3rd biochemical recurrence. What is next?

[rnewman751]

My 2nd bcr was 2019. Treatment included imrt 25x to the pelvic floor, abiraterone and lupron injection monthly. Undetectable psa until yesterday. I know at 0.05 the level is very low. It does appear to be my 3rd bcr. What are the next in Treatment protocols? Thank you. I'm receiving care at MSK in nyc.

[Kaliber]

I’m with Kaiser and Kaiser doesn’t test psa below 0.1. My oncologist says variations below that can be regular body fluctuations or test equipment calibration/ standards. My understanding is that my oncology team doesn’t start being interested until my psa increases back up to 2.0 or higher.

That’s how Kaiser does it. I just got my first 2025 psa test back a couple days ago, remaining at >0.1 , thank goodness.

❤️❤️❤️

[rnewman751 in reply to Kaliber]

Thank you

[dhccpa in reply to Kaliber]

Great!

[Kaliber in reply to dhccpa]

lol …. ❤️❤️❤️

[Tall_Allen]

That is not BCR by anyone's estimation.

[rnewman751 in reply to Tall_Allen]

Thank you T.A.

[swwags]

A biochemical recurrence is diagnosed when a man's prostate-specific antigen (PSA) level starts to rise after treatment, even if no other signs of cancer are detected through imaging tests.

So I'm not sure biochemical recurrence is the correct term but hey, semantics right? It looks like it might be back. Imaging tests are ineffective and frankly useless with a PSA less than 2 and even at 2, many false positives/negatives. Understand if the PSA test was accurate, and there's no reason to think it wasn't, the cancer is microscopic.

Consider paying attention to you PSA doubling time (how fast is it growing.) That will help you understand it's aggressiveness but your doc will likely wait until your PSA is higher so he/she can image it. I would expect the doc to check your PSA every 3 months. You can ask for every 2 months if it puts your mind at ease.

[rnewman751 in reply to swwags]

Thank you, I agree with everything you wrote. Since this will be the 3rd time if it continues to rise, I'm obviously concerned with future treatment options. I do feel it's still hormone responsive, but no longer curative.

[TJGuy in reply to swwags]

Let me comment on a couple of points, there are charts with expected % of finding hits on PC with PSMA scans at various PSA levels.There are a number of things to keep in mind, do you still have your prostate? The prostate can be responsible for containing a huge amount of the value of your PSA mine started around 60.

After RP mine has never been higher than 3.8

Was your prostate radiated. If so 2.0 added to your lowest PSA would represent recurrence.

If you know longer have your prostate, then you should have 0.00 PSA theoretically.

Recurrence with no prostate is defined as >=0.2 with two subsequent PSA verifying that.

The imprecise definition of undetectable is < 0.1

We know that with the better tests today that we can " detect" PC far lower than 0.1

So having said that. You can detect metastases reliably at low levels such as 0.5 but it depends

1. If you have few or one metastases, meaning the PSA is coming from few places.

2. The more aggressive the PC can help in detection but we don't want more aggressive PC so don't wish for that.

3. Are you coming off ADT, your PC and PSA will continue to be affected by the ADT over a long period of up to a year.

So I look at it like this, say you have a "bucket" of PSA. Let's use a child's beach plastic bucket and fill it with beach sand. Now let's distribute that bucket over a acre of land that has grass. If you dump that entire bucket in one spot you'll likely see "detect" it with your eyes. If you distribute it in three, five, ten piles you're less likely to see those smaller piles in the grass, they are there but you can't "detect" them until you add more sand on them.

So the fewer metastases you have the more likely you're detect them with a PSMA scan.

I had five metastases after RP, it took until PSA of 3.8 to detect them, whole pelvic radiation killed all of them.

Later coming off ADT I had one lymph node light up at 1.83. at that time another matastasis was not visible but predicted by special software at Mayo oncology. So I had SBRT on the one detected and my PSA dropped to 0.633 and began rising. That other spot now became detectable at 0.646 and again at 0.872

I had SBRT on that second spot ( if you've been counting that's 5 plus 2, so seven matastases)

Subsequent PSMA scan shows the two spots hit by SBRT are continuing shrinking. No new metastases have been found to date, and I've been off ADT since 2021.

My PSA at last test was 0.619 and declining. You can test every month if you wish, I'll test again in two months.

My doctors have stated that MY PSA is correlated very very well with MY PC, meaning any increase in my PSA means a increase in PC, and vise versa.

I've been controlling my PC with PSMA scans, and MRIs, attacking any metastases found and living a normal life without ADT.

Since I removed the "mother ship" my prostate, I am only dealing with the minimal PC that originally escaped.

The hope is this approach will continue to allow me to live out my normal life, off ADT completely or as long as possible.

[rnewman751 in reply to TJGuy]

Thank you very much for the detailed response. I had radical prostatectomy in 2014, Recurrence in 2015 and 2019. Both times imrt, 1st to prostrate bed,, 2nd to pelvic floor. Psma lit up 1 lesion on rt side of pelvic floor. Along with abiraterone and lupron. Completed adt in November 2023. The low psa of 0.05 appears to be following the previous 2 biochemical Recurrences.. Best wishes to you.

[TJGuy in reply to rnewman751]

Yes Thanks FYI I hit a low of <0.01 while on ADT.

[StayingOptimistic in reply to TJGuy]

Me too but after one year of vacation and the testosterone recovered, it started going up. It’s at .04 as of today. Not sure when I should start treatment back of adt+ Erleada

[jazj in reply to TJGuy]

You should add that info and expand as necessary in your profile. You have an interesting approach which appears to be, forego returning to ADT and its side effects for as long as possible while employing a "scan and zap" treatment strategy. I've read studies the past 3 years and I could swear I'm seeing a trend where newer emerging evidence is that the addition of ADT to radiation therapy doesn't have as big of a benefit as previously assumed for some, not all, patient categories.

[Mascouche]

Bio recurrence is at a psa of 2.0 if you still have a prostate, which you do, and at 0.2 if it was surgically removed. At your current psa level, you are still fine.

[rnewman751 in reply to Mascouche]

Prostatectomy in 2014. Bcr 2015, 2019 and possibly now. Thank you for responding

[Mascouche in reply to rnewman751]

Then in your case it would be considered bcr once your psa reaches 0.2

[j-o-h-n]

Who do you see at MSK?

Good Luck, Good Health and Good Humor.

j-o-h-n

[rnewman751 in reply to j-o-h-n]

Susan Slovin

[rnewman751 in reply to j-o-h-n]

And you?

[j-o-h-n]

She's good and she's around the bend from my M.O. at Kimmel (Dr. Michael Morris)....

Good Luck, Good Health and Good Humor.

j-o-h-n

[London441]

Have you had ADT at any point?

[rnewman751 in reply to London441]

Yes, came off abiraterone and lupron last November

[rnewman751 in reply to London441]

Apologies, off ADT November 2023

[StayingOptimistic in reply to rnewman751]

Wow, and your Psa is at .05 still? I was off adt in November 23 too and Psa just hit .05 and T recovered.

[ron_bucher]

My case has some similarities to yours - see my bio for details. PSMA testing is my newest friend and is probably in your future. It usually shows a tumor or two by the time post-prostatectomy PSA reaches ~1.0. Mayo Clinic has a number of patients who showed tumors on PSMA with undetectable PSA. My tumor first appeared on PSMA at PSA = 0.45.

Has your oncologist discussed chemo?

[rnewman751 in reply to ron_bucher]

Had consult today. Will retest in 2 months to see change in psa. Psma showed 1 leison after 2nd bcr. The psma was effective w psa at .26. Best wishes to you. Thank you for responding.