PSA climbing after prostate removed

[arcflashed]

I'm new to this site. After having my prostate removed one year ago my psa level has begun to climb again. Before surgery 8.75. At this point one year later my numbers are at almost 0.1. I am trying to learn the best treatments for stopping the cancer growth. Going to a center that does laser therapy for a consult today. I'm seeing that hormone therapy is sometimes use along with laser therapy. Any information you can give me at this point will be appreciated.

[GP24]

Your URO should recommend salvage radiation with IMRT. See an RO for that. This is the standard treatment in your case.

[YostConner in reply to GP24]

Together with hormone therapy ...

[GP24 in reply to YostConner]

If he is low risk he could get away without hormone therapy.

clinical-genitourinary-canc...

[arcflashed in reply to GP24]

At this point after my appointment today it appears that I will be getting the IMRT. I hoping this will stop the new growth without the hormone therapy. Time will tell i guess.

[Emak1 in reply to arcflashed]

Don’t be afraid of short term ADT. I just had salvage radiation ending last June. And I had 6 months of ADT along with it. I was 3+4 with a reoccurrence 18 months post surgery. There are namograms (calculators) that show statistics on the success of salvage radiation. And adding ADT has a measurable increase. It wasn’t great but no terrible side effects. Excercise is a big must

[GP24 in reply to arcflashed]

Do not wait for time to tell. If time tells you that the radiation did not work you will have to continue with long term hormone therapy and have done six weeks of radiation in vain.

Put yourself more on the safe side and add six months of hormone therapy.

[arcflashed in reply to GP24]

Thank You. I am willing to do whatever is needed to slow this thing down. It's starting to appear that this cancer could become an aggravating problem for years to come. I'm at the beginning of educating myself on all of this.

[Filotimo62 in reply to GP24]

I agree. My partner will be having that - he is 8 on Gleeson scale. Surgery, hormone and radio (and possible chemo) . Seems to be the gold standard of treatment in Australia! Most of the cost is paid for by government funded (read tax payer) Medicare that everyone has.

[Filotimo62 in reply to Filotimo62]

Don't wait as this seems to be the best chance to stop re-occurrence. Read quite a few articles that also support this.

[Shepard in reply to GP24]

Agree. 42 treatments of IMRT did not work for me. Lupron and bicalutamide brought the psa down to less than .1 for several years. I was stable with that treatment for four years or so and then psa began to rise so now am supplementing with Xtandi. This is a journey or more likely a roller coaster ride. I am doing well now with pretty good energy. This disease is challenging, but one that you can live with and enjoy that which is meaningful to you. Blessings and good cheer to you.

[Tall_Allen]

Laser therapy? on what? you already had your prostate removed.

What did your pathology report say? Any positive margins? Size of margins? Gleason score at the margins? EPE? SVI? With persistent PSA, the usual next step is salvage radiation.

[arcflashed in reply to Tall_Allen]

My Gleason was 3+4. The pathology report said the cells were up against the margin and most likely beyond. The radiation will be centered on the removal site.

[Tall_Allen in reply to arcflashed]

So this is radiation (X-rays), not laser.

[arcflashed in reply to Tall_Allen]

Yes radiation - IMRT.

[arcflashed in reply to Tall_Allen]

I now see why you asked about the laser or radiation therapy. Mistakenly wrote laser therapy in my beginning question. It will be radiation.

[arcflashed in reply to Tall_Allen]

My biggest question at this point is whether or not there is some kind of protection to guard against collateral damage caused by the radiation to other healthy tissues such as the bladder, rectal canal, etc. I was told to show up with a full bladder and cleared bowels before each treatment. Are there other things that can be done to protect what is still good.

[Tall_Allen in reply to arcflashed]

The best thing you can do is exercise - the more, the better (if you don't have heart problems that preclude it). It oxygenates and protects healthy cells, and the extra oxygen helps the radiation destroy cancer cells. It also helps fight fatigue. I did take NSAIDs to keep the inflammation from getting out of control. If you have urinary or rectal symptoms, you can treat them symptomatically. Here's what you can expect:

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

Avoid vitamins and supplements.

