Detectible PSA two years after RP

[Hutchig]

I had a radical prostatectomy in June of 2017. I had several different Gleason numbers from the biopsy prior to surgery. The highest Gleason number was 7. My PSA was 23 prior to the biopsy. Surgery was successful and margins were clear at the post biopsy. I had my 2 year check up last month and my PSA was .06 detectable for the first. I had not expected a reoccurrence. Last week I had bone scan and MRI last week, both negative. If my PSA increases from the current .06 to .2 radiation will be recommended. Anyone had a similar experience?

[Tall_Allen]

The change in PSA is more important than the number for someone in your situation. If your PSA increases on two subsequent tests or if it goes up more than 0.05 in a year, it's a good idea to talk to a radiation oncologist at that point.

[dans_journey]

Hi Hutchig,

Sorry to hear about this. I'm in the same boat, but a few years ahead of you. I had a radical prostatectomy in January 2011 and everything came out cleanly. Gleason 3+4, negative margins, no extra-capsular extension, negative lymph nodes and seminal vesicles. Nothing. My PSAs remained undetectable for 54 months in September 2015 when the PSA came back at 0.05. I was stunned.

I've been tested every four months ever since, and it's been slowly climbing. Four of the last five tests were either 0.10 or 0.11, with an outlier that was 0.13 (it went back down to 0.10 after that one--go figure). I've been using the same lab throughout, so there shouldn't be any variation caused by different labs.

I've used the Memorial Sloan Kettering PSA Double Time calculator to see what my PSADT is: 155 months. It's important to understand the doubling time. If it's less than 10 months or so, it indicates what's coming back is more aggressive and should be dealt with much sooner than later.

That said, however, I went to a radiation oncologist in May 2018 when my PSA first broached the 0.10 mark, and because of my consistent upward trend, he recommended salvage radiation right away. I declined and told him that I wanted to see another test result or two before going ahead. He was okay with that.

My big concern is that salvage radiation doesn't have all that high of a success rate and it can come with some long term side effects that I would like to avoid. Of course, even the most sensitive imaging techniques out there won't have a good chance of detecting where the recurrent cancer is located until the PSA starts getting into the 0.2 and above range. If I'm going to get zapped now with a PSA of 0.10 and risking side effects, I want to know that we're zapping in the right location to have the highest chance of success. It's a Catch-22.

My urology team said that with a PSADT of 155 months, I may not have to do anything for a while, if at all. I like the sounds of that, but I'm also not sold on it.

Interestingly, I work in the same hospital as the radiation oncologist who recommended treatment 15 months ago. About 4 weeks ago, I had a hallway conversation with a second radiation oncologist and he said that he generally recommends zapping when PSA hits the 0.10 threshold. That's made me rethink my approach a little. I know that catching it earlier is better when it comes to long term survival.

I go for another PSA test in October and, if it resumes its upward climb, then I have some serious thinking to do. Both ROs recommended 7 weeks of salvage radiation.

I hope that helps. I know it's a scary time, and I wish you all the best. We each have to decide what's right for our own unique circumstances.

—Dan

P.S. You can check out a chart of my PSA and read about all of this on my blog, dansjourney.com.

[Londear1992 in reply to dans_journey]

Dan, have you looked into salvage HIFU? It used when a recurrence has happened after RALP but may not have such side effects as radiation. I know it is offered when there is a recurrence after RALP and radiation, but maybe you could check out salvage HIFU first if it is considered effective in you case. So sorry to hear of the recurrence. Your stats from the RALP looked very promising. All the best to you.

[Hutchig in reply to dans_journey]

Dan, that is very helpful. Thank you

[JoelT]

In reference to your consideration of salvage radiation: Salvage radiation is thought of as a single type of treatment, but in reality I believe that we should consider it as two distinct types of treatment; radiation to just the prostate bed or whole pelvic radiation.

In the most recent post to The New Advanced Prostate Cancer Blog we discussed the superiority of PSMA scans. The data from the trial led us to conclude that whole pelvic radiation (as salvage radiation) will, for a significant number of men be a better alternative than just prostate bed radiation. Of course, the potential side effects are also increased with whole prostate bed radiation.

The following is one paragraph from the post:

One of the important take-home messages is that we can attribute more prostate cancer recurrences to pelvic lymph nodes (stage N1) and extra-pelvic metastases (stage M) than to cancer in the prostate bed. This finding indicates that when you have salvage radiation treatment, it might be beneficial to have whole pelvic radiation over just salvage prostate bed

So, when you are discussing salvage radiation with your doctor you need to clarify exactly what is being discussed, just prostate bed radiation or whole pelvic radiation.

[Hutchig in reply to JoelT]

Thanks Joel

[Magnus1964]

Your PSA is still low so relax. This could be due to an infection. As mentioned by others here look for 3 rises in a row.

[julianc]

Interesting thread as I am at 0.05 after RP in 2015. My research suggests doing something at 0.1 rather than waiting to 0.2, and wider than just the prostate bed. I was not aware of salvage HIFU and will investigate. I also follow the dietary advice from Prof Robert Thomas book Lifestyle after Cancer. Good luck to all in this situation.

[julianc in reply to julianc]

Actually I think salvage HIFU is for men who had RT rather than RP.

[Jeff85705]

It is my understanding that 0.06 ng/ml is considered undetectable. Actually anything under 0.1 is biochemically undetectable and most likely within the range of error (including human error), with 0.2 considered biochemical recurrence of disease. I think Tall-Allen may be premature in advising further care here with your numbers. What confounds me is all the PSA numbers being thrown around these days, including out to the third place behind the decimal (0.008 for instance). My lab only measures in tenths, so under 0.1 is considered undetectable. Besides range of error, consider differences between labs and technicians. Do you consistently use the same lab? What does your urologist or oncologist recommend?

[Hutchig in reply to Jeff85705]

My urologist recommends radiation at .2 if and when I get there.

[Jeff85705 in reply to Hutchig]

That make sense. 0.2 is the "definition" of BIOCHEMICAL recurrence (though it may not actually BE so). Your urologist is doing the right thing, not recommending treatment until/if it reaches 0.2. That is according to my research anyway. In my opinion, all these people here offering well-meaning suggestions for further treatment (salvage radiation, HIFU, etc.) are premature. My lab report shows "less than 0.1 ng/ml" and that is good enough for me to continue just watching my PSA number, hoping it stays undetectable. Best wishes.