PSA rising while ALP continues to drop? - Advanced Prostate...

Advanced Prostate Cancer
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PSA rising while ALP continues to drop?



Is it possible to have PSA rising during Chemo while ALP keeps dropping? And what could be the cause of it?

My father who's been dxed stage 4 with numerous bone mets back in July 2017. He started ADT early August and started Chemo Sep 25, just finished chemo #6(last one) on Jan15.

His intial PSA was 700 and ALP 578. Since the start of ADT, his ALP initially rose to close to 1000 than started dropping drastically. PSA has been quickly dropping too until Dec. It was 2.21 on Dec 8 and now 2.26 on Jan 23. While his recent scans showed improvments both on bone mets and lymph nodes, I am a bit discouraged by the slight rise on PSA. His ALP is still dropping steadily, from 77 in Dec to 61.6 now.

Should I be concerned with the slight PSA rise? Do these tests fluctruate some times? Or is he heading to CRPC? :(

Any input or personal experience is greatly appreciated.



23 Replies

First I will say he has done amazingly well since dx. The Alk phos dropping well into the normal range and also the scans showing improvement in bone and ln is also excellent. I have often seen fluctations where it went up a bit and I got worried , only to see it down on the next psa actually often throughout my years.The rise of a mere 5 one hundreths of a point IMO is insignignificant, and something I would consider stable,Stable is always good. this is my opinion. You can read my history on my post. Wishing you and your Dad the best.


hzang2027 in reply to Dan59

Thank you so much Dan. I guess I was really expecting a PSA drop so got a bit panicky when I saw a small rise instead.

You are right, his disease is stable and that is good news.

Very impressed with your history. It gives me hope. My dad is much older but he was in pretty good health all his life up to the diagnosis.

Best wishes to you too and thanks for the input.

Hailin---look-> be at ease. The .05 difference, is inside the margin for error, as to the PSA test. Many Oncologists will not use a test that goes to 2 decimal points, as the accuracy is not possible. If 3 Blood samples were sent to 3 different labs you would surely get 3 different results---and this is in the 95% confidence level of statistical analysis. My PSA tests are always to 2 decimal points also. And some nationally known Lab testing companies, do not go below 0.1---in Florida when there my PSA numbers start at 0.1---when home the start at 0.03

The Head of Prostate Cancer Research at John Hopkins says anything that is under 0.1 is undetectable. Not 0.10.

As to the ALP---it can only come from bone or the liver--and close to a very high certainty it is the bone in your Husbands case. And this drop is showing things are working, as with the PSA. After a last Chemo---the PSA over a period of about 4-6 weeks continues to drop on its own. It is surmised that the cancer cells got so knocked around by the Chemo--but all did not die initially---and like an old dog went off into the woods to die. While on the way to dying they can still put out some PSA protein--to say I AM HERE---but not for long.

Stage 4 is obviously is more difficult than stage 3b, which I have---so in some cases there will be a PSA number that is above undetectable. That is when the ADT drugs---and in many times combined with Zytiga, or Xtandi, often will get to undetectable.

Be patient---you missed the bullet. All I can say now. My best.


hzang2027 in reply to Nalakrats

Thanks Nalakrats! I tried to look for some info online regarding the accuracy of the PSA test but did not find much. So you answered my question right on and put my mind at ease. Fingers crossed his next PSA will come down even more.

My father is actually on the ARASENS trial:

So its 50/50 chance he is getting the new drug Darolutimite which is along the line with Zytiga if I understand correctly . We choose this trial because it already exercises the latest protocol for HSPC with upfront chemo. This way even he is getting the placebo he is still in good hands.

Thank you for taking time providing me the valueble info. All the best to you too.


This is from a 15 years ago , He had a psa test every day for a month to see if there was fluctuations day to day,

hzang2027 in reply to Dan59

Thanks Dan. Looks like a .05 fluctuation is negligible. So my dad's cancer has stablized for the time being.

My PSA went down from 5,006 to as low as 1.0 on initial treatment, and stayed below 3.0 for almost two years. I am now a 4 year and 2 month survivor, having started with numerous bone mets and lymph node mets. The PSA "number", especially when measured in the hundredths, is far less important in advanced prostate cancer clinical decision-making. The totality of scan results, symptoms, other blood markers, etc., taken as a whole, becomes more important. He is doing very well so far, and we all wish him good success on the Clinical Trial.


hzang2027 in reply to ctarleton

Thanks for sharing your experience. It is encouraging as well as inspiring.

Nakalrats is right - you can only compare PSA scores if they are tested by the same lab and minor fluctuations are normal. Also beware of too much precision - it isn't possible. Try not to obsess on it - how do you feel personally? That's the most important thing.

Thanks. I will try not to be so obsessive. :)

He had bone pain several places at the time of diagnosis. The pain went away after the first chemo. However he later developed some pain/discomfort/weakness on his left hip area and is not able to walk for long distances now. Doctors have not pin pointed the root cause to it. We are hoping he can get better now that the chemo is finished. Will have to wait and see.

