I was diagnosed in July 2018, PSA 103.0, Gleason 9, a few mets to bone and lymph nodes. No bone pain. I am 2.5 years into this journey and have responded very well to chemo and ADT (Zoladex). My nadir PSA (0.17) occurred one year after diagnosis. During the last 8 months, my PSA has slowly risen from 0.35 to 0.70. My latest scans were in April 2020 and showed no new growth.
My question is ... at what point will it be determined that I am castration resistant? Will my PSA suddenly start escalating rapidly? Will my PSA just continue to slowly increase until the oncologist determines it is too high and then, likely, start me on abiraterone as the next line of treatment? I'm curious what other men's experiences have been.
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MarkBC
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Definition of Castration Resistance: When total testosterone stays below 20 ng/dl and PSA continues to significantly rise in a series of 3 times or more in a row....(Fluctuations in PSA is not considered continuous rise)You need to rule out other possible causes of mild PSA rise...such as excessive exercise, inflammation, Prostate infection or simple ebbs and flow of PSA readings within a narrow range including lab errors.
Do Not jump to conclusion quickly about castration resistance lest you are subjected to more body and mind damaging treatments.
There have been cases of reversion of PSA after a 7 day course of antibiotics, ..after eating 50 grams of raw Ginger for 15 days ...after stopping strenuous exercise....after stopping bicycling ..AND even after stopping wearing a tight underwear...(No kidding)
Waiting and rechecking PSA a few times in next 6 to 8 weeks (preferably every 2 weeks)
will remove false alarm about castration resistance.
First thing to do is to check total T...Is it below 20 ng/dl...? That's the key !
God Forbid..if you truly have progressed to castration resistance.. then.. get new shiny weaponry to deal with it along with anti cancer diet, exercise and immune regulating tecniques... .Time for Comprehensive care (SOC+ Non SOC + Supplementary interventions)
I had monthly testosterone tests since I started treatment and the results varied between 5.7 and 11.5 ng/dl. The doctor stopped ordering testosterone tests about 6 months ago. Should I request another one to see if it has been rising as well?
PS I don't think the underwear has ever been too tight. 😀
Testosterone above 20 but with a rising PSA (on Lupron) would mean what? My last PSA was tied for all-time low of 0.7, but T was at 15, all-time high since beginning Lupron.
Think of total testosterone as water coming from a garden hose(pipe) .....If the tap is fully dry. ...means there is not even a drop of water (testosterone) coming, the grass (prostate cancer cells ,Androgen dependent type) dries up and die.If Testosterone is above 20 ng/dl..it means drops of water are still leaking and some grass is still not drying and not dying,.. indicated by PSA higher than 0.2 (in intact prostate AND 0.1 in removed prostate)
When Total T is less than 20 ng/dl and PSA is rising...be alert...this might be an early warning sign that Androgen Dependent Cancer Cells are starting to become Androgen Independent. But the rise in PSA has to be a clear and steady upward trend..(not just up and down)
Q: "T above 20 and rising PSA(on Lupron) would mean what ?"
It may mean that your PCa androgen sensitive cells are responding by growing ...as now, they are getting some testosterone again. Those cells are still androgen dependent if they are reacting by growth when T is available.
Hammer testosterone down again below 20 and most likely your PSA will fall.
But If You Keep hammering your Testosterone down too strongly and for too long, non stop ..the Cancer Cells will adapt to very very low or No T, and convert into Androgen Independent or even worse, Neuro Endocrine type.
LearnAll, I disagree with that. If you get your testosterone below 20 ng/dl you will have the longest period till castration-resistance develops. If you only get it below 50 ng/dl, it will be shorter period. The castration-resistant cells develop more quickly if you do not get the testosterone below 20 ng/dl.
See this study by Prof. Klotz:
ncbi.nlm.nih.gov/pmc/articl... The patients who got their testosterone below 20 ng/dl = 0.7 nmol/L did have a good chance to stay hormone-sensitive for over 10 years. These patients had surgery and salvage radiation and started ADT because of a rising PSA.
There is no disagreement. GP24. Getting a lowest Nadir Testosterone is very very important BUT continuously keeping androgens super suppressed for months and years continuously is what promotes Androgen Independence and/or Neuro Endocrine Variant albeit to varying degree in different men. .depending on their propensity for differentiation.
You have to wait until the PSA value gets above 2.0 ng/ml. It will usually not rise more quickly but you will get over this level as long as it keeps rising.
Definition of CRPC
Castrate serum testosterone < 50 ng/dL or 1.7 nmol/L plus either:
a. Biochemical progression: Three consecutive rises in PSA at least one week apart resulting in two 50% increases over the nadir, and a PSA > 2 ng/mL
or
b. Radiological progression: The appearance of new lesions: either two or more new bone lesions on bone scan or a soft tissue lesion using RECIST (Response Evaluation Criteria in Solid Tumours).
Symptomatic progression alone must be questioned and subject to further investigation. It is not sufficient to diagnose CRPC.
I agree that you should get the testosterone level below 20 ng/dl. But in the current NCCN guidelines they still refer to 50 ng/ml for the definition of castration-resistant PCa (PROS-14).
You're doing fantastically well. You will have a lot of treatment options if your PSA does continue to rise. I used to worry about my PSA rising, then neuroendocrine cancer exploded in my body and I learned the futility of trying to predict what the cancer will do because each case is unique. That said, most likely you will get lots of warning if the cancer returns before things get out of hand.
Castration-resistance means that "progression" has occurred in spite of castrate levels of testosterone <50 ng/dl.
There are definitions used in various research studies, but no real standard definition of "progression." NCCN states that "increasing PSA [while T<50 ng/dl} should not be used as the sole criteria for progression. Assessment of response should incorporate clinical and radiographic criteria."
Many research studies use the Prostate Cancer Clinical Trials Working Group 3 (PCWG3) definition, which you can read about here:
As you can see, they recommend a thorough assessment of diagnostic info before declaring that progression has occurred. But you are not in a clinical trial. This is really between you and your MO and your ability to get the new therapy covered.
My dad is on Zoladex and I've read studies show that only 28.4% of men treated with goserelin achieved testosterone lower than 20ng/dL. Before diagnosis my dad had very high T levels which makes me worry it'll be harder for his to come down - we are getting them checked tomorrow but is there anything else we can do to bring T down if it's not below 20? Switch to a different hormone therapy?
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