I am about 15 months post 25 weeks of radiation to my prostrate and pelvic area. I had 6 months of ADT with two months prior and 4 months post radiation. My current PSA is 0.07. It has showed a slow rise from 0.04 to 0.07 over 5 months or so. For about 4 to 5 months it held steady at 0.05 doing monthly tests. I am assuming that in fact my Nadir after radiation treatment has been reasonably established at 0.04. This has been the lowest reading since T recovered to normal.
I had a follow up visit with my MO who told me I had biochemical cancer recurrence. This is not uncommon in up to 30-50% of cases.
In my research I have found various definitions of biological recurrence being used in the literature. Basically they range from a rising PSA after radiation to a more classic research oriented one of Nadir plus 2 after radiation. This is the classic Phoenix definition. As you can see that is a broad spectrum to define biological recurrence after radiation. The parameters after surgery are much tighter.
My MO has obviously defined me using what I consider to be the strictest definition of a consistent change of PSA. Consequently I was given two options.
First, begin immediate two level hormone treatment to lower PSA or
Second, do active surveillance by monitoring my PSA and deciding down the road what action to take after PSA rises to where scans would indicate where the cancer recurrence actually is.
I choose the second option of wait and see. I was in no hurry to do ADT again for various reasons involving QOL mostly.
I would appreciate your thoughts on this and perhaps other alternatives you have had experience with.
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Mgtd
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I agree with your choice. It is not going anywhere fast so there is no need to rush. If it gets above 0.20 you may be able to pin it down with PSMA PET. ADT has its own substantial harms and using it on a continuing basis will likely lead to castrate resistance. best of luck and live well. MB
Your MO clearly doesn't understand radiation. Calling that a "recurrence" is ridiculous. Your main doctor should be a radiation oncologist. Why are you even talking to a medical oncologist?
TA is 100% correct. Consult your rad onc regarding this, your MO is mis informed. Having had 80 radiation treatments and many visits with a rad onc I disagree with your MO. Your psa following radiation needs to rise much higher than 0.07 before you can scan or even declare a recurrence.
I'm in a similar position, but with a higher PSA level post-radiation.
I had a radical prostatectomy in January 2011 that failed, and completed 35 sessions of salvage radiation therapy (SRT) to the prostate bed only in August 2022, with concurrent ADT, just like you (2 months before radiation; 4 months after).
I went for a PSMA PET scan in November 2021 when my PSA was 0.22 and the scan was inconclusive at the PSA level. In January 2024, my PSA had climbed to 0.37 and I went for another PSMA PET scan, and it, too, was inconclusive, not showing any hot spots. I was really hoping that the scan would be able to guide the radiation oncologist where to zap. I decided to go ahead with the SRT not knowing the exact location.
I went into radiation with a PSA of 0.37 and my nadir after was 0.11, but it began to rise again about 14 months after the SRT ended (October 2023). In May 2024, it shot up to 0.52 and I met with both the urologist and medical oncologist, and we agreed to monitor over 6 months. (I'll go for another PSA test at the end of October to see where we're at.)
I suspect that my PSA will be closer to 0.8 to 1.0 at that point, and we'll try one more scan to see if we can determine what's going on.
If the scan reveals the location, we may try additional radiation. If not, the medical oncologist said she would wait until my PSA hit 2.0 before considering ADT; the urologist said she would wait until metastases were evident before starting ADT. Both said they would start with a mono therapy alone, but we didn't have a discussion whether it would be continuous or intermittent. We'll cross that bridge when we get to it.
When I was on the six-month dose of ADT for the radiation, I fared better than most guys, I believe. I had some mild-to-moderate fatigue and moodiness/more emotional, but I escaped hot flashes and weight gain.
We all have to be comfortable with our own risk tolerance, and I've been okay following the course that I'm on. Like you, even though my experience with ADT was better than most, I'm in no rush to experience it again. Plus, I don't want to start it too early so that the cancer cells become resistant to it sooner.
