A urologist told me that residual prostate tissue may account for PSA detection after an RP of PSA under 0.1.
Another urologist old me PSA below 0.03 or so can't be trusted because of the assay.
A radio oncologist told a member of my surgical cohort that any measurable PSA after an RP is coming from somewhere other than the prostate because there is no prostate-- hence without positive margins, the the PSA should be 0.01 . Anything much above that means their is cancer somewhere in the body.
No on has addressed these seemingly inconsistent responses to my satisfaction.
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Steve507
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I was on ADT for 2 years. My doctor does not use the ultra-sensitive test for post RP, post radiation metastatic cases like mine because he says we wouldn't treat before reaching PSA of 0.2 or higher anyway. ADT took me to <0.1 within a month. After the 2 years I asked for a vacation. One year into the vacation my T has recovered to 304, PSA <0.1. I have only now, one year after stopping ADT, just starting to feel stronger.
He tells me that before 0.2 it is impossible to find the source in any imaging, and the test is not very accurate at those low levels anyway. Honestly, I am not sure what to believe, other than the fact that no one really knows. Frustrating.
Well, your RO has the most support behind his explanation. PSA from residual healthy prostate tissue vanishes quickly. However, not all prostate cancer progresses, so some men have very stable low uPSA. Recently it was found that a man can comfortably wait for 3 consecutive uPSA increases or PSA reaches 0.1 - outcomes are no worse than immediate treatment.
Well, post primary treatment, the one critical value to keep an eye on is PSA Doubling Time rather than just the presence of measurable PSA.
As noted, too frequent testing is considered noise, and the mere presence of PSA is not necessarily an issue as there is sometimes remnant tissue that eventually dies off.
Post RP, recurrence is considered when multiple PSA tests, usually spanned over 10-12 weeks each time, detect PSA at .05ng or above. With RT, that recurrence is considered when PSA is measured at 2.0ng above the nadir established by previous tests.
In any event, the most sensitive scanning (G68-PSMA-PET) will be most proficient at a level of at least .5ng, better at .8ng and almost any test will work above 1.2ng... but the G68-PSMA-PET scan will still see the smallest lesions.
I don't see any inconsistency other than those delivering the information. But if you search and examine studies and their results and multiple reports and responses, you'll find the above data consistent.
Again, so post primary treatment, the real issue is examining the PSADT because this is the best predictor of not recurrence, but the possibility of progression. The presence itself of some PSA isn't nor should it be alarming. PSADT of less than 6 months is considered agressive and usually will cause immediate reaction towards additional testing and treatment. At that point, timing is everything! When to scan, when to treat...
Just want to throw out some of my thoughts here. I'm not a doctor, just a survivor. The detection of PSA is incredibly small. When you talk about 0.01 ng/ml it is like talking about an extremely small amount of prostate specific antigen. It can be thought of as a fish in a lake.
If you are talking about a doubling time then you are talking about two fishes in a lake that are reproducing. Still the quantity is quite a tiny amount. Just finding those two fishes is a rather difficult task, but we try. It's a bit like our attempts to find the Loch Ness Monster. Once in awhile the monster surfaces and causes a spectacle but then when others try to see it it's unfindable. Bigfoot is similar. Finding the monster is rare, even when specialists are looking intently.
A nanogram is 1,000,000,000th of a gram. A PSA of 0.01 is 100,000,000,000th of a gram. To grasp this you need to think of a bacteria in a lake. It is tiny.Just to be able to find it at all is quite a remarkable achievement.
When a person is assessed for prostate cancer a biopsy is the usual means, in which a relatively large core drilling device is used to puncture the prostate gland, through the skin, through the rectum, through the microscopic blood vessels and flesh. Then to make things worse the core drill is removed through the flesh and blood vessels and skin. Often this simple analytical procedure causes bleeding into the bladder and possibly into recirculating bloodstream as well as nearby flesh. You can imagine that this process alone is like a surgical procedure that can cause traumatic internal rise in PSA into the bloodstream, due to stimulation of the prostate like a massive digital rectal exam. I have not read about this anywhere, I am just explaining what I have imagined and it is not any more than imaginary, but is is a good exercise in thought to understand what we are doing.
So then this biopsy effort is one means by which the cancer can be spread throughout the body in ultra-small quantities but nevertheless it takes only one prostate cancer cell to get into the bloodstream to spread to other locations, most likely through the lymph system or blood vessels, where it becomes trapped somewhere and continues to grow.
The body has defense systems including lymphocytes and cells that go about and search for and destroy cancer cells, but they also are small little things, kind of like predator cells in the lake looking for those a tiny number of bacteria. They may be able to find and destroy a bacteria here and there but not every bacteria in the lake. And so the number of bacteria in the lake multiplies over time, silently but exponentially.
Prostate removal is similar to biopsy but at a much greater scale. And radioactive therapy is like removal but it does not affect areas outside of the prostate, usually. Nevertheless the probability to kill all prostate cells either by surgical removal or radiation, is rather like putting a fence post on a property line. Often the fence is off, sometimes by a tiny amount, sometimes by large amount, regardless of how much precision the fence builder applies. Even a surveyor has limits to his precision, due to imprecise tools. My point is that to expect 100% removal of all prostate cancer cells in the body during RT and radical prostatectomy is not expected to be a flawless effort.
Hence we have prostate cancer metastasis. Although not something that is clearly preventable, it is something to be rather expected as with most any kind of cancer.
As Abe Lincoln said, "You can fool some of the people all of the time, and all of the people some of the time, but you can't fool all of the people all of the time."
Well, your concern does have some validity: PSA above the detection threshold after successful RP should go to non-detectable. Otherwise there is prostate tissue (cancer) still in the body. 3 consecutive rises or a level above 0.20 many would consider BCR (Biochemical recurrence). Then scans need to be done to exclude metastasis outside of the pelvis. However not all scans will be positive at such a low level so this creates uncertainty.First look at the pathology from your RP. Is there any suggestion of tumor to the surgical margins or extra-capsular extension? What about lymph nodes that were sampled?
With a rising PSA after RP (BCR) and no evidence of disease outside the pelvis, then salvage radiation therapy is called for (SRT), to the prostate bed and an extended field to include all of the pelvic lymph nodes. This is accompanied by a course of ADT for up to two years. That is the best chance for "cure" before it gets away.
The uncertainty in the numbers comes from balancing the possibility of false-negative scans for metastasis and waiting until PSA is higher, vs. getting treatment as early as possible.
The Gleason score could also provide guidance on how aggressive to be. 9 or 10 and I would want to be proactive and aggressive with the SRT. The above perspective is my own opinion. Research might provide further guidance otherwise. (I do like the fish metaphor!)
Causes uncertainty only to uninformed docs & patients, also promoted as an excuse by docs that would not like to adjust their practice to the latest imaging. Following graph is self explanatory:
A negative/positive fossa PSMA PET/CT gives a WAY BETTER prognosis for a 3 year freedom from progression compared to the minuscule improvement detection gets by ascending PSA. It doesn't need one to be a Nobel laureate to understand that when the lesions are smaller, hence undetectable by imaging, they are more vulnerable to radiation.
Steve 507 & Tim fc, WOW! You are in a place most of us aspire to be. Take in the moment. Breathe deeply. You are 2 of the fortunate. Now your immune system has a fighting chance. Your mind can help to heal the body. Enjoy your partner and family and friends. Laugh. Do not focus on these excellent PSA numbers other than to rejoice at your progress.
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