Understanding blood report before oncologist visit

[Life5]

Hello everyone,

Wanted your help with the blood test results in order to ask the relevant questions to our MO

My dad is on 750 mg of zytiga and 5 mg of prednisone since August 2019. We had a quarterly PSA test today and the results have shown a slight increase from 0.001 to 0.007 - it is the same lab and I understand from the forum that it is still undetectable if rounded up to two decimals and we have to monitor it to see an increase in trend for another three PSA's

His last result was in August 2020 which showed an increase in sugar levels, high cholesterol and presence of protein in urine. The GP and MO said that the protein is present (+) which is fine, if it increases to ++ it will be a matter of concern, they started him on metformin and a combination of statin plus aspirin. He also took an ECG which was normal - the statin + aspirin caused some vertigo and we consulted a cardiologist who said its okay if he does not take it as the cholesterol were not that high. Then we noticed some facial swelling -to which our MO assistant said it was a known side effect of abiraterone acetate and prednisone and not to be worried and come back with the test results as per the schedule.

The abnormal test results/decrease during the current reports are:

Hemoglobin and RBC has shown a declining trend:

Feb20:14.7%, Aug20:13.6%, Nov20:13.2%

RBC

Feb20:4.78, Aug20:4.33, Nov20:4.2

ESR has increased from 18 in august 20 to 25 in november 20 (it was 30 in feb 20), NLR though normal has increased from 1.53 in Aug 20 to 2.05 currently.

Alkaline Phosphatase was 51 in Feb20, 33 in Aug 20 and is now 43 in Nov20 (He was taking zometa injections but has not taken them since Mar20 due to Covid)

While URIC Acid has always been low for him at 3-3.10 mg/DL, this time Sodium is at 132 (normal range 136-145) and so is Chloride lower at 97 (normal range: 98-107). Potassium is normal at 4.4.

Creatinine was 0.89, 0.91 and is now at 0.90

While in august, Protein was present in his urine, there was also presence of 4 epithelial and 4 squamous cell and 2 casts. Currently also protein and epithelial cells are marked as present (+). Negative protein is less than 10 Mg/dl, trace is 10mg/dl and + is 25 mg/dl.

Sorry for the long post, I would be grateful if you could help with my queries:

1. Given the marginal increase in PSA should we ask MO to advise testing as per the usual - in another 3 months or should we insist for doing it sooner?

2. Are the above results and facial swelling signs of taking low/more prednisone - like should the dose be adjusted from current 5 mg to 10 or 2.5 mg? or do they indicate some issues with the kidney (creatinine is normal) and we should insist and take a referral for a nephrologist ? In August the MO had said presence of protein is okay, we should be concerned if it goes to ++ i.e.: 75 mg/DL

3. I have read on the forum the ESR and NLR ratio are markers of inflammation - could the increased inflammation have caused the increase in PSA ? Could there be an infection somewhere? or does it indicate the cancer is progressing ?

4. Dad was diagnosed in July19 with a PSMA Pet CT scan - he has not had any scan since, should we insist for a PSMA Pet CT scan as the PSA has shown a rise? or will it not show anything at such low PSA level?

I know these are questions to be asked to the doctor, but what I have learnt is that MO's at times tend to focus only on treating Pca and not focus on its side effects - so we need to be vigilant and ask him relevant questions on treatment.

[LearnAll]

Hell oh .. Life !

Let me read your Dad's report point by point.

Hb. 13.2 and RBC count 4.2 ...both are in good range. Some decline in Hb and RBCs is considered normal for people who are on ADT. Its called Anemia of Androgen deprivation.

This is caused by bone marrow slowing in utilization of Iron. This should not be treated with Iron supplements unless serum iron levels are low or very low. Generally..issue here is not lack of iron but it is lack of bone marrow ability to utilize iron due to low T.

ESR from 18 to 20 is not significant. It is a marker for amount of inflammation in the body.

A better marker for this purpose is C Reactive Protein (CRP)

His NLR is 2.05 still good as cut off point for NLR is 3.0 for PCa people.

ALP going down from 53 to 43 is good news. It means his bones are happy and not letting cancer cells corrode them.

Uric acid and chloride level: basically unremarkable.

Creatinine from 0.89 to 0.90 is too little a change and can vary from one testing to other.

Protein in urine is not good..A urine culture may show bacteria infecting his urinary tract(bladder,kidneys) Ask Doc to find out cause of leakage of protein in Urine.

Last but not the least. .PSA change ..I will not worry at all as long as there are two zeros in front of a number. Worry starts only after 0.1.

Overall, I find your Dad's report very good. A word about Zytiga...Its very effective medicine but very harmful too. It's side effects are increase in blood pressure and increase in blood sugar. Need to lose weight, eat heart healthy diet and monitor heart frequently. Best Wishes.

[j-o-h-n in reply to LearnAll]

You guys are the cat's pajamas.....

Good Luck, Good Health and Good Humor.

j-o-h-n Tuesday 11/03/2020 6:17 PM EST

[Tall_Allen]

PSA of 0.007 is zero and 0.001 is zero - that is NOT an increase - it picks up benign non-prostatic sources of PSA. It will fluctuate and will not show a trend. Who gave him that test? His MO should not be using a super-ultrasensitive test like that. Most of your questions are assuming an increase. That is incorrect. Use a less sensitive test and test no more than quarterly to avoid anxiety and overtreatment.

The one number that really stands out is the low sodium. Some of his symptoms may be related. (kidney function, moon face, confusion/dizziness). That has to be investigated. It may be as simple as reducing his water intake or his BP meds. Or it may require hormonal adjustment.

[j-o-h-n in reply to Tall_Allen]

You guys are the cat's pajamas.....

Good Luck, Good Health and Good Humor.

j-o-h-n Tuesday 11/03/2020 6:18 PM EST

[Hidden]

Low sodium is the only thing that I would address. Mine decreased to 131 and my oncologist was concerned. I had switched from a more standard diet to a vegan diet. She advised that I simply add a little salt into my diet (I was already getting most of the other electrolytes from my diet). I added salt in limited quantities and my sodium level hovers between 138 and 143.

Prednisone has a short half-life and serum level. I split my dose. I don't know if this would help you. I'd ask my MO if taking 7.5-10mg a day would be okay. If it is I'd try that but ask about the benefits of split dosing.

AA can raise BP. Prednisone is converted to prednisolone in the liver. Prednisolone is a glucocorticoid and can help counter the BP increases. Is your dad's BP okay?

[j-o-h-n in reply to Hidden]

You guys are the cat's pajamas.....

Good Luck, Good Health and Good Humor.

j-o-h-n Tuesday 11/03/2020 6:19 PM EST

[Life5]

Thanks a lot for your help everyone. The meeting with the MO went well, he was not concerned with the reports - he said the reports were good and said to continue the medicines and come back in 3 months time with PSA and scans, scans as we haven't had any since diagnosis in July2019. He did not show any concern on the protein, sodium etc. He mentioned sodium could be as he has started exercising - and walks 15000 steps daily so could be due to sweating...RSH1 His BP levels are normal, but he did end up having diabetes due to AA for which he started medicines in August 2020. We will consult his GP to get the protein and sodium issue checked.

[NecessarilySo]

I notice the RBC low, alk phos is low , possible liver disease. Nothing real serious, just something to ask doctor about. Ultra-low PSA is in my opinion no concern at <.200.