[arcflashed in reply to Tall_Allen]

Thank You. I've just started reading your articles. They are very informative

[PGDuan in reply to arcflashed]

Funny about the exercise. I'm just finishing 6 of 7 weeks adjuvant EBRT and I normally have no desire to start exercising, but after 10-15 minutes I start to feel good and when I'm down I feel great, physically and mentally. I guess this sounds really cliche, but this dynamic is much much more pronounced then before I started my treatments.

[Hidden in reply to arcflashed]

You might want to consider spaceOAR.

learn.spaceoar.com/patient-...

[Excell in reply to arcflashed]

I am 4 weeks into radiation and hormone therapy, hormones aren’t so bad hot flashes and lower sex drive. The hardest part for me so far is filling up the bladder and holding it during the process and going pee for the rest of the day every 20 min. I might be a little more tired the usual, but with that said have no fear. YOU CAN DO THIS.

[Patrick-Turner in reply to arcflashed]

I'm 71, and I have had a long history of failing treatments one after the other since diagnosis in late 2009 because my Psa was less than 6 but I was found to have in-operable tumour at PG early in 2010, so no RP. I had 2 years of ADT + EBRT which is high power Xray radiation. 2 years after this treatment began I stopped ADT and Psa went back up to 9, so I restarted ADT and have been chemically castrated ever since. I've also cycled about 100,000km to stay fit. I had salvation IMRT with Calypso method at Epworth Hospital in Melbourne in mid 2016 after Psa went up when ADT failed, and I also began Cosadex added to ADT, and Psa went down, but mets began showing up in Psma scans. The IMRT is also X-rays. A gel pad was installed between rectum and PG to prevent too much RT to rectum. Despite the gel pad, I had severe radiation colitis after IMRT for 2 months but I am OK now with bowel and urinary function. But Pca marched on, and Cosadex failed, then Zytiga failed, and many bone mets all showed up in scans and I did 5 chemo shots which sent Psa from 12 to 45 in 3 months. Now I will have third Lu177 in about 2 weeks from Theranostics Australia at Macquarie University Hospital in Sydney. So far, Lu177 is the only thing that actually kills the Pca cells; ADT and Cosadex and Zytiga merely put Pca cells to sleep, but they mutate and grow slowly while asleep and making a low Psa that makes us think it all OK when it ain't.

Last week I got my latest PsMa scans that showed all my many soft tissue mets have become too small to be seen by scan. Bone mets have reduced in size and no new ones were seen. Psa was 25 before I began Lu177 therapy and now Psa is 17, and I may need the full 4 x Lu177 infusions costing usd $29,000 approx.

I have probably spent $20,000 of my own money and Medicare has probably funded care and treatments worth about $150,000 so far including specialists, scans, attempted surgery, GP visits ADT, Cosadex, Zytiga, chemo and in 2 years the Pca may well come back strongly and maybe be even more difficult to treat with anything. 30% of men diagnosed with Pca die from its effects, or of side effects of treatments. 20,000 men are diagnosed with Pca each year in Oz, so about 7,000 die from it, and

in many cases we just don't read much from them because they are just so

ill, and many are not savvy with Internet.

I hope by 2 years time there is some good immune therapy available; some big advances for breast cancer and melanoma are being made.

But even if I were to get all Pca to just die, its effects on my bones will stay with me. I started Lu177 when my bone mets were small, with Psa only 25, but the trend in Germany where Lu177 therapy was invented is that men come to it earlier, rather than later, when Psa is 250+.

These last 3 weeks my 5 areas of slight bone pain have got less painful but a hip is reluctant to get better. So instead of doing much cycling I built a 40M long fence, laid pavers, laid bricks, and worked hard in the heat. Hip is no worse for it, and yesterday I cycled 47km with no dull pain at night.

So far, so good, QOL is more or less continuing as a single active man who has a life that is probably better than about 6 billion other ppl at least on Planet Earth.

Early detection of Pca is the only chance any man has of avoiding a long battle. I suggest all men insist they get fully examined when Psa reaches 2.5 so that by the time examination happens Psa is still under 3.0. I would have gladly had my PG removed surgically before any Pca was present and when it might have been possible to avoid cutting through any nerves wrapping around the PG. But I bet my Pca began maybe 4 years before diagnosis, and by the time it became in-operable and a Gleason 9, the Pca already spread,

so even if I did have RP, it would have made no difference to my long term survival.

