Dad's 2nd BCR- Best course of action?

[MsBoBo]

Dear Friends, please see Bio for more info. My dad is experiencing his 2nd BCR. PSA has gone from 0.12 to 0.20 in the past 3 months. As I'm aware, he could get a PET / PSMA scan now, or wait for PSA to get higher then have a scan. Due to his experience in the past, this waiting to 'let it grow and spread' gives him (and me) a lot of anxiety. If a scan gives us nothing, should he start ADT and at what PSA, with what ADT is recommended? His oncologist advises starting ADT as late as possible, but from all the research I have read this isn't always the best course.

Thank you for your invaluable input and advice 🙏

[Justfor_]

His report reads 0.2 or 0.20? VAST difference (0.2 can be just 0.15 rounded to a single decimal place).

[MsBoBo in reply to Justfor_]

It is 0.20. I'll fix the post, thanks for noting!

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

MsBoBo,,,,, I think you made a BooBoo...

Good Luck, Good Health and Good Humor.

j-o-h-n

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

Ha ha

[Tall_Allen]

There's nothing worth doing until PSA reaches 1.0 and PSADT<9 months. Then he can consider the EMBARK or the PRESTO protocols:

prostatecancer.news/2023/05...

prostatecancer.news/2022/09...

[MsBoBo in reply to Tall_Allen]

Thank you very much for providing this information.

[ron_bucher in reply to Tall_Allen]

Not true in my case.

[Zdub83 in reply to Tall_Allen]

Hi Tall Allen. I’m 41 with 1st BCR after RARP in 2020. Diagnosed at 36. G7 3+4. They believe I have a small amount of cancer left in my prostate bed / fossa. MSK recommends Orgovyx for 6 months + EBRT. They say I can still be “cured”. I would appreciate your perspective here and whether I should push for Nubeqa also, or even low dose chemo. I am horrified about ADT and long term effects of radiation. I have near perfect continence and sexual function today, even after RARP. Nothing showing up on PSMA scans. PSA .23.

[Tall_Allen in reply to Zdub83]

There is nothing in your profile. What were your pathology results, and what is your PSA history since RP?

[Zdub83 in reply to Tall_Allen]

Pathology below -

After surgery in 2020 I went to .023 and remained “undetectable” for about 18 months, however it’s been a slow and steady creep up to .23 over the last 3.5yrs. MSK removed and examined 27 lymph nodes during surgery, all clear.

Prostate and seminal vesicles: Procedure: Radical Prostatectomy Tumor Type: Adenocarcinoma Histologic Grade: Primary Gleason pattern: 3 Secondary Gleason pattern: 4 Total Gleason score: 7 Grade Group: 2 The amount of Gleason pattern 4 is approximately 8 % Intraductal Carcinoma: Not identified Tumor Location: Involves right posterior Involves right anterior Involves left posterior Involves left anterior Dominant tumor mass located in: Left posterior and anterior, apex to base Tumor Multifocality: Multiple foci of invasive carcinoma are present Tumor Quantifications: Percentage of prostate involved by tumor: 7% Presence of Extraprostatic Extension (EPE): Tumor confined to prostate Seminal Vesicle Involvement: Not identified Bladder Neck Involvement: Not involved Surgic al Margin Involvement: Involved by tumor, non-limited (>=3mm) Tumor present at left posterolateral margin Treatment Effect: Not identified Lymphovascular Invasion: Not identified Perineural Invasion: Identified High Grade Prostatic Intraepithelial Neoplasia (HGPIN): Identified Non-neoplastic Prostate Tissue: Exhibits nodular hyperplasia Pathologic Stage Classification (AJCC 8th Edition) Primary Tumor (pT): pT2: Organ-confined Regional Lymph Nodes (pN): pN0: No regional lymph node metastasis TNM descriptors: R1

[Tall_Allen in reply to Zdub83]

Ask you Urologist: what is the Gleason pattern at the surgical margin? It says: "Surgic al Margin Involvement: Involved by tumor, non-limited (>=3mm) Tumor present at left posterolateral margin." But it doesn't say what the Gleason pattern is there. If it is all pattern 3, you can feel safe just watching it. If pattern 4 is present at the margin, you will want salvage radiation.

