04 PSA <0.1 (not 3rd generation test) 5/10/05 PSA <0.1 (not 3rd generation test) 10/19/05 PSA 0.050 2/3/06 PSA 0.082 3/23/06 PSA 0.110 3/06-6/06 IGRT SRT 9/06 PSA 0.044 12/06 PSA 0.025 3/0/07PSA 0.019 I also agree with what your husband's doctor, and everyone else replying to your inquiry has said. Radiation does have side effects. As I understand it, impotence is the most common long lasting one, though I have never seen any clear statistics about how many men have this. Other long lasting side effects are possible, but are not as common. The radiation itself is entirely painless and very easy to take. It may increase your husband's tiredness towards the end of treatment but he will recover after treatment ends. There is no hospitalization and he will be able to drive himself to and from treatment every day. It is possible that no treatment is necessary. Your husband's PSA seems to be slow growing. It is likely that he would go at least five years without developing symptoms and it is more likely that he could go 10 years or possibly a lot longer. Still, if it were me, I think I'd go for the treatment. Cancer can be a terrible way to go and I think I'd prefer to take a shot at curing it through radiation, even knowing that the treatment might not work and might have side effects. Try to find a radiation oncologist that you think is very good and uses late model equipment. Look for one that does a lot of prostate cancer treatment. There are radiation oncologists who mainly treat other kinds of cancers and may not be quite as up on the latest techniques for prostate treatment. It might not be a bad idea to ask for a consultation with a second rad onc for a second opinion. You could ask each one what kind of equipment they would use, how many greys of radiation they would prescribe, and how large an area around the prostate they would treat. You won't know what the "right" answers are (I certainly don't), but you will get a sense of how deeply each doctor thinks about the problem and you will get information that you can use to query the other doctor. Best of luck to you and your husband. Alan
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