[cujoe]

arcflashed, I always recommend patients take a look at this AUA document when considering adjuvant or salvage RT. While it was last updated in 2013, I still think the recommendations apply. Altho' I think there has been some clinical research suggesting that a shorter-term/higher dosage treatment is as effective as the longer-term (+/- 8 weeks or so) I did 3 years ago.

Adjuvant and Salvage Radiotherapy after Prostatectomy: ASTRO/AUA Guideline

auanet.org/guidelines/prost...

You should also do some research on suggested dietary modifications (like reducing anti-oxidant foods/supplements - since radiation kills by inducing oxidative stress in cancer cells). There are also a few supplements that are reported to help radiation do its job.

Be Well and Good Luck with the IMRT - cujoe

[arcflashed in reply to cujoe]

Thank You

[cujoe in reply to arcflashed]

A bit of additional info (based on some comments by others since i first posted above). My pathology was non-organ confined, extracap & rt. seminal vesicle involvement, negative lymph nodes (at least for the ones biopsied). My PSA went to "undetectable" < 0.1 shortly after surgery and IMRT was done proactively based on the AUA document in the above post. Adding ADT to the IMRT was discussed, but we decided against. I think current info seems to indicate that it is good idea. Others here can help answer that question better than me.

From my reading, RT after RP seems to help some people and not others. I'm not sure I got any major benefits from it, but other than the inconvenience of weekday hospital visits, had no noticeable effects during the treatments. Some people apparently do have some minor digestive/urinary issues and with fatigue toward the end.

I did have severe incontinence issues unrelated to the radiation and several years ago had surgery to place the AUS 800 artificial sphincter. (I now pee at the press of a button.) When I had the cystoscopy during my urodynamic evaluation for the AUS 800, I asked about some "splotchiness" on the inside of my bladder and the surgeon said that was scarring from the radiation. So that is first-person evidence that even IMRT can cause tissue damage which might affect urinary and bowl functions. The AUA document discusses this, so you can get an idea of what the risks are. To date (five years out), I have yet to discern any effects from the IMRT. (Maybe a bit less bladder capacity due to less flexibility from the scarring?)

Hope this helps you with your decision and treatment(s). IMRT is pretty advanced method for RT, so with a good RO, it should give excellent results. Be Well - cujoe

PS Eventually I had a biochemical recurrence and went on ADT for 3 months. I've been off treatment for over a year now. There are lots of treatment options if and when you might need them down the road, so get through the radiation treatment decision and get back to living a full life.

[charlesmeyers1964]

so u are now at a 1.0 right. u do know that a normal male without cancer is from 0-4.0 so your at 1.0 every 6 months get it checked out. i don't know who told u having surgery or having ones balls doesn't stop the psa from growing at some time. first there is no cure for pcancer. if your lucky depending on ones age u should die of something else not related to pcancer. if not then u will die from pcancer until they find a cure. i'm on my 11 year and i'm at 37. i would say when u reach 1500-2,000 u will die. so relax there are so many meds out there and trial runs before u run out. also remember these drugs are temporary cures. relax dude and live long

charlie

[arcflashed in reply to charlesmeyers1964]

One year after my prostate was removed the PSA has begun climbing. Just trying to stop the growth before it gets into the lymph nodes or bone. At 0.1 I'm hoping it's still located in the prostate bed. I'm sorry you're having to deal with this crap at such a young age. Take care.

[Harry_B]

Hello. I see good questioning and advice from the forum. Like Allen, I read that you are contemplating radiotherapy not laser. I think the thing to understand is that the rising PSA indicates that you have active PCA tumour cells somewhere. The probability is that these are located in the pelvic lymph nodes but they could be located elsewhere also (eg. bone). If you proceed with salvage radiotherapy to the prostate bed and pelvic lymph nodes and your PSA stops increasing and then decreases then you can happily associate the treatment with the benefit. Wherever the tumour cells are, note that hormone therapy will, for a time, make them calm and less likely to spread. However, this comes at a cost to quality of life. You will find lots of good advice on this forum. All the best. Harry

[arcflashed in reply to Harry_B]

Thank You

[billyboy3]

I am a STRONG STRONG believer in IHT, as it works!!!!!!-in most cases. there are always side effects from any medical treatment form, so get used to some pain and discomfort!

