Biochemical recurrence: I feel I should... - Prostate Cancer N...

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Biochemical recurrence

dentaltwin
dentaltwin

I feel I should know the answer to this by now, but I'm a worrier. I had my RP in September 2018. Since then, I've had PSA readings every 6 months or so (last 2 were a month or two late). The PSA readings have NOT been ultra-sensitive; they have been under threshold--either <0.05 or <0.1.

Just got a reading of 0.1, and of course I'm jumping to conclusions. So what are the recommendations? Go for ultrasensitive test and follow? Go straight to the RO?

30 Replies

Get it confirmed in a months on an ultrasensitive test. If still at 0.1 or above, talk to an RO about SRT. What were your prostatectomy pathology findings?

G 3+4, grade group 2, 20% of prostate involved:

Tumor Multifocality:

Multiple foci of invasive carcinoma are present

Tumor Quantifications:

Percentage of prostate involved by tumor: 20%

Presence of Extraprostatic Extension (EPE):

Tumor confined to prostate

Seminal Vesicle Involvement:

Not identified

Bladder Neck Involvement:

Not involved

Surgical Margin Involvement:

Free of tumor

(multiple additional levels were examined)

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

Steve507
Steve507 in reply to dentaltwin

My clinical profile and pathology is nearly the same as yours. I had one surgical margin of 0.5 mm. I opted for radiotherapy therapy with a 3 month course of ADT at PSA 0.05. Other cohort with same surgeon and ON has PSA of .05, but he will wait till .08 .or 09 since margins clear.

Confirmed in how many months?

Sorry - typo - I meant to write "a month." No adverse pathology then. You may want to wait for a pattern of uPSA increase.

Thanks!

Justfor_
Justfor_ in reply to dentaltwin

Monthly tests alternating two different labs at 2 decimal point resolution. This is what I am doing. Serious decisions like sRT must be based on concrete data.

dentaltwin
dentaltwin in reply to Justfor_

Monthly seems a bit much. Why 2 labs? I would think you'd want to use one lab for consistency (unless you're suspicious of the lab, in which I would guess you wouldn't use them at all).

Justfor_
Justfor_ in reply to dentaltwin

You want to assess two different metrics; 1. The PSA rate of rise and whether it is compliant to an exponential type of increase. 2. The absolute PSA value so to know when to start sRT. For the first you treat each lab individually, expecting the same outcome. For the second, you just take the average as a more accurate value. In case of a large descrepancy between the two a third one should be called in for a majority vote decision, You think it is too much but if you have to live the rest of your live with the late toxicities of RT, you better double and triple check your numbers. Personally, in 20+ measurements I have found two that were +600% and -300% in error. These two labs were of course banned from any further use.

Steve507
Steve507 in reply to dentaltwin

The lab and the assay. One lab used Abbot, the other Siemens. Same results from .02 to 0.5.

Same consistency: Am now <0.01 for both labs 40 days after one ADT. 10.8mg subcutaneous injection.

Radiotherapy finished 3 weeks ago. Been dancing 2x and potency at attention with Viagra and her belly dance 💃

Justfor_
Justfor_ in reply to Steve507

Totally understandable and anticipated. I also had same numbers from 0.02 to 0.06. The rounding error from 0.05 to 0.06 is: (0.06-0.05)/0.055=18.2%, same order as the allowed 20% of inter-lab error. If you had 3 decimal number tests, then you could had detected any offset.

Steve507
Steve507 in reply to Justfor_

I used two different labs. Same results

Justfor_
Justfor_ in reply to Steve507

I have an 20-30% offset in absolute PSA values (over 0.06 where the rounding error is comparable/more than this inter-lab offset), but the PSADT of both are almost in perfect alignement. It has to do with the equipment and assays each lab uses.

You are setting yourself up for a really rough 30 days of mental anguish. Convention wisdom suggest you try not to dwell on the wait. In reality, those thoughts will flood most of your waking hours. Be good to yourself this month. Do the activities you enjoy most even if you have no current interest in doing anything. Be extra mindful of people who love you. Love them back. Be mindful of the moment. That PSA test should not be allowed to rob you of 30 days of life.

dentaltwin
dentaltwin in reply to Jvaughan0

One of my therapists long ago told me that I "live in the negative prediction". Hated the guy, but he was right about that.

It's been a tough year; pandemic helped force me into retirement; lost my wife in December. But my daughter moved back in, and that helps a lot.

Thank you for the kind words.

dentaltwin
dentaltwin in reply to Jvaughan0

Well, you're right. Don't feel like doing much of anything. Given what a gorgeous day it was yesterday in NYC, I did manage to get out the door and do 3 laps of Prospect Park on my bike (which had me wondering if pressure/friction from the saddle was dislodging micrometastases throughout my body. Don't look that up--there is no literature I could find--that's all me)

I did manage to schedule a PSA draw for Monday, and a FaceTime session with my surgeon for Wednesday

Jvaughan0
Jvaughan0 in reply to dentaltwin

I took to road and a little trail biking last year with my son to give us both a little pandemic hobby. My PSA was not detectable until I started cycling. Ironic thought, but I'm sure it is coincidental. Still, I wouldn't trade these rides with him for anything. After prostate removal, ADT and radiation over the past seven years, I am headed for a first visit with a MO in a couple of weeks. Rather be on another trail for sure.

