What PSA # indicates bio chemical re-occurrence in Stage4 metastatic patients who still have prostate and did not have radiation or chemo?

[No_stone_unturned]

In my case I went straight to adt. what PSA values indicate BCR in a man with metastatic disease who still has a prostate? I'm having a difficult time finding this information. My MO just says that they look for trends (dblng) but does an increase albeit in a normal range indicate BCR?

[CAMPSOUPS]

Hey friend looks like you didnt get a chance to read my other reply in that thread.

BCR doesn't apply to you and I who started and continue on systemic treatment.

Trends, doubling time, scans are what we go by to let us know if our treatment is keeping the brakes on progression.

I went along for about a year with PSA of 8 to 9 after chemo. Lowest was 5.4.

Then after a year rose to 40 in about a month and started Zytiga. Zytiga brought PSA down to 1.8 at one point but after a year on Zytiga my PSA has trended upward on 3 tests a month apart. I am going to be starting new treatment soon.

[No_stone_unturned in reply to CAMPSOUPS]

Thank you for the reply. I did however read the one about creating a new post. Lol.

So about what psa# do we start thinking that the adt isn’t working by itself anymore? 4?

[CAMPSOUPS in reply to No_stone_unturned]

Please remove the idea of a PSA number as an indicator. Only applies to those whose cancer was minimal enough to have a chance of cure by surgery and or radiation.

I can see your PSA is trending upward period. It means the Zytiga is not doing its job anymore. Time to move onto next treatment which very well might be docetaxel. I see you are on hypertension meds and maybe hypertension caused your Dr. to reduce your Zytiga to half dose.

I see a lot of supplement bottles. I hope you are not taking something which is masking the actual PSA reading making it look like you have less cancer than you actually have. I also hope you have at least told your Medical Oncologist all the various supplements you are taking.

[No_stone_unturned in reply to CAMPSOUPS]

Got ya. Yes my MO knows everything I do. I took a one month sabbatical from zytiga last November to see if it would help the hot flashes. It did not, so I went back on a 1/2 dose at his suggestion. I instead cut the lupron (in April 2022)which helped a little. Only now has my PSA started to rise. Perhaps it’s the T starting to recover. I have blood work tomorrow.

[d3is4me in reply to No_stone_unturned]

Hi Did you take1/2 dose zytiga with food

[No_stone_unturned in reply to d3is4me]

no, without food.

[d3is4me in reply to No_stone_unturned]

Thank you

[Concerned-wife in reply to No_stone_unturned]

There are meds that can help with the hot flashes, rather than cutting your Lupron and Abi.

[No_stone_unturned in reply to Concerned-wife]

Thank you for your reply. Yes, I’ve tried gabapentin, clonidine, cymbalta, Estroven. All the suggestions from MO to no relief. Any of the other repurposed drugs they either won’t prescribe bcs it’s not SOC and insurance doesn’t cover it. I actually found that estrogen gel is working, but it’s been a challenge getting it, expensive and out of pocket. Is there something else I should look into?

[Concerned-wife in reply to No_stone_unturned]

venlafaxine helped my husband, covered by insurance. Good luck!

[Tall_Allen]

BCR only refers to PSA increasing after curative therapy has been attempted. It does not apply to your case.

Why are you taking only a half dose of Zytiga?

What you are monitoring for is a rapid PSADT, which would indicate Zytiga is failing and it's time for docetaxel.

[No_stone_unturned in reply to Tall_Allen]

Thank you TA. I’m get soo excited when you respond.

[allmo in reply to Tall_Allen]

There is the concept of a 2nd bcr after salvage therapy usually in reference to salvage radiotherapy after prostatectomy and a 1st bcr.

[allmo in reply to allmo]

In the future, if a subset of patients who are in the "oligometastatic state", possibly more restrictively defined by advanced imaging such PSMA-PET, proves to have durable (however long that will be defined) remissions with treatment, possibly with combined metastasis directed therapy (MDT) and systemic therapy, then there could be a 3rd bcr state.

[allmo in reply to allmo]

And there is salvage pelvic radiation after a 2nd BCR following prostate bed only radiation which could result in a 3rd BCR . Just trying to be complete.

[allmo in reply to Tall_Allen]

Just ran across a recent phase 3 study which describes another bcr state which does not have curative intent.

