Advanced Prostate Cancer
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PSA Recurrence - confused on next steps?

PSA Recurrence - confused on next steps?

Wondering best course of action? What do these number mean for my risk profile?

• Prostate Surgery April 2016,(PSA was 9.6) - last PSA – 0.48 (01/18) - PSADT 4.6 months

•Time to recurrence – 0.10 @ 9 mths; 0.2 @14 mths

•Pathological Gleason score – 4+3 (7)+T5 = act like G8

•Stage: p2Tc – PNI - (clear margins, SV, lymph nodes)

I understand men with a Gleason Score of 7 (4+3) with tertiary Grade 5 have a similar risk of PSA recurrence compared to men with Gleason Score of 8, 9–10 . Apparently the presence of PNI suggests an increased risk of metastasis.

Research suggests if PSA doubles in less than 6 months, it is likely that cancer has already metastasized to bones or organs? If the PSA level rises within the first year after surgery, it usually indicates metastatic disease.

Researchers concluded that a PSA of 0.4 ng/ml or greater reflects the threshold at which a PSA increase becomes durable and shows the strongest correlation with subsequent systemic progression.

I am in Thailand and recurrence treatment is handled by urologist unless referred to radiation oncologist. Dr plans on PSMA PET/CT scan and MRI (after next PSA test) in the next month to try and find source of rising PSA. Talked about but not certain regarding SRT. Dr said may need to look at combined therapy of ADT & Chemo if things progress? From research and use of nomograms success of salvage radiation is on 37%? Watchful waiting at the moment tracking PSA.

Thoughts on treatment steps? - all research leads to much confusion - some treat, some don't (treat cancer not PSA!) - some seek aggressive treatment and some not so before it spreads?

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My MO would probably want to see 2-3 rising PSAs, then would recommend treatment.

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Thanks - I have had 7 rises in PSA since surgery - thus being able to track doubling time.

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I had a reoccurrence at 14 months out 0.18. But rose to 0.27 quickly. Doubling time around 3 months. Decided on ADT to stop any progression and starting SRT soon

Agreed the research is all over the place. I have seen that 0.5 is a critical threshold In terms of SRT

My scans at 0.2 did not reveal anything. Oncologist expected that Nomograms put me at 60-65% so taking a chance

It could be all for not or I get lucky but worth the risk for me.

Next step. Go aggressive with drug treatment

Good luck These decisions are not easy

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You never reached a complete Zero or Undetectable PSA for a certain given of time. So I would expect that you would need to be watchful---and IMO, and I am not a Doctor, do not let it get to far away---and there are arguments to where the red line is. But since you are early, in your disease. The new standard is to hit it with Chemo while on a particular ADT Drug choice---or Zytiga and Chemo. Now in my case life, I am doing everything possible to avoid Chemo---but that is me. Drugs and supplements worked for me for 22 months and I am a Gleason 9, on vacation.

I am fully aware that I can have a biochemical relapse, at any time--but I maintain my program--as if I still had a significant PSA--outside of not taking the 2 ADT drugs I was on.

Nalakrats

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Good luck. I am off ADT too. Do you get your PSA measured every 3 months?

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No we do it every month T and PSA--just got mine today--still undetectable and my T has gone from 20 to 65 now 105==I expect at 6 months my T will hit its max---which I do not expect will be more than about 180-200.

Reason for every month is my Pathology, of Ductal Cribriform---we cannot afford to let this get out of the bottle too far. We are prepared every 30 days to re-treat if necessary.

I did not opt for IADT--I opted for complete vacation.

Nalakrats

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Thats great news on the undetectable PSA and T rising. Good luck.

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You need at least 3 PSAs over 0.1 for a valid PSADT. So you're saying you don't want to even try SRT, considering the odds? Why not do an advanced PET scan and decide based on that? If it finds mets outside of the whole pelvic treatment field, your suspicions are confirmed and you can move to ADT/ If not SRT may still be curative. Don't wait any longer - your PSA is getting too high. PSAs above 0.2 have much less chance of being cured.

pcnrv.blogspot.com/2016/09/...

pcnrv.blogspot.com/2018/02/...

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Thanks for the feedback - I have had 3 PSA rises over 02 - 2.6, 3.8 & 4.8 in past 6 months. My plan is a PET scan later next month before my visit to the specialist. Your thoughts mirror my thinking - I think!

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sorry got the numbers wrong - 3 rises over 0.2 - 0.26, 0.38 & 0.48 - clearly meeting the PSA recurrence definition?

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I agree with Tall_Allen. The way it was explained to me was, yup at 0.2 or under it is difficult to see (there is the new GA-68, but did not get a test on that). So it is either, left in the bed or already in bone/tissue (distant) or both. It is all statistics, like you said 40% for you, I am looking at 60%. Now if you can confirm it is outside the bed, then yes, no reason to risk radiation.

Otherwise, you take the chance, and the big difference is if you get lucky and it can be very long remission to curative.

I looked at the stats like playing roulette. I sometime play the '12s', basically a bet that you have a 33% chance to win 2:1. Now naturally, I don't want to play this for my life :) but it helped my get my head around the chances and they are not impossible by any stretch.

I am also on ADT, the theory there, the doubling time shows it is progressing at a fast clip, so lets stop it. Treatment is over 8 weeks and it gets tougher to treat if you are trying to radiate and the cancer is progressing quickly at the same time.

Not going to sugar coat it, there are plenty of stories of men who did this and either had immediate failure or failure within 12-18 months.

But there are others where is worked, with similar bad variables (double time, under 3 years, etc.) . yananow.org/display_story.p... and this guy is going on 6 yrs without anything

Key for me was without proof this was outside the bed, this is a potentially curative option

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My Gleason was 4+5 + 9 before I had a RP in May 2016, T2c N1 MX (one positive lymph node , negative margins) followed by taxotere with Lupron "boost" (stampede protocol) and PSA recurred within 7 months of treatment. PSADT was less than 2 months, so I am now back on Lupron. MO's focus on PSA until there is something else to peak their interest.....

Typically, ADT is a standard treatment with "biochemical recurrence" because it knocks down your testosterone and thereby lowers PSA. This is for systematic recurrence when there's no evidence of metastasis. Radiation is often used when metastasis is present and the location can be identified. Before you end up on Lupron, get the Axumin PET or other advanced PET BEFORE you lower your PSA with Lupron. They typically won't do the advanced PET on PSA lower than .2 That's how I missed my chance.

Good luck!

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Hi ! Get the scans before the ADT ! I almost went straight to ADT because insurance refused to pay for Axumin scan.

The axumin scan changed the whole treatment plan from palliative to curative .

There are no guarantees but I will be happy I did all I could when I had the chance .

I won’t know if radiation worked for until I stop Lupron in another 17 months but so far PSA undetectable and I deal with the side effects and have HOPE ! That in itself helps .

Best of luck to you and all my brothers ! Live long Live strong !

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