It is easy to think of it that way, but my understanding is that "resistance" is not what actually happens.....some PCa cells mutate to a form that doesn't need T, or actually mutate to a form that produces its own T! Also, I'm not aware of studies showing that delaying ADT result sin better long-term results.....indeed, the opposite is my understanding.....but very much welcome correction if my understanding is wrong!! Out of control metastatic PCa is a very horrible QOL compared to QOL impact of ADT, IMHO.
Am I missing something? You have had radiation to the prostate together with ADT and your Nadir was 0.04 and now when your off ADT and Testosterone is back your PSA measures 0.07 correct?
Correct me if I’m wrong but isn’t recurrence after radiation +2 on the PSA level? How then can a ’increase’ from 0.04 to 0.07 be considered a ’recurrence’, especially if you still have the prostate left, your off ADT and T is back again, then you still have a very long way to go (PSA 2.04) before they can call it recurrence.
Well, perhaps I’m missing some important information here or ultrasensitive PSA testing is playing serious mind games somehow.
Anyway, best of luck to you and I really hope that this increase is just some sort of ’normalization’ of the prostate and has nothing to do with a recurrence.
Sounds good that you are scheduled to an appointment and that gives you a fair chance to ask what are the facts that convince the MO that you rise from 0.04 to 0.07 is actually a sign of recurrence.
I mean, you are talking of an extremly low rise and what if you test your PSA tomorrow and it’s back to 0.04; is it still a recurrence then and do you still need to go all in with treatment?
I suppose there is a very good reasons that ONCO Community has stated some basic facts for a good reason - a rise of +2 from Nadir can be considered recurrence - if you’ve had radiation to your prostate you can have bounce(s (plural)) and that’s more of a very good sign than a bad one and finally - one PSA test doesn’t have any prognostic value if you don’t do follow up measurements. I suppose there is more good basic facts to concider and all of them, for me, is saying to slow the f-k down, check and the check again and don’t freak out the first thing you do.
This whole ultrasensitive PSA testning and all discussions and conflicts it creates with all the pros and cons is really surprising to a non-american like me (living in Sweden)
I’ve done PC treatment both here in Sweden and in Finland and in both countries a PSA < 0.1 is a very good sign when you’ve had PC treatment and specifically when RT + ADT is the primary treatment with the prostate left.
And before somebody questions that from a laymans perspective; BOTH Sweden and Finland are very high up in the would statistics of success rates of treating and curing prostate cancer
So, to conclude. My personal opion is for you to have really good dialoge on your next appointment and perhaps only dedice when to have the next PSA test and my own personal guess that there is really no need to stress on any path forward, if you even need to think in terms of treatment pathways… I mean, this PSA value could just be bloody ’hickup’ in your prostate and you might already be back under 0.07 again. I really believe everything is totally ok with you and that your’e looking at very long remission and hopefully that you’re ’cured’
Thanks for taking the time to respond. I admit I was a little shocked when she used the term recurrence but that pasted quickly. Unfortunately I am scheduled for a telephone visit so I will drop off some questions in advance so it is an efficient use of my time.
First question. What leads you to believe it is recurrence?
Kind of an open ended question but that should start the ball rolling without being challenging or I know more then you or Dr Google and my friends on the cancer forum think ….
I have learned over the years that the first rule of good communication is to understand.
Thoughts? Your mere MO who knows you personally does not think you are cured and is concerned your cancer is on the move, whilst non-docs, based on a few lines of text, judge your doc incompetent? Fascinating!
Seems to me a lot of men would like do-overs with the broad definition of recurrence as well as the broad spectrum of what to do and when to do it to stay ahead of this beast. Although others will say I am wrong I am grateful I do a variety of imaging methods and liquid blood biopsies well ahead of common thinking. Perhaps your mere MO who is concerned for you would support these additional investigative methods?