[NanoMRI]

Post RP I am not willing to wait. As difficult as imaging can be to get, if available, I would not hesitate to have a look.

[MsBoBo in reply to NanoMRI]

I agree..

[EdBar]

I’ve gotten a PSMA scan twice, both times are when my PSA reached 0.2 and both times it identified a tumor on a different rib. Both times I treated with SBRT and my PSA fell back to nearly undetectable. These were performed around a year or so apart. My oncologist, Dr. Sartor is who recommended a PSMA scan when it hits 0.2. Personally I’ve always taken an aggressive approach to treatment and I don’t want the disease to be able to gain a foothold. This strategy was something that Snuffy Myers would preach back when I was seeing him as my specialist. It’s worked for nearly 11 years now, I’m not changing.

Ed

[Cyclingrealtor in reply to EdBar]

I can really appreciate your approach. It reminds me of the statement, "Fu@k around and find out". It's easy to quote various trials but I believe in patient choice. While trials give some background, none of these trials comes with any guarantee.

My Kaiser Permanente RO was willing to wait but my consult outside of KP was very clear. "It's only been 8 months since RALP, obviously you have cancer that wasn't contained, you're too young, you don't wait"!

[EdBar]

Lol, I like that…FAFO, I’m familiar with the saying but never applied it to my cancer, perfect phrase for treatment of an aggressive form of cancer!

Ed

[TraveledonBicycle]

I had a scan once. Just to say at the outset, correlation is not causation. Before the scan my PSA had wobbled around 18, that following a TURP and subsequent biopsy with a (4+3 or 4+4 depending on who read it). About a month after the scan my PSA began to rise at around 2 per month. Last read was 81. A bone scan uses 5 millicuries of tecnicium 99 (which is a * ton of exposure) concentrated in the area of the met, producing ionizing radiation - a mutagen. PCa genomes have already become unstable and probably cannot repair radiation damage to their genomes. I am not blaming anyone, I understand what it does to DNA and I did it anyway. But, just to say, the payoff must outweigh the risk. My scan was negative. Oh, and just to say, a PSA is not tha t precise. A rise from 0.12 to 0.2, to me, doesn't mean anything. My PSAs before the scan were at three month intervals and were 18.34, 15.99, 18.20.

[ron_bucher]

With the caveat that no two cases are the same...

When I was in a similar situation, I also was not comfortable giving cancer time to grow until it could be seen on a scan (that was prior to general availability of PSMA scans). I was able to get another 4+ years of undetectable PSA by getting docetaxel plus radiation of lymph nodes above the local area. ADT was only 9 months.

When my PSA returned and reached 0.48, a PSMA scan revealed one tumor which got radiated with SBRT and my PSA is trending toward undetectable again.

[MsBoBo in reply to ron_bucher]

I just read your bio. Very glad that early action has been so effective for you to date and I hope you will be in remission. My dad's outlook was very good after RP. He had BCR 12 years after RP and then it was a slow doubling time until it wasnt. If it was not for the urologist and GP who failed him and dismissed his rising PSA until it was well past (PSA 1.4 at time of SRT whole pelvic) I believe he would have been cured and spared of this now.

My dad's psadt is faster than yours was. However we will have to get 2 or 3 readings after 0.1 to have a more accurate picture. I sure am hoping that targeted spot treatment will work for years to come. He has other health issues and adt will be a heavy burden.

[ron_bucher in reply to MsBoBo]

All three of my oncologists are seeing a lot of success with SBRT for oligometastatic cases, even without ADT.

[garyjp9 in reply to ron_bucher]

What was your PSA at your first BCR, when you went on docetaxel and RT?

[ron_bucher in reply to garyjp9]

When I started docetaxel, that was actually my second BCR. PSA was 0.06 but doubling in less than 6 months after it had been undetectable for 7.5 years. That's when I added Mark Scholz to my medical team, and the triplet therapy was his idea when I told him I wanted to be aggressive on my rising PSA.

[garyjp9]

Thank you