Another disappointing PSA

[hwrjr]

After 7 years post-proton treatment, my PSA continues to increase incrementally. I really had hope that this year I'd return to my nadir reached in 2017, or at least drop a little. In the prior past 2 years my urologist felt I was fighting prostatitis and believes that either that has caused the increases, or that my remaining healthy prostate is just generating a small amount of PSA. Unfortunately, up again for the third consecutive year. By the old ASTRO definition, I'd be declared BF now.

Seeing my urologist today. It'll be interesting to see what he has to say about this 3rd increase. My guess is he'll prescribe an antibiotic and have me retest in 4-6 weeks. I'd like a mp-MRI or PET to see what's going on, if anything, but don't know if Medicare will approve that now, or even if it's appropriate at this stage. My RO doesn't do any testing for recurrence until the Phoenix definition of BF is met which for me would be PSA of 2.75.

Age 69 DX 06/14 1 of 24 cores positive, 5% involved, (3+4), psa 6.2

2nd opinion from JH (3+3)

3rd opinion from UFPTI (3+4)

mpMRI Duke: 50% chance of SV spread

SV fusion biopsy Duke 10/2014 negative

proton at UFPTI 11/14-01/15

PSA:

07/15 2.5

01/16 1.3

07/16 2.6

01/17 .8

01/18 1.4

04/18 .8

07/18 .9

01/19 .8

01/20 .9

02/21 1.0

02/22 1.2

[Magnus1964]

Prostatitis or any irritations can cause an increase in PSA. I don't think I would worry yet.

[tucker_man]

At least you had a low nadir at one point, I haven't gone below 2 and it increased last check. I see my urologist today to get latest results. He didn't message me in the portal ahead of time like normal so that has me a little worried.

This is my history:

4.5 8/2017

4.8 9/2017

4.32 3/2018

6.08 9/2018

7.74 12/2018

5.4 3/2019

**IMRT 4/2019

4.06 7/2019

3.70 10/2019

5.4 1/2020

4.0 5/2020

2.75 8/2020

2.19 02/2021

2.61 08/21

[Tall_Allen]

Why are you seeing a urologist rather then a radiation oncologist?

ASTRO switched from the "3 in a row" definition to "nadir+2" definition because the old definition was picking up too many non-recurrences. Antibiotics are useless, and only create resistance. You may be able to get an mpMRI, but you will need a radiologist who has experience with post-radiation MRIs.

[hwrjr in reply to Tall_Allen]

I consult via phone with my RO. He goes by the Phoenix definition of BF and doesnt intervene until then. I see my Uro for PSA tests, DRE, and other Uro issues if needed.

TA, what's your opinion on the increases?

[Tall_Allen in reply to hwrjr]

see comments above

[hwrjr in reply to Tall_Allen]

Sorry but I dont see any comments on your opinion of the increases I have had and what might be the cause. As much I hate to say it, it really seems like I'm in the early stage of a recurrence.

[Tall_Allen in reply to hwrjr]

I only know what you tell me. I don't have any unexpressed opinions. I suggest you only deal with what you know, instead of making yourself anxious with possibilities that may or may not be true.

[addicted2cycling in reply to hwrjr]

PLEASE excuse my ignorance but hwrjr wrote --- " ... Age 69 DX 06/14 1 of 24 cores positive, 5% involved, (3+4), psa 6.2 with

2nd opinion from JH (3+3)

3rd opinion from UFPTI (3+4)

mpMRI Duke: 50% chance of SV spread

SV fusion biopsy Duke 10/2014 negative

proton at UFPTI 11/14-01/15"

????????????? Can't fluctuating PSA from remaining prostate be a result from BPH or infection or irritation or exercising too hard before PSA?.

[hwrjr in reply to addicted2cycling]

Uro did say yesterday that effects of long term prostatitis could be part of the increase. He believes too that my prostate at 30 grams with a good testosterone level will continue to grow and generate incremental PSA.We discussed my activities in the days prior to the PSA test and I mentioned that I had not had sex in a week and had stopped intensive exercise for a few days prior. He asked if had been riding a bike. I said yes, but a recumbant bike without the typical pointed seat that pressures the prostate. Plus, I put a towel over the seat for additional padding. I also work out on a rowing machine with a similar seat and use a towel there too. In addition, I use all of the leg machines and elliptical in the gym, and walk 3 miles a day. The Uro thought the bike and rowing machines could pressure the prostate and advised stopping those for a week or so before the next test.

[addicted2cycling in reply to hwrjr]

hwrjr wrote --- " ...The Uro thought the bike and rowing machines could pressure the prostate and advised stopping those for a week or so before the next test... "

My Dr. also agrees with stopping the bike riding before a PSA whether it be on my road bikes or the recumbent.

[redonthehead]

It appears your nadir is 0.8, thus the Phoenix definition of BCR is 2.8. Your PSA is 1.2 now, so by definition you do not have a recurrence. Hopefully merely a benign bounce.

[maley2711]

You had 1 core of 24 with 5% of that one core as 3+4, negative SV biopsy. Seems an excellent chance of good long-term results. Check out the MSK post-RP nomogram for a better idea! We'll assume the proton RT similar efficacy to RP..that's what the guidelines say. Don't knowif a PSMA Pet would be covered at this point for you.....I guess at Nadir plus 2 it would be? Your PSA bounces too much right now to show a definite trend IMHO. And in addition, so far VERY long doubling time...though don't know how that is calculated for an RT-treated man with residual PSA? Highly paid Docs should have all the info/answers?