Until recently there was a guideline to speak from one's own experiences - IMO the withdrawal of this reasonable guideline is a detriment to the forum. This said, are you not criticizing me for expressing my view? And is it okay to criticize someones doc - especially when based on just a few lines of text and with no formally acknowledge medical training backing up the criticism?
no I am not criticizing you personally, and if it came across that way I apologize. I was observing that I didn’t think people here were trying to assume the role of a physician, but just making personal views of their experiences of a situation.
Again, sorry if I didn’t express myself adequately and if it came out the wrong way, I apologize.
My $.02 worth is that 16 years ago I was in a similar situation. After radiation therapy to prostate my RO waited till my PSA rose to 4 before calling it recurrence and after it rose to near 10 I started hormone therapy. Since then I was on intermittent hormone therapy and every time I had hormone therapy, three shots 90 days apart), my PSA fell to <.1 and then gradually rose to 4 before considering repeat hormone therapy. I have gone through a couple of MO's since then, (my RO passed me on to an MO), and I understand now how MO's are on a different track from RO's. They are much more wary of PSA rises. Also, they are much less open to intermittent treatments. I suppose there is a reason for that...they see all types of cancer and the way they progress, without as much knowledge or consideration for the special progression and control of advanced prostate cancer.
Somebody misunderstood something. TA is right. That is in no shape, form, or fashion a BCR. WTH. If and when it gets to .5 or above you can do a PSMA scan if you want.
Could it be that your MO thinks you had an RP? If you'd had an RP and radiation after it, and ADT after that - then that change might mean something, but probably not that your cancer returned, more likely a different guy calibrated the machine that day.
Don that is always a possibility but Dr Conlon is more like a family GP. I and my wife have been seeing her quarterly for over 2 years with my wife’s blood cancer.
I attend all her appointments. In addition my granddaughter “shadowed” her before medical school. During visits she always asks me directly how my treatments are coming along, etc.
Good point on the lab. The lab manager is part of our pickelball group so I will ask him how much variation there is.
Well, my experience...remember, this is a heterogeneous not homogeneous disease, so, may not apply to you,
My sensing is there is no consensus on what constitutes BCR with USPSA. \In my case, my medical team and I have decision criteria in place to guide our decision making about when to go on treatment, with what and for how long. Generally, we look for three or more consecutive USPSA increases spaced three months apart, PSA between .5 to 1.0, then image and use all the clinical data both historical and current to make a decision.
That treatment decision is usually an aggressive one, doublet or triplet therapy given my high-risk status - GS8, GG4, PSADT and PSAV, time to BCR...The imaging is an important part of the treatment decision.
We generally have decision criteria about when to come off treatment, this last time it was if the PSA dropped to undetectable in the first three months and stayed there through 12 months. We also had criteria about adding an ARI, if the Orgovyx did not drop the PSA to undetectable within the first three months...it did, we didn't.
Our decision making criteria has served us well, reducing panic decisions surrounding changes from one USPSA test to another. Mine has risen in the past then gone back down, My medical team has no explanation why, the art behind the science, they don't know.
We are also comfortable with letting the PSA rise to between .5-1.0 as we do not believe it lets the PCa get out of control and be more difficult to treat. It does have the benefit of more time off treatment, perhaps delaying the onset of resistance, quality of life...
The conundrum we all face, deciding if, when, with what and for how long to treat. We don't want to treat too early, too late, too long, not long enough...guidelines such as the NCCN's AUA and others are useful as starting points for discussions with our medical team. I try and keep in mind they are solid science but still, population based and historical.
Were I facing the decision with the clinical data you present, I would do exactly what you did, nothing, continue to actively monitor. It's not your time, enjoy life off treatment.
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Time to PSA Nadir ... following Radiation and Androgen Deprivation Therapy.
Biochemical recurrence...now what?
Definition of Biochemical Failure
Surgery+radiation+ADT orRadiation + ADT
