Do I have biochemical recurrence, is this hopefully just the bump?

[SongofFred]

One year and three months ago a had HD Brachyboost with full pelvic radiation for 4+3, but with high .88 decipher. Initial PSA 4.8

I was on one year Orgovyx and Nubeqa and finished three months ago. My nadir on ADT was 0.006.

Today was my first post-ADT PSA test. It’s .313 and I’m shocked. I know above .2 over nadir is biochemical recurrence.

Is there any chance this is the “bump”? Does the bump matter if you’re already .2 over nadir?

I know Crook’s definition of cure is below .2 at 4-5 years. Is there any possibility of me achieving that at this point or is it time to search for an MO?

Thank you

[Tall_Allen]

" I know above .2 over nadir is biochemical recurrence." You got that wrong. That's only for prostatectomy. For radiation, the definition is nadir+2.0.

It is expected that your PSA will rise when your testosterone returns.

[SongofFred in reply to Tall_Allen]

Thank you!! Thank you!! Of course. I feel so dumb. I conflated Crook’s with Phoenix criteria.

I was still shocked at being above .2 so soon. Is there a good chance it could still get <.2 in four years since it’s well past that at 15 months and my nadir was so low?

Is there a typical prognosis for guys with this timeline who haven’t achieved <.1 after the first year?

[Tall_Allen in reply to SongofFred]

It took me about 4 years to get below 0.5 and about 10 years to get below 0.1

[SongofFred in reply to Tall_Allen]

That is so good to hear.

Thank you so much for responding. I really appreciate you. Your presence here is truly invaluable.

[maley2711 in reply to Tall_Allen]

Is the nadir determined while on ADT post RT?

From my reading, BCR recurrence determined using nadir +2 is questionnable as far as waiting to do followup scans. One group developed a scheme for detecting actual metastatic-type BCR that resulted in detection 14 months earlier than using just nadir + 2. They noted that their method would not apply for the cases in which ADT was added to RT. Their investigation was based on the observation that various studies that have found very similar 5 yr BCR rates for surgery and RT also found very significant higher PCa-specific mortality for RT. Perhaps those studies were based on irrelevant older RT methods? or just very poorly constructed studies?

[Tall_Allen in reply to maley2711]

"Is the nadir determined while on ADT post RT" Yes

ASTRO has not changed the definition of BCR.

[Mgtd in reply to Tall_Allen]

Hi Tall Allen

Could you please clarify and correct my thinking on this. It is my understanding that biological recurrence is a lot more clearly defined after surgery than after radiation.

After radiation Biological recurrence occurs when there is a rise in PSA from three consecutive PSA tests not including a potential bounce in PSA.

For example after radiation and after completing ADT if your PSA went from <0.01 to 0.04 to 0.05 PSA you would be classified as having biological recurrence but there would be no need to take immediate action.

However you would not have met the Phoenix research definition of biological recurrence of Nadir +2 that was agreed upon to be used in research so all researchers were using the same definition and trials were able to compare apples to apples.

To add to this we have the discussion of when to do a high level scan for a rising PSA. Some say a PSA of 2.0 and others say 0.5 PSA. Some even go lower than that. The value of the PSA chosen determines the probability of finding cancer recurrence and then taking action on it.

All that said what is the standard most doctors use to declare a patient is having biological recurrence versus actionable clinical recurrence.

I guess in my mind there are different uses for a rising PSA - standard for research, clinical decision making and the definition of biological recurrence as a starting point to begin watching.

Am I incorrect? In my mind the only one I need to be concerned about is its use in clinical decision making.

Thanks for clarifying this and for correcting any misunderstanding I have expressed above.

[Tall_Allen in reply to Mgtd]

Biochemical (meaning PSA-determined) recurrence (BCR) is, by convention, defined differently for prostatectomy and for primary radiation.

After prostatectomy, BCR is defined as a confirmed PSA ≥ 0.2. The importance is it is usually the signal that salvage radiation (sometimes called "early salvage") is needed for a cure. 3 clinical trials have found there is no risk in waiting for PSA to reach 0.2. There are exceptions:

prostatecancer.news/2021/10...

After radiation, the prostate is intact and contin ues to output its own benign PSA, so BCR has to be set quite a bit higher. By convention, it is set at nadir (the lowest PSA ever achieved after RT) + 2.0. At this point the search begins to determine whether it is a clinical recurrence or just a bounce (as can occur if there is a history of prostatitis). If cancer is found it can probably be cured with salvage radiation and hormone therapy.

[Mgtd in reply to Tall_Allen]

Thanks. Appreciate you responding. Your wording is always so precise and specific that it takes the ambiguity out of my laymen understanding.