[hwrjr in reply to maley2711]

I'm faxing my latest PSA to my RO and will have phone discussion about my PSA and my increases. I expect he will respond the way he has in the past, that until my PSA reaches 2.75 there is nothing to do.

Doubling time 67 months.

mdcalc.com/psa-doubling-tim...

[davenj]

I've had prostatitis twice. Once the PSA shot up to 11 and the second time, 8. Both times a few weeks on an antibiotic brought the PSA down to 2. You don't say how much of your prostate remains or if you have any prostatitis symptoms. If you had an infection, you'd likely have symptoms besides a rising PSA.

[hwrjr in reply to davenj]

From my Urologist's notes from our meeting this week:

"CT scan from 2 weeks ago demonstrates a moderately sized prostate measuring about 20-25 g, certainly capable of producing some measurable PSA.

Additional risk factors include his previous prostatitis, perhaps ongoing cellular changes secondary to prostatitis. Additional sources of PSA detection include his vigorous exercise, rowing machine, recumbent bicycle, etc."

[hwrjr]

RO who treated me at UFPTI called to discuss the latest PSA. He basically had the same explanation that he had last year after the 2nd increase that these increases do not mean much at this point. There could be benign reasons for them such as bounces, prostatitis, vigorous exercise, sex, biotin supplement, difference labs, etc. He has a few patients who bounce around several years after treatment and a few who reach a nadir a long as 10 years after treatment.

I could have some scans and biopsy and maybe cancer would be found. I would probably have to pay for the tests out of pocket. There has been considerable discussion about when to begin the testing and the concensus is 2.0 over nadir. The previous definition of 3 consecutive increases falsey classifed too many men as BF.

[maley2711 in reply to hwrjr]

I truly suggest you do something that gives you enjoyment and forget about this until next PSA or Doc visit. For a PCa patient, right now evrything favors your continued good future. PLEASE use that MSK nomogram !!!

[maley2711 in reply to hwrjr]

I'm 4+5 and will have PSMA PET tomorrow to look for doomsday metastases..that is scary..meanwhile time for shower, pick up wife at work, walk, talk , read, prepare dinner.....life goes on until it doesn't ? weare all doomed as you know ...all 7 billion of us!!

[jdfamily]

Just some thoughts on my situation, had a prostectomy two years ago, now psa is there again so far at .20, urologist says watch for some time, monitor and then consider radiation. So just waiting. Would appreciate any thoughts folks would have

[jimalong51]

Wow, hwrjr! I hope my PSAs follow that pattern 7 years down the road. Three months after my combo SBRT/IMRT treatment, I’m at 0.3. I expect fluctuations along the way going forward. No expert here, but I would not be embracing too many worrisome thoughts with those numbers if I were you. Keep us posted.

[dcroson]

Hi HWRJR, I notice that the rise in your PSA seems to be very slow, in fact it has not yet doubled from your nadir value of 0.8. So many docs might suggest waiting until a stronger pattern of increase settles in. With that said, when my PSA got to 1.0 (it had doubled in approx 18 months) I decided to get a PSMA scan and to then to decide on additional treatment. This is because my GS was high at 9 and I didn't want to mess around and let the cancer spread. I ended up with MRI guided cryo at Mayo.

Previously, I had proton treatments in 2010 with a nadir of 0.4, then cryo in 2015 when my PSA got to around 3.

Best of luck

Dave C

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

Greetings dcroson,

Would you please be kind enough to tell us your bio. Age? Location? When diagnosed? Treatment(s)? Treatment center(s)? Scores Psa/Gleason? Medications? Doctor's name(s)?

All info is voluntary, but it helps us help you and helps us too. When you respond, copy and paste it in your home page for your use and for other members’ reference.

THANK YOU AND KEEP POSTING!!!

Good Luck, Good Health and Good Humor.

j-o-h-n Thursday 02/10/2022 11:28 PM EST

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

Hi j-o-h-n, here is my info (not very interesting!)

Age 67, first diagnosed in 2010 at age 55 with GS 5+4. I decided to go the Proton route and completed treatments in April of 2010. PSA before Proton was 9.4 and after was a nadir of 0.4, and it remained below 1.0 for about 18 months but then started increasing.

When it hit 3.0 I decided more treatment was needed and decided on cyro with Dr Onik in Ft Lauderdale. PSA then went to 0 and stayed there for almost three years, before it started to slowly creep up; when it hit the 1.0 mark I again decided to take further action since my GS was so high.

In early 2021 I went for a PSMA scan at MSKCC in NYC, which fortunately did not show any distant cancer, but did show some cancer on one of the seminal vesicles. Further biopsy confirmed this and so I started looking at a second round of cryo. I ended up going to Mayo in Rochester in Sept 2021 with Drs Woodrum and Mynderse, and had a very positive experience there. (Also, they repeated the biopsy - this time with MRI guidance; at MSKCC it was ultrasound guided). Three month post cryo PSA is <0.1 but that is just one datapoint, hopefully all is under control for now.

[Cooolone]

I believe a Medical Oncologist is what should be in the mix at this point. The urologist isn't an oncologist... And the statement you claim he has made is disconcerting as it lends to fall within the realm of his knowledge but dismissed possible diagnosis outside of it. The RO goes the same... A MO has such a wider field of view in my opinion. Lastly, at your current PSA, you would be ok for some sensitive scans that would reveal the causation, or actually, dismiss the possibility of any progression of cancerous tissue being the cause of increased PSA. No guessing, like the urologist! Lol

Good Luck!

[Garp41]

Why wait and worry? Go for an MRI and/or Pet and see what's going on. I believe Mayo does both.Best,

Doug