The choice is to stay alive longer, lose some quality of life during the process but extend your life for several or more years. A psa level of .1 is low but you are correct in being concerned. There are many possible side effects from radiation treatments as well.

If you use the IHT -intermittent cycles of on drugs, then off, it will greatly reduce the side effects of HT. If it were me, I would jump on HT NOW, and continue it for 3 or 4 months-until you reach nadir in the reading-which you are almost at. Keep us updated on your progress as we need to build some structure around keeping track of treatment modalities and outcomes. Good luck and live large!, make up a bucket list, clean your plate of stresses and love your family and those around you.

[tennis4life]

Cool logo!!!!

[j-o-h-n]

Make sure you get "the best" radiologist you can find.... BTW tell us your age, location, where you're being treated and doctor(s) names, this info helps us help you. When I was zapped "in my bed" 39 times it was like having an ex-ray at the dentist. Years later I found out it fried my left urinary tract. So beware.

Good Luck, Good Health and Good Humor.

j-o-h-n Friday 02/08/2019 5:51 PM EST

[ian222]

Not so clear, if ADT in this settings is resonable:

"Further, post-hoc analysis of RTOG 9601 failed to show a benefit from the addition of ADT for patients with pre-salvage PSA levels < 0.7 ng/mL.[21]

However, the benefit from ADT that was observed in GETUG-AFU 16 did persist for patients with pre-salvage PSA levels < 0.5 ng/mL compared with patients with pre-salvage PSA levels > 0.5 ng/mL.[22]

Therefore, although we do recommend ADT with salvage radiation for patients with PSA levels < 0.7 ng/mL, our recommendation is not as strong as it is for patients with PSA levels > 0.7 ng/mL, and we will support omission of ADT in these patients if they are opposed to hormone therapy."

cancernetwork.com/prostate-...

"Salvage radiotherapy alone is standard of care for men with PSA <=0.5 ng/ml.

Salvage radiotherapy with hormonal treatment is standard of care for men with PSA >= 0.7 ng/ml."

ASCO 2018: Precision Risk Stratification and Treatment in Biochemical-Recurrent Prostate Cancer

urotoday.com/conference-hig...

"When a man’s PSA level is low, less than 0.5, we are more confident that radiation alone will prevent recurrence. Using ‘early’ radiation and higher doses with modern techniques has improved outcomes, and thus the addition of hormones is more carefully measured in such patients. This study did not find survival benefit for patients with PSA levels of less than 0.7, supporting our emphasis on this strategy."

utswmedicine.org/stories/ar...

When to add ADT?

"Conclusions ADT combined with SRT appears to improve OS in patients with a PSA level before SRT of >0.7 ng/mL. In patients without persistent PSA after prostatectomy and PSA levels of <0.7 ng/mL, ADT should not routinely be used, but may be considered in patients with additional risk factors such as Gleason Score >8 and negative surgical margins."

From:

Translating Trials to Practice - Updates in Prostate Radiotherapy Bridget Koontz

Radiation Oncology Duke Cancer Institute

"Dr. Briganti summarized his great talk reiterating a few important points. Men that are potentially suitable for salvage curative treatment should not be treated with ADT. When indicated, salvage radiotherapy should be given at the earliest sign of disease recurrence (especially in men with adverse features at radical prostatectomy)."

From:

EAU PCa 2018: Salvage Treatment for Recurrent Disease - Dr. Briganti

urotoday.com/conference-hig...

I have PSA 0.62 now (21 month after RAPE, 2 weakly positive pelvic node 4 and 6 mm in PSMA-PET), proton therapy planned ), and I want wait till 0.7 with ADT (but not my recommendation for anyone).

PSA doubling time (PSADT) is also important but online calculator doesn't receive values bellow 0.1 (where the interpretation is yet problematic).

mskcc.org/nomograms/prostat...

[daleboy3]

Can I suggest follow & you read this link

nattokinasehearthealth.com/...