Yet another fork in the road

[shueswim]

Quick summary:

- G9 PCa Dx in 2016: RP and adjuvant radiation and ADT therapy.

- 2018 biochemical recurrence with 6 week PSA doubling time.

- Participated in Condor Trial. PSMA scan located recurrence in a handful of LNs. Treated with RT and 20 months of ADT/abiraterone/prednisone.

- Undetectable (<0.02) PSA for 33 months...until this month. Reconfirmed 2 weeks later when the PSA tripled to 0.06.

I was disappointed, but not surprised that I've had another recurrence. My hope was that the PCa had not progressed any further than the pelvic area LNs that were detected by the 18F-DCFPyL-PET/CT, but apparently it had. Now what? I have an appointment with my local MO in two weeks to get his opinion. I assume the choices are immediate systemic treatment (ADT, perhaps in combo with abiraterone again...or something else?) or waiting until the recurrence is detectable on the recently approved PSMA scans. How high would my PSA need to rise in order for the PSMA scans to have a likelihood of detection? I'm leaning to that approach to at least see where the PCa is before (presumably) repressing it with ADT+.

[GP24]

I would suggest to let the PSA value rise above 2.0 ng/ml. The chance is about 90% that you detect mets then.

[Tall_Allen]

That is not a recurrence by any stretch of the imagination.

I assume that ALL of the pelvic LNs were treated and not just the ones you could detect.

[shueswim in reply to Tall_Allen]

Yes, all pelvic and retroperitoneal LNs. RT plan developed by local RO in consultation with Dr Zietman at Mass General.

Not a recurrence? Please explain.

[Justfor_ in reply to shueswim]

After sRT the definition of recurrence is nadir +0.2. Officially you will be recurrent when you had breached 0.2 since your nadir was undetectable.

[shueswim in reply to Justfor_]

Thanks, I appreciate the clarification.

[Tall_Allen in reply to Justfor_]

There is no "official" definition of BCR after SRT.

[Tall_Allen in reply to shueswim]

I heard Zietman is retiring - that is a loss.

First biochemical recurrence (BCR) has to be at least 0.1. For a second BCR, you will want to see a marked PSA increase, say, over 2.0, but at least 0.5, before you do anything about it.

prostatecancer.news/2019/08...

Playing whack-a-mole with metastases has no known value. Systemic treatment does. So if you want to get another DCFPyL PET when your PSA is over 0.5, and zap any discovered mets, that is reasonable, but only if you start ADT as well.

[Magnus1964]

Your PSA numbers are small. I would not worry over that. Small fluctuations like that can be caused by an irritation or inflammation in prostate bed.

[shueswim]

No, PSA was undetectable as soon as RT & ADT+ began. The drug vacation began June of ’20 … 16 months so far.

[Carp1707]

I was Gl9 also.

RP in 2014, ADT from 07/14 for 20 months, PSA rose, so I went back on ADT (lupron+Zytiga), went 37 bouts of radiation. Stayed on ADT for 30 months, a short vacay until PSA started rising again, DT of less than a month, had an Axumin scan, went back on Eligard+Abie, in 01/2021.

In the interim they ran germline and somatic genetic testing. Even though my Dad passed from PCa, they found no germline causes. They did find on the somatic side that I am very good candidate for Keytruda.

PSA has found a bottom of 0.14 and has stayed there for 6 months now.

Have you had any gene testing done?

[j-o-h-n in reply to Carp1707]

Keytruda is working for my lung melanoma.......Hope it works for your Pca....

Good Luck, Good Health and Good Humor.

j-o-h-n Friday 10/29/2021 10:58 PM DST

[shueswim in reply to Carp1707]

Yes, Decipher test pre-surgery, then FoundationOne CDx upon recurrence in 2018. The first test showed "genomic high risk" which guided the decision to do adjuvant RP and ADT after the RP. Nothing actionable disclosed in the second test. Findings like PTEN loss and TP53 V272M mutation, but again nothing with treatment implications.

[Blueslover]

GeneSorry about the spread. Let us know what your DR says.

My next scans are in December - have not had a sophisticated scan as you have, but it was apparently in my retroperitoneal nodes. Have been on Lupron now constantly, and Nubequa for about 18 months. My ONC at Duke never recommends RT. Had an awful case of radiation cystitis with obstruction by clots last year, but seems completely cleared with hyperbaric oxygen for which I am thankful! Waiting to see.......

Hugh

[shueswim in reply to Blueslover]

Thanks Hugh...disappointing but not surprising. As a few folks have pointed out, I haven't yet officially met the criteria for BCR, but it appears inevitable. Once we are in this boat it seems like the best we can do is make good decisions...and keep bailing water so we don't sink.

Bailing water

[Blueslover in reply to shueswim]

For sureAll the very best!

[teacherdude70]

U was G9 in Oct 2015. PSA 20.61. Lupron 24 monthe IGRT 25 sessions after 4 months of ADT.Then HDR Brachy two sessions.

PSA rose 18 months after stopping Lupron. PET scan found two suspecious spits in lymph nodes. Bi ipsy said not cancer but got five rad sessions to be sure.

9 months later ADT failed PSA hit 1.78 started Nubeqa and now PSA now 0.03. 5 months later. Still in monthly Lupron.

Draw your own conclusions but my results good so far. Fyi gene tests negative because no Cancer floaters in my blood.