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Medical Forum / Diseases and Disorders / Prostate Cancer / April 2008Slight drop in PSA, but the right direction
As a recap, had seeds 10/23/06, then 35 IMRT. PSA dropped from 13.8 at diagnosis to 3.3 on 1/23/07. Then to 2.2 on 4/23/07. So far so good. Then on 10/23/07 it went up to 2.5. A little scary. I sent an email to Strum on P2P. He pretty much said I was doing everything right with diet, exercise, and supplements. Good cholesterol, very high Vitamin D (67.9), etc. He advised rechecking PSA in January. My rad onc said there was no need. So, I went to another lab and got the PSA checked in January. It was 3.5. Very scary. That's about a 6 mo. doubling time. I know I'm at the most likely time for a bounce, but it still scares the hell out of you. So, I went back to the rad onc for my six month check this week. The PSA was 3.2. A small drop, but at least it's in the right direction. I told my rad onc I'm very glad I had the test in January. If not, right now I'd be thinking it is still rising. I guess the moral of the story is, if you're having a bounce, get your PSA checked often. John > ... > I guess the moral of the story is, if you're having a bounce, > get your PSA checked often. Yes, otherwise, as you say, it's hard to tell what you're dealing with. If you can stand it, I think you're better off waiting this out until you know whether you've got a bounce or a recurrence. Once you decide to go on ADT, you won't learn any more for a long time. For what it's worth, I think that the highest bounce ever recorded was in the 20's. Also for whatever it's worth, men who have bounces apparently have a higher rate of cure than men who don't. If you have any prostatitis (inflammation, infection, and/or pain in the prostate, that could account for the rising PSA. But plain old radiation can account for it too. As I understand it, radiation doesn't kill cancer cells right away. It damages them. The damage is such that when they attempt to divide and multiply, they fail, generally dying in the process. During this process, or so I've been told, they can put out more PSA than normal. Best of luck with it. Alan Alan...A couple of points in your post caught my eye > Also for whatever it's worth, men who have bounces apparently > have a higher rate of cure than men who don't. Is this true for all forms of radiation? Do you have a reference? > As I understand it, > radiation doesn't kill cancer cells right away. It damages them. > The damage is such that when they attempt to divide and multiply, > they fail, generally dying in the process. Are you saying that when the damaged cells divide, they die in the process? My understanding is that damaged cells, no matter how produced, are detected by various proteins and then destroyed (e.g. the importance of non-mutated p53). That's what the immune system is supposed to do. Unfortunately for most people with cancer, their immune systems have already failed once...ron > Alan...A couple of points in your post caught my eye > [quoted text clipped - 3 lines] > Is this true for all forms of radiation? Do you have a > reference? I've done a search but can't find any evidence to support my claim. So I may be wrong, though I don't think I made this up. I believe I read it somewhere. If I find something, I'll post it. In the meantime, John should probably ignore my statement as unsupported. > > As I understand it, radiation doesn't kill cancer cells right > > away. It damages them. The damage is such that when they [quoted text clipped - 8 lines] > most people with cancer, their immune systems have already > failed once...ron I think so, see for example: http://www.prostate-cancer-radiotherapy.org.uk/psa_bounce.htm As I understand it, the immune system is unable to deal with aggressive cancer. The leukocytes may bind to the cancer cells and transfer the molecule that signals apoptosis (i.e., the cell killing itself), but due to changes in the cell that have damaged the response mechanism, the cell ignores the signal. However, I don't think radiation damage causes apoptosis. It's not that the cell commits suicide, rather it is unable to complete mitosis and the daughter cells are left in a non-viable state. Alan > http://www.prostate-cancer-radiotherapy.org.uk/psa_bounce.htm Looking at that citation again, I find this: "... the longer the time to reach the PSA nadir and the lower the value of the nadir, the better the chances are of remaining disease free." however it also says: "It should also be noted that an analysis of PSA records of 4,839 patients from nine institutions in the US showed that there was no difference in long term survival or cure between patients with bounce and those without - Horwitz et al (2004)." which argues directly againt my claim. It is possible that I was imagining that men with a PSA bounce took longer to reach nadir, and therefore have a better long term prognosis. But I don't have any facts to support the first part of that claim, so I have to withdraw it. Alan >> http://www.prostate-cancer-radiotherapy.org.uk/psa_bounce.htm > [quoted text clipped - 12 lines] > > which argues directly againt my claim. I suspect they pretty much ignore the numbers during the bounce; assuming the nadir comes after. > As I understand it, the immune system is unable to deal with > aggressive cancer. The leukocytes may bind to the cancer cells [quoted text clipped - 6 lines] > complete mitosis and the daughter cells are left in a non-viable > state. Alan, Thanks for your comments. As far as the immune system goes, the article at: http://www.sciencedaily.com/releases/2007/11/071108130155.htm talks about a mechanism some cancer cells use to create an "invisibility cloak" to hide from the immune system. I read somewhere that the cloak is similar to that created in pregnant women so the immune system does not attack the fetus. The way radiation kills cancer was explained to me pretty much the way you describe it. The radiation creates huge amounts of free radicals. (That's why we should not take large doses of antioxidants immediately after radiation.) The free radicals damage the vertical sides of the DNA ladder in each cell. During mitosis, in a normal cell, the rungs of the ladder split down the middle and go to each pf the two new cells where a new vertical side is created. In a damaged cell, the broken vertical sides cause the rungs to float around in disarray, the new vertical side