Post RP, WPRT, and ADT+ abi; 2 year PSA <0.01, “progressed”(?) to 0.01, now 0.03

[August13]

Full details in bio. PSA trends and question below:

09/2021, before RP: 45

10/2021, after RP: 4.

12/21, after one month of ADT + abi: 0.04

01/22, just before IMRT began: 0.01.

04/22, after IMRT completion: <0.01.

04/202 — 02/2024: uninterrupted, no variation, same lab, same equipment, monthly tests: <0.01.

[11/2023, ended 2 year ADT + abi course, and testosterone begins slowly creeping back up, from nil to 99 this week.]

April - August 2024: monthly PSA at 0.01; continued same lab and same equipment as before.

Now 0.03.

Seems possible, maybe likely, that already-disseminated occult disease outside of radiation field, was in testosterone starved quiescence and is now starting to wake up. Thoughts, including hopefully from TA?

[August13]

Forgot to add: somatic only genetic mutations from LN: PTEN and SPOP. Microsatellite stable; low tumor mutational burden. Decipher high risk @ 0.96.

[Tall_Allen]

Nothing worth doing until PSA reaches 1.0 and gets rapid.

[August13 in reply to Tall_Allen]

Thank you, Sir.

[Hawk56]

a similar situation,...

Came off my last treatment in April, 12 months of Orgovyx combined with SBRT.

July labs .01, then October .03.

So, is there activity, likely.

Is there actionable activity, not based on the decision criteria my medical team and I have to manage my prostate cancer:

Three or more consecutive increases spaced three months apart.

PSA between .5 -1.0.

Why these two criteria?

For us it ensures a trend not possible variations in PSA (see my attached clinical history, it has gone up and down before).

It provides a statistically better probability of the imaging if being successful.

We don't think k it entails risk of my PCa getting out of control.

I use the analogy that I can look "far" down the track and see the headlight on the engine of the train that's coming. My medical and I don't know when it will get here, we just know given my clinical history that it will.

That may be another 12 -18 months...

I have thought about treatment next time, discussed with radiologist and oncologist. Depending on the imaging it may be SBRT with 24 months of Orgovyx and Xtandi. Then again, who knows what the options are if that time frame is correct!?

I am not at the continuous phase of this journey so still thinking in terms of defined treatment periods.

In the meantime, just live your life. Wife and I just got back from two glorious week in Glacier, Waterton and Banff National Parks. My daughters will be home for Thanksgiving and Christmas joined by two of my sisters and their husbands at Christmas.

So, think about and discuss, develop, agree on your decision criteria with your medical team about when to treat based on clinical data.

Kevin

Clinical History

[NanoMRI in reply to Hawk56]

compliments on well thought out strategy and writing!

[NanoMRI]

Thoughts? The likelihood of lingering cancer stem cells and/or quiescence has been my focus since my salvage ePLND, nearly seven years ago. That procedure, done at 0.13 after unsuccessful salvage RT, confirmed six metastatic nodes including common iliac and para-aortic. Despite nadir of <0.010 (no ADT), I carry on with regular uPSA testing, annual imaging with comparative methods and began liquid blood biopsy testing early 2023.

My uPSA has been holding very low stable 0.03X range since June 2021. 0.05 is a key indicator for me as this was my RP nadir. If/when I realize 0.05 I will do extensive imaging and ponder the start of ADT if the imaging does not yield potential targets. My intent, if it comes to it, is to defer ADT and CR for as long as possible. Hope this helps. All the best!

[August13 in reply to NanoMRI]

Thanks Nano. Would you mind sharing what type(s) of annual imaging you do?

[NanoMRI in reply to August13]

mpMRI with Ga68 or Pylarify PSMA and also either NM bone/joint whole body or fluciclovine. This year if my Pylarify was clear, as it was expected to be, I was going to have Mayo's Choline. I believe there is sufficient evidence that one flavor may well work ahead of others - which one is the challenge.

I share that the Ferrotran nanoparticle MRI I had done at 0.13(corrected) identified five of my six cancerous pelvic nodes whilst the Ga68 was clear. Unfortunately, the Ferrotran still has very limited availability and only in Germany last I checked.

I shall add the thinking to wait until the PSA is high enough to assure findings makes no sense to me. First, with general acceptance that imaging does not find all the mets, it seems to me waiting provides time for even more cancer to be present. Second, I want as early as possible identification.

My Pylarify PSMA PET CT done this past July at 0.31 did indeed identify a singular 2cm liver lesion; likely metastatic but unknown type. Additional imaging confirmed lesion and biopsy confirmed a surprising melanoma met. This early finding has given me a better chance with this 2nd cancer beast in my life.

[August13 in reply to NanoMRI]

Thank you.

[NanoMRI in reply to August13]

correct - nanoMRI at 0.13 - not 0.013 it's not that good.

[August13]

Thanks Kevin, for your thoughtful response, including encouragement to, “in the meantime, just live your life.”