Recurrence? Yes, it's slight but...

[jimbay]

Hi Everyone, I had a RP 11/18. PSA at the time 8.9. I was 52. One 4+3 tumor 1.5 cm. Good margins. Was undetectable PSA until now. Current PSA: 0.008 ng/mL (Roche ECLIA). So that is low, but not undetectable (test went to 0.006). What should I do next? Another test? Different test? Consider that good enough? I know you all have posted advice on this before, but I would really appreciate the latest advice. Thanks.

[Magnus1964]

That is a great number. Stay the course.

[jimbay in reply to Magnus1964]

Thanks so much. Its just tough to see any number after not seeing one for 3 years.

[Tall_Allen]

That is excellent! The third decimal place is where non-prostatic PSA kicks in. Switch test to one where lowest value is about 0.03

[jimbay in reply to Tall_Allen]

Hi Tall Allen. Thanks! I was hoping you would weigh in. I have been watching your posts for years and appreciate your knowledge. It's funny, without notice, Labcorp switches between .014 and .006 as the cutoff. I wouldn't have stressed or noticed if they did the higher one. Still, while I'm grateful, I was spoiled with seeing nothing for so long. I'm going to need a doctor to tell me this is nothing to worry about. But your post has gone a long way in helping me. Conversely, are there any contrary opinions/studies from anyone else? Or is this a done deal not to worry?

[Tall_Allen in reply to jimbay]

No one has been able to find any useful correlations below 0.03, and since RADICALS no one really cares or should care:

prostatecancer.news/2019/09...

[allie2020 in reply to Tall_Allen]

I'm with TA all the way. I had RP a little before you and all of my uPSA's have been by Quest Labs. The least their equipment can read is .03 and all of my results have said <.03. I'm very good with that, I have no interest in a test that reads to the thousandths.

[Bethpage in reply to allie2020]

Every single one of my husband's Quest labs have always reported <0.04. I wish there was some consistency.

[Tall_Allen in reply to jimbay]

Idk if this qualifies me as an expert, but at least I'm published on the subject:

auajournals.org/doi/10.1016...

[jimbay in reply to Tall_Allen]

I think you are about as expert as it gets. Here is the type of report that gets me concerned. Notice how .01 PSA has 50% chance of BCR. So anything near that concerns me. Please poke holes in this research: ncbi.nlm.nih.gov/pmc/articl...

[Justfor_ in reply to jimbay]

You are not high risk like the people of the paper you mentioned, are you?

[jimbay in reply to Justfor_]

Justfor, thanks. No, I am not. With my anxiety up, I didn't read the article well.

[Tall_Allen in reply to jimbay]

You will notice that Dr King is the coauthor of my study too. Our response to the Johns Hopkins study was that 0.01 was a very poor indicator. But, all those concerns raised by observational studies in 2015 were put to bed in 2019 by 3 RCTs: RADICALS, GETUG-AFU-17 & RAVES. Please read this:

prostatecancer.news/2019/09...

[jimbay in reply to Tall_Allen]

Thanks again, Allen. I knew you could put this in perspective. Please keep letting us know as information becomes available.

[Teufelshunde in reply to Tall_Allen]

Do we have to pay to read this? I am not a member of the site.

[Tall_Allen in reply to Teufelshunde]

No- just click on the link and on the "redirect notice"

[Teufelshunde in reply to Tall_Allen]

I clicked on this is the redirect link and created an account but shows pay to get access to article for 24 hours. Am I not at the correct place?

auajournals.org/doi/10.1016...

[Tall_Allen in reply to Teufelshunde]

Below is the fulltext - as I said, it is no longer relevant since RADICALS

Re: Do Ultrasensitive PSA Measurements Have a Role in Predicting Long-Term Biochemical Recurrence-Free Survival in Men Following Radical Prostatectomy?

Several retrospective studies this year reported that early ultrasensitive PSA (uPSA) following prostatectomy reliably predicted eventual conventional biochemical relapse (cBCR). The published conclusion seems to have missed the optimal cutoff that we infer from their data.

In spite of three randomized clinical trials , , that have demonstrated the benefit of adjuvant radiation in limiting progression in patients with adverse pathology compared to “wait-and-see,” and in spite of ASTRO and AUA endorsement of adjuvant radiation, only 43% of men who get radiation after prostatectomy do so within the first 6 months. The reluctance to follow those guidelines may be justified: a recent study found that among men with adverse pathology, only 17% actually went on to have a cBCR within the median 51 month follow up. To avoid overtreatment, we seek to safely avoid adjuvant radiation, if possible, by using an early indicator that salvage radiation may be beneficial. The optimal cutoff emerging from several studies, including the cutoff we infer from this one, seems to be a uPSA of 0.03 ng/ml.

In the current study, among men whose first uPSA was ≥ 0.01 ng/ml, about half eventually suffered cBCR: a uPSA cutoff of 0.01 ng/ml on a first test was no better than a coin toss at predicting eventual cBCR, and would lead to a great deal of overtreatment. On the other hand, a first uPSA cutoff of 0.03 ng/ml correctly predicted cBCR 77% of the time. The 0.03 ng/ml cutoff missed 15% of men who would eventually reach cBCR, statistically no different from the 14% of men missed by the lower 0.01 cutoff. Clearly, a 0.03 ng/ml uPSA cutoff is prognostic of cBCR, but a lower cutoff is not. The authors seem to miss this point in their conclusion.