Patients with (1st) BCR that was "high risk" defined as PSA DT < 9 months. Note: this 2nd BCR is not the same as the one defining the non-metastatic hormone resistant state as the patients are not in a state of <50ng/dl of testosterone, as hormone suppression was stopped after 1 year.

PRESTO: A phase III, open-label study of androgen annihilation in patients (pts) with high-risk biochemically relapsed prostate cancer

cancertherapyadvisor.com/ho...

Yes. I know. This does not apply to "no stone unturned". My apologies to no stone unturned. Just wanted to be more comprehensive in the discussion of other bcr states including one not with curative intent. With so many new treatments including combination treatments in combination with the new "disruptive" advanced imaging: redefining metastatic states, there will be new bcr states.

Admittedly, this may be a semantic argument, in that if one truly knows for sure that there is no cure in a particular new (and thus to date unstudied state), instead of for example saying a PSA >0.2 defines BCR, the correct term is biochemical progression. However, many thoughtful researchers believe that there is

1. an "oligometastatic" (curative - stage 4) state, informed in part by the historical acceptance in renal cell carcinoma and colon cancer (e.g. metastasectomy for stage 4 disease is accepted). And immunotherapy is in infancy with apparent (too early to be sure) cures of stage 4 melanoma, the poster child of "hot" tumors. Curiously, prostate cancer, a "cold" tumor, is the one and only cancer with an FDA approved cancer vaccine: Provenge. And molecular characterization of one's individual tumor is in its infancy.

2. There is a bcr state that is a benign recurrence, including the concept of active surveillance in this benign state, most likely indicated by a high Doubling Time such as >15 months.

One corollary of this discussion is that Stage 4 prostate cancer patients, most with horizons of years, have the real promise of future better treatments, and should be encouraged to enter cancer trials. And should be encouraged to get both somatic (on their tumor) and germ line testing including with the aim to get into "personalized/precision" molecularly directed clinical trials. One recent study showed that only 3% of patients with actionable molecular mutations have entered clinical trials. At that enrollment rate, it will take years for many uncommon mutations to be tested. It is whole new "exponential" part of the research curve for the cancer cure.

[Shooter1]

I started with mCSPC and drove PSA to undetectable.... After 4 1/2 years PSA and Alk/Phos both climbed and then skyrocketed. Called it a BCR and tried mult treatments to slow it down, Still trying and it is still climbing after another year and 4 new treatments.. of course it is now mCRPC and a whole new ball game... PSADT now about 15 days down from the 12 days it was earlier...

[No_stone_unturned in reply to Shooter1]

If I understood your bio correctly, you had your prostate removed. Am I reading that right?

[Shooter1 in reply to No_stone_unturned]

Yes, prostatectomy and rising PSA afterward instead of dropping to near zero. Pathology showed a spiderweb of gleason 9 though out abdomen in nerves an veins, so no radiation possible without major damage to everything in there. Jumped right to Lupron and chemo.

[Shooter1]

Definitely on ADT acct Orchiectomy to get off lupron for life... After years of very low and undetectable PSA it when up and up and I was told BCR. If wrong term acct treatments while castrate sensitive and now castrate resistant must just be terminology difference. I don't know...

[dhccpa in reply to Shooter1]

yep we're getting hung up on a term.

[Shooter1]

Well we started out looking for curative treatment as scans showed everything contained in the prostate... just didn't turn out that way.....

[dhccpa]

I suspect what they mean is that present treatment is failing, and when is it time to move on to or add on a new treatment?

[dhccpa]

I understand that. I doubt he did it deliberately. I knew what he was asking, I just wasn't certain of the correct answer.

Of course, if he admits to using the wrong term deliberately, we can all come down hard later on.

[No_stone_unturned]

I stand corrected. Terminology aside, I’m getting the answers I’ve been looking for. Thank you everyone for your feedback.

[mperloe]

I agree that this is more a transition to castrate resistance. If you have not done genetic testing, check the PROMISE study which offers free testing for 30 different mutations.

If you do not have a medical oncologist who focuses soley on GU cancers at an NCCN center of excellence, please get a second opinion.

[Boywonder56]

im rowing the same boat...mets at dx....was told treatment pallative.....thats scary.....also...would stay on adt forever and the double blokckade till psa got to 2.0.....aint there yet 4yrs 11 mos...