Best wishes to you.

Hi there.

It was the same for my husband. His ALP got a lot better during treatment but his PSA continues to raise. It went up from 129 to 295 over the last five months or so while he was on Chemo and while ALP kept dropping.


Thank you Mel. I have been following you for a while now and I am very happy for you that the Chemo is working for Paul. :) All the best!

In my case all of the cancer indicators have shown increases at times. My PSA did rise from 2.15 to 2.61 from one infusion to the next. My PSA later fell and is now at 0.23 after my 17th infusion. You need to look at the PSA trend after the next few infusions before you can have any meaningful conclusion. I am on ADT plus Chemo (Docetaxel and Carboplatin)

vandy69 in reply to eggraj8

Good Morning eggraj8,

I just completed 6 cycles of Docetaxel/Carboplatin chemo and am worn out and do not feel that good.

How have you tolerated 17 cycles? Did you have breaks between some cycles? You have my admiration!

Best wishes. Never Give In.

Mark, Atlanta

hzang2027 in reply to eggraj8

Thank you for sharing the experience.

When my cancer metastasis first happened I was in terrible shape I then started Chemo which improved me a little. I am retired and spend most of my time at home. I am weak particularly in the days after each infusion. I had a break when my ankle swelling showed I had Deep Vein Thrombosis. I had a second break when I fell and broke my ankle. I have tried to maintain the three week between infusion schedule as best I can. I keep my hands and feet on ice during the Docetaxel infusion to limit neuropathy. I have to be very careful about my stability especially since my blood pressure often gets low.

The good news is that I walked my son down the aisle. I went to my grandsons birthday. I am planning my next vacation.

I can’t do what I used to do but I realize that I never will but I still can take care of myself and do many pleasing things.

I found the effects of the Chemo remains the same as the number of infusion goes up but to me that is tolerable. I am happy to be able to write this as I didn’t think I would be able before the Chemo

Never give up



My impression is that ALP comes from mets in the bones, whereas PSA comes from any active prostate cell.

So that obvious (possibly incorrect) interpretation is that the bone mets are resolving, wheras the prostate cells continue to grow.

I think a factor in PSA is "leakage". There is supposed to be PSA inside the prostate, but not in the blood. So it could be either that a leak is getting bigger, or that more is being made and leaking is at the same rate.

It would be nice to be able to seal off the prostate.

Looks like a nice Trial. Multi-center for one thing. so a lot of people seem interested. NCT02799602

As best as I can tell, people expect nadir at 7 months. So you are about there.


hzang2027 in reply to Hidden

Thanks for the info on PSA and ALP. First time I heard about the 'leakage', it does make sense.

Do you have a source on the '7 months to nadir'? I was wondering about that. I do hope his PSA can drop even more.

Thanks a lot.

Hidden in reply to hzang2027

Well here is something I found.

Not exactly what I was looking for,

and somewhat surprising. (One study) THEY SAY:

At 7 months, a PSA under 4 is good.

A quick nadir was not as good a sign as a slower nadir.

Getting to nadir later was better. (?)

That's what I got out of it anyway.

This was without taxane.

"Median OverallSurvival after ADT initiation was 7.0 years. "

[long!- these were patients metastatic at presentation.

although PSA dropped from 47 to less than 1 on average.]

some of the sentences I could not understand

((eg: On univariate analysis: TTN <6 months, a PSAD >52 ng/mL/year, PSA nadir ≥ 0.2 ng/mL, a PSA≥47.2 ng/mL at ADT initiation and Gleason score >7, were associated with a shorter OS. ))


oh wait - if nadir < 6 months and PSA at nadir >0.2 (!!small)

PSAdoubling<??meaning PSA increase??> greater than 52 in a year

with PSA of 47 at start of treatment and Gleason score >7

then shorter overall survival.


hzang2027 in reply to Hidden

Thanks. I believe I have came across this before while I was researching for TTN. Theory is the faster PSA comes down, the more aggressive the cancer is?

Hidden in reply to hzang2027

That makes no "sense". Of course that does not mean it is wrong. It may be right, and my (our?) understanding is wrong.

Hidden in reply to hzang2027

I just made up the "leakage". PSA is not normally in the blood, except tiny amounts. The prostate is a gland. It secretes stuff. Does not have a lot of blood vessels in and out, so the stuff it secrets gets into the blood by passing through the walls. Most of the gunk goes into the urethra, right? So as the prostate grows, the walls stretch. That's sort of the idea. Makes sense to me. You hear of guys with a 4000 PSA. Well, what's that? They dont have 4000x more prostate cells than a person with a 1 PSA, and 400x times more than a person with a 10 PSA, and 40 times more than a person with 400 PSA.

How is your dad doing? My husband goes in next week for psa after three months off of doing nothing but the odm. His main complaint is back ache and knees. He is back working out at gym with light weights and walking. He has hot flashes all the time with no specific pattern. We are hoping it’s the odm causing these and not just the lupron shot. He’s pretty upbeat for all of this craziness.

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