In their study, 42 of the 44 cystoprostatectomy patients had uPSA<0.01 ng/ml, and the other two had low values, 0.01 and 0.02 ng/ml, ostensibly from extra-prostatic sources. All were below the 0.03 ng/ml cutoff. Koulikov et al. found that only values above 0.03 ng/ml that steadily increased were prognostic for cBCR, while lower values and non-increasing values could safely be ignored. Kang et al. found that a 0.03 ng/ml cutoff at any time after surgery optimized cBCR predictions with a median 18-month lead-time advantage among men diagnosed with adverse pathology (pT3 and/or positive margins). And in a separate analysis among men with more favorable pathology (pT2, irrespective of margin status), Kang et al. found that a 0.03 ng/ml cutoff on a first uPSA was predictive of later cBCR (at a median of 33 months).

While we await more definitive results from randomized clinical trials, there seems to be an emerging consensus that 0.03 ng/ml is the optimal uPSA cutoff. Adjuvant RT or early salvage using a 0.01 ng/ml cutoff will lead to over-treatment. Moreover, there seems to be no risk attached to waiting for the higher value. Provisionally, we believe 0.03 ng/ml should be viewed as a surrogate for the traditional definition of cBCR following surgery.

Wiegel, T. et al., Adjuvant Radiotherapy Versus Wait-and-See After Radical Prostatectomy: 10-year Follow-up of the ARO 96–02/AUO AP 09/95 Trial, Eur. Urol., 66(2):243-250, Aug. 2014

Bolla, M. et al., Postoperative radiotherapy after radical prostatectomy for high-risk prostate cancer: long-term results of a randomised controlled trial (EORTC trial 22911), The Lancet, 380(9858):2018-2027, 8 Dec. 2012

Thompson, I.M., et al., Adjuvant Radiotherapy for Pathologic T3N0M0 Prostate Cancer Significantly Reduces Risk of Metastases and Improves Survival: Long-term Followup of a Randomized Clinical Trial, J Urol, 181(3):956-962, Mar. 2009

Sheets, N.C., Hendrix, LH, Allen, I.M., Chen, R.C., Trends in the use of postprostatectomy therapies for patients with prostate cancer: A Surveillance, Epidemiology, and End Results Medicare analysis. Cancer, 119(18):3295-3301, 15 Sept. 2013

Kang, J.H., et al., Concern for overtreatment using the AUA/ASTRO guideline on adjuvant radiotherapy after radical prostatectomy, BMC Urol, 14:30, 7 Apr. 2014

Derived from corrected NPV in Table 2 of unedited MS.

Koulikov, D., Mohler, M. C., Mehedint, D. C. et al.: Low detectable prostate specific

antigen after radical prostatectomy--treat or watch? J Urol, 192(5): 1390-1396, Nov. 2014

Kang, J.J., Reiter, R.E., Steinberg, M.L., King, C.R.: Ultrasensitive Prostate Specific Antigen after Prostatectomy Reliably Identifies Patients Requiring Postoperative Radiotherapy. J Urol, 193(5): 1532-1538, May 2015

Kang, J.J., Reiter, R., Kupelian, P., Steinberg, M., King, C.R.: (P005) Ultrasensitive PSA Identifies Patients With Organ-Confined Prostate Cancer Requiring Postop Radiotherapy. Oncology, Proceedings of the 97th Annual Meeting of the American Radium Society, April 30, 2015

[Teufelshunde in reply to Tall_Allen]

Thanks. Good to know historically.

[Justfor_]

You need to assess your PSADT (Doubling Time) if any. It is good that you take high resolution tests. You will get an early warning and have ample time to decide on further steps. For a somewhat reliable PSADT you will need 5-6 time samples for "noise reduction". If your PSA ever breaches 0.06 then you should start worrying. Until then suspend worrying.

[jimbay in reply to Justfor_]

Thanks.

[Hidden]

Sonora Quest threshold for undetectable PSA? 0.1. Those ultra sensitive tests just provoke needless anxiety.

[jimbay in reply to Hidden]

Well, they certainly provoke anxiety. And I think you and the other folks may be right that it is needless.

[allie2020 in reply to Hidden]

I spent at least a couple of hours on the phone with Quest on two different occasions because I wanted to fully understand the sensitivity of their uPSA tests. Eventually, I was able to speak with "technicians" who seemed to understand their uPSA tests completely. The least their equipment can read is 0.03. My results have always been <0.03. Hence, my PSA could be 0.0001 or 0.0299 or anywhere in between. I already have enough PSA anxiety every six months without finding out my PSA went from 0.005 to 0.007.

[jimbay in reply to allie2020]

I'm right there with you! Also, different equipment and testers have different minimums. Labcorp went back and forth in their minimums from .006 to .014 with no explanation. I spent over a month trying to get a simple ruling that it was the equipment change and not me - they would never reply and I gave up.