cannot be created, then the cell dies. Healthy cells also get damaged by the radiation, but because they do not divide as often, they have more time to repair the damage. Also, cancer cells are not equipped as well to repair damage. In any event, most cancer cells die during mitosis which may be a year or more after radiation. This is part of the reason my rad onc prefers iodine seeds over palladium or cesium since they have a longer half life. One theory for the bounce is that dying cells release more DNA than living ones do. My doc has seen a few bounces go higher that the PSA at dianosis. Rare, and scary as hell, but possible. John > Also for whatever it's worth, men who have bounces apparently > have a higher rate of cure than men who don't. Alan, You were correct according to http://tinyurl.com/43dae4 This pubmed article says: PSA bounce predicts early success in patients with permanent iodine-125 prostate implant. OBJECTIVES: To determine the clinical and dosimetric factors that predict prostate-specific antigen (PSA) bounce after iodine-125 prostate brachytherapy and to determine the predictive value of PSA bounce relative to biochemical relapse-free survival (bRFS). METHODS: A multivariate analysis of factors thought to predict for PSA bounce was performed in 295 consecutive patients with T1-T2 prostate cancer treated by prostate brachytherapy as the sole radiotherapeutic modality and a minimum follow-up of 2 years. The variables examined included age, initial PSA level, biopsy Gleason score, use of androgen deprivation, occurrence of PSA bounce, dose received by 90% of the prostate gland, and volume of gland receiving 100% of the prescribed dose. A PSA bounce was defined as a rise of at least 0.2 ng/mL greater than a previous PSA level with a subsequent decline equal to, or less than, the initial nadir. A second analysis investigating the same factors and adding PSA bounce as a predictor of bRFS was also performed. RESULTS: The median follow-up was 38 months. A PSA bounce was noted in 82 (28%) of 295 patients. On multivariate analysis, only younger age (younger than 65 years) significantly predicted for a PSA bounce. Patients who experienced a PSA bounce were less likely to have biochemical failure (P = 0.037). Overall, the bRFS rate at 5 years in those experiencing a PSA bounce was 100% versus 92% in those with no bounce. CONCLUSIONS: Immediate salvage therapy in patients with a rising PSA level after permanent prostate brachytherapy should not be initiated provided the PSA increase does not exceed the pretreatment PSA value. A PSA bounce may be associated with improved bRFS but was not associated with any of the pretreatment clinical and dosimetric factors examined. John > As a recap, had seeds 10/23/06, then 35 IMRT. PSA dropped from 13.8 at > diagnosis to 3.3 on 1/23/07. Then to 2.2 on 4/23/07. So far so good. [quoted text clipped - 16 lines] > I guess the moral of the story is, if you're having a bounce, get your > PSA checked often. John, Your rad onc has nothing left to do with you. Your next radiation treatment will be palliative if you cancer wasn't killed with the first. I don't know much about "bounce", but it would appear that you never nadired, which would be a sufficient concern, I think, to warrant quarterly PSA checks. I'd recommend a medical oncologist with a prostate expertise.  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 PSAD 0.19 years EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 PSAD .056 years Lupron 07/03 (1 mo) 8/03 and every 4 months there after PSA .07 .05 .06 .09 .08 .132 .145 PSAD 1.4 years Casodex added daily 07/06 PSA <0.04, <0.05, <0.04, <0.04, <0.1 2/12/08 Non Illegitimi Carborundum > Your rad onc has nothing left to do with you. Your next radiation treatment > will be palliative if you cancer wasn't killed with the first. I don't know > much about "bounce", but it would appear that you never nadired, which would > be a sufficient concern, I think, to warrant quarterly PSA checks. > > I'd recommend a medical oncologist with a prostate expertise. Steve, I value your opinion. Lord knows, you've been through it all. I'll continue to see my rad onc every six months (and get my quarterly checks as well) for one main reason. He has done over 3,000 seedings (he was formerly the primary doctor at RCOG) so he has a lot of followup experince. He is telling me that, unless we see several serial increases in PSA, we won't do any intervention for two to three years after initial treatment. Strum, on P2P, told me pretty much the same thing. One source of valuable information I've gotten is from former RCOG patients. They have a group at: http://health.groups.yahoo.com/group/RCOGgroup/messages The group maintains a database of PSA scores over time. Although I was not treated at RCOG, my treatment was almost identical to theirs, so the numbers are very meaningful to me. Many of them have had more of a rollercoaster than I'm having. But, I completely agree with you. If I get to the point where I'm convinced I'm not cured, I plan to see three medical oncologists. Those are Drs. Bob Leibowitz, Strum and Myers. My inclination would be to go down Leibowitz's route, but I'd want to hear what Strum and Myers think about his protocol. John He is telling me that, unless we see several serial increases in PSA, we won't do any intervention for two to three years after initial treatment. Strum, on P2P, told me pretty much the same thing. But, I completely agree with you. If I get to the point where I'm convinced I'm not cured, I plan to see three medical oncologists. Those are Drs. Bob Leibowitz, Strum and Myers. My inclination would be to go down Leibowitz's route, but I'd want to hear what Strum and Myers think about his protocol. ==> Of course, you should follow the advice of the doctor in which you have trust. I concur with the waiting for excalation of PSA, but I do not understand the limitation of the PSA tests. Should you lose confidence in your doctor, remember he is, by the sound of it, a very good brachiotomist (I'm sure that's not a word). 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 PSAD 0.19 years EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 PSAD .056 years Lupron 07/03 (1 mo) 8/03 and every 4 months there after PSA .07 .05 .06 .09 .08 .132 .145 PSAD 1.4 years Casodex added daily 07/06 PSA <0.04, <0.05, <0.04, <0.04, <0.1 2/12/08 Non Illegitimi Carborundum |
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