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Advanced Prostate Cancer
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Question about PSA Nadir

Hi everyone,

My father has been on Zytiga and Lupron since May 2018 and his PSA has slowly dropped from 42 to 9.5 but has now been around 9.5 for the past couple of tests (aprox for a month). He had his prostate removed in January but unfortunately his PET PSMA showed multiple mets shortly after. His doctor says that as long as his PSA isn't rising, they won't change his treatment but I thought that the goal was to lower the PSA to undetectable levels and 9.5 seems fairly high. Does this mean that 9.5 is his PSA nadir or is it possible that his PSA will continue to lower? If it is his nadir, is it worth changing his treatment? Does this fairly high nadir have any significance in terms of OS? He Gleason is 8 (4+4) and is 72 yo. He had bad side effects from the Zytiga so they had to take him off/on a couple of times and change the dosage so he's only been back on the full dose for about a month.

Thanks so much

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You could try Xtandi instead.

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I cannot prescribe--not a Doctor--but I would start a conversation--demanding--what technology your MO has/knows that will reduce the PSA--if unsatisfied, it is time for a second opinion--with a MO who only specializes in Pca, and is at a big center of excellence--as related to Cancer. In other words not being in your shoes--I would not be happy with the response of the Doctor--In my life I have fired about 6-7 Doctors over the last 30 years. Most recently a GP--who claimed to be Integrated--was not--we got into it, he called me some names, I called him back, some; had him put in front of a Peer Review board--and they moved him out of town. I do not take C*** from Doctors--I have played golf with them for 40 years at various country clubs--and when their ass itches in the locker room they scratch it like any other man.

Nalakrats

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OMG - you're my hero - concur completely.

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Geez Nalakrats "re: doctors"... stop beating around the bush and tell us how you really feel.

Good Luck, Good Health and Good Humor.

j-o-h-n Monday 11/19/2018 10:232 PM EST

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You want to treat his cancer, not his PSA. There is no reason to take him off Zytiga until his biomarkers increase (PSA and bone alkaline phosphatase) AND he shows signs of radiographic progression. At that point, he may want to try switching from prednisone to dexamethasone, which may keep the Zytiga working even longer.

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I agree with this answer. It easy to treat the PSA, but it's only one indication. The conventional wisdom is to not make decisions based on PSA alone. I discussed this with my doctor last week at my appointment and he agreed, although he said if your PSA starts taking off and is getting really high you have to look at that, regardless of anything else.

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9.5 of PSA is a bit high but the MO is right, as long as it doesn't keep increasing Zytiga is still considered effective, at least to control it and slow it down a lot.

STABLE IS STILL GOOD and better than progression, don't take him off the drug until there are clear signs of disease progression.

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good response Ralph, exactly, if it stays there, keep going as is. and LIVE LARGE

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first of all what is a nadiar? 2nd when u have had radiation or surgery to remove the prostrate no one mention a Gleason score its no longer important. since your psa is 9.5 and from what u said he's only been fighting this problem for a short time. remember this, there is no positive cured from pc unless surgery. 9.5 is great, all treatments will eventually will stop working and then u have to face what other med out there or what time frame u have left. enjoy the 9.5 monitor the psa and move on.

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Charles,

I have previously commented on comparing PSAs in men who have 'elevated PSAs >4.0, BPH, or in those who have been diagnosed with PCa and have not undergone treatment'...with men who have had RPs or RT. You can NOT compare the results since PSAs 'should' be substantially different after treatments than before; hopefully, if treatments are successful, remain at levels far below 4.0. Please read the following:

Understanding PSA Numbers

After the surgical removal of the prostate, or prostatectomy, PSA 'should' drop to virtually undetectable levels, (less than 0.1). This is effectively 0, but by definition can never get all the way to zero, given the sensitivity of the test and the fact that, at very low readings, other proteins may be misread as PSA protein. In contrast, because normal healthy prostate tissue isn’t always completely killed during radiation therapy, the PSA level rarely drops to 0 with this treatment. Rather, a different low point is seen in each individual, and that low point, or NADIR, becomes the benchmark by which to measure a rise in PSA. Usually, a rise by more than 2.0 ng/mL 'is typically cause for concern.'

Because the starting point is different whether you had surgery or radiation therapy, there are 2 different definitions for 'DISEASE RECURRENCE' as measured by PSA following initial therapy.

Following a prostatectomy, the most widely accepted definition of a RECURRENCE is a confirmed PSA level ≥0.2 ng/mL. In the post-radiation therapy setting, the most widely accepted definition is a PSA that is seen to be rising from the lowest level (nadir) by at least 2.0 ng/mL.

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Great explanation...take a bow....

Good Luck, Good Health and Good Humor.

j-o-h-n Monday 11/19/2018 10:37 PM EST

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Thank you again "j-o-h-n"!

Good Luck, Good Health and Good Humor to you also!

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At first Zytiga gave me muscle cramps and joint pain at night. My oncologist gave me a prescription of valium. It's a muscle relaxer, and it totally did away with my bad side effects. My psa at diagnosis was 183. After 3 weeks on Lupron, then Zytiga and Prednisone, my psa has been undetectable. I've been on it since last March. Good luck!

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