AlanMeyer
AlanMeyerModerator

It's a long shot but not at all impossible that whoever wrote up your results left off the "<". I once read a study of errors made in PSA tests and the numbers were surprisingly high. All sorts of errors were made from incorrect reporting, to mixing up samples, to incorrect calibration of the machine, to failure to properly clean the equipment to prevent blood from one sample from contaminating the following sample.

Here's hoping that's all it was.

Alan

dentaltwin
dentaltwin in reply to AlanMeyer

I'll have to get a repeat test, I'm guessing ultrasensitive. My brother never got to undetectable after his RP; he read 0.1 for a few years. Then he got a 0.2, which is obviously concerning; but on the following test it was back to 0.1, where it has remained.

My test was listed as Siemans.

I havnt found much to convince me that PSA readings and accuracies at that level can be significant. Do we really understand the process of PSA production in the body to be worries when it is so low anyway??

Those are still really low numbers for PSA. If they keep going up you have a lot of options as far as treatment going forward.

Hey dentaltwin!

I have had a test on a Monday showing a 25% increase. The same lab on a Friday drew blood and the old number came back! The following Monday my onco told me that is the reason why he doesn't place that much credibility in "a" PSA test. Erratic results while not frequent, do happen. If the second test has similar results then look for other reasons as well as recurrence, don't think the worst until verified.

A friend doing AS was hovering in the 4's. His test results went from the 4's to the mid teens! He is a bit excessive with the frequency of testing. If there had been a six month interval there would have been reason for concern. I told him to get tested again. His PSA was a bit lower than it had been and he breathed a sigh of relief!

Get retested. Best of luck to you!

Currumpaw

dentaltwin
dentaltwin in reply to Currumpaw

"don't think the worst until verified. " LOL--but that's me all over!

As a retired scientist (physics mostly) - the significance of 0.1 vs <0.1 is insignificant. Unless you know how much less than 0.1 the <0.1 reading was it really means nothing. If the real number had been 0.09 - you're talking 1/100th of a unit. Variables in the lab can easily account for that difference. It's really meaningless.

I just got my most recent number back. It's exactly like yours - 0.1 vs the <0.1 I've been getting for the past year. Since I had radiation/ADT it really means nothing, and if it does mean anything it may actually be positive (PSA "bounce" 12-18 months after the conclusion of radiation indicates better results in at least 1 study, maybe more. And the bounce is attributed to increasing testosterone - which I've had, from none to 300+.)

I'll be talking to my rad-onc this Friday, his background is as a scientist and MD (PhD and MD) and an engineer. If I had to predict what he's going to say is - forgeddaboutit. It's not a significant difference and is really meaningless.

I had a different tech draw the blood at a different Quest site this time. I've got to check if the same MD at Quest certified the results, and if the same machine was used. Since the draws were at different sites it's entirely possible the blood was sent to a different Quest lab - meaning the results aren't comparable.

My suggestion to you is the same - forgeddaboutit. If you want to do a retest, ask for the script. Chances are excellent the retest will come back <0.1.

dentaltwin
dentaltwin in reply to Don_1213

I well know that lab values, normal ranges etc. can vary. What set this into alarm for me was the difference between being detectable and non-detectable. I'd had previous readings that were <0.05 and <0.1; to me that meant they were both under threshold for determination. In any case I have a message in to MSKCC and see what they say.

I have seen talk here about ultrasensitive PSA--how in some circumstances it can lead to unnecessary alarm. But I wonder if it makes more sense in the determination (or lack therof) of "biochemical recurrence".

Justfor_
Justfor_ in reply to Don_1213

Your rad-onc will tell you "forgeddaboutit" because there is nothing she/he can do at this point. According to the book, she/he will wait for nadir 0.1+2 =2.1. This is not the case with dentalwin. His 0.1 can be anything up to 0.149. In engineering schools the first thing students learn in their first measurement courses is that for any measurement the meter's accuracy must be, at least, one order of magnitude better than the reported value. If not, then they are in the wrong classroom and in particular that of statistics and Monte Carlo random generator is discussed. Younger engineers ignore/forget this fundamental principle because they believe that if the value comes off a computer or some meter with a fancy digital readout, it must be accurate.

FYI - My RO wanted to be sure we started SRT before PSA went to .2 (better chance of success based on studies). I got to .16 and started ADT (Firmagon 4 months and then Orgovyx) and it went to T in teens and undetectable PSA almost immediately. 38 sessions of Radiation (8 to go)...after Covid vaccination.

Let us know how you're doing hun. Post an update when you get it. I know the anxiety. Hubs had an uptick in PSA one year after his RP. He eventually did need SRT but was advised not to have ADT.

dentaltwin
dentaltwin in reply to fluffyfur

Thanks for asking. Surgeon sent me to the Brooklyn infusion center of MSKCC. Didn't even want to look at the patient portal--was too anxious. So my daughter did: <0.05 ng/ml. So all that worrying was for naught. Surgeon didn't even want to keep our Wednesday appointment. "Make an appointment for another PSA read in 6 months--bubye!"

Justfor_
Justfor_ in reply to dentaltwin

Make it 3 months for peace of your mind. It is equally bad practice to be alarmed as well as reassured by isolated measurements.

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