Hard to believe that it’s been 12 years since my prostatectomy. So many health issues since then that PCa has moved down my list of worries. My PSA for the prior 2 years was .008. This year’s result just back and it’s ticked up to .009. I don’t think it’s anything to worry about, but of course I will. For background, at surgery my PSA was 3.5 and pathology was Gleason 6, organ confined.
I’ve read here and other places that the most conservative approach is to consider salvage treatment at .03 and that lower than .03 is still considered undetectable, even though technically PSA was detected. Is that still the current thinking?
Thanks and best wishes to all dealing with this.
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jeff1257
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Jeff - I doubt the change from 0.08 to 0.09 is meaningful. Numbers that low can vary a small amount for no apparent reason. And even if it is meaningful your doubling time would be quite low. I think the official (SOC) cutoff for recurrence is 0.2 but many people use 0.1 and/or 3 consecutive rises (I never heard of using a 0.03 cutoff). If you are worried (and I see no reason to be) you could get it checked again in 6 months rather than wait a full year.
Thanks for the reply and the articles. Is BCR still considered 0.2? I’m confused because some studies define it differently. Also, is an uptick from .008 to .009 even statistically significant? If the test was two decimal places, they’d both be <.01.
I did read the articles. My confusion stems from the fact that the 2021 article clearly states that BCR is defined as PSA of 0.2, while the 2019 article uses the following definition for early salvage radiation:
“Early salvage" radiation (eSRT) was defined variously as treatment when PSA ≥ 0.1ng/ml or 3 consecutive rises (RADICALS-RT), PSA≥0.2 ng/ml and rising (GETUG-AFU-17), or PSA≥0.2 ng/ml (RAVES).
If “early”implies that the salvage treatment is given before BCR, then the last choice of PSA equal to, or greater than 0.2 wouldn’t belong there.
If early means at the time of BCR, then the definition is saying BCR includes at least the four listed alternatives. One is PSA >= 0.1 and another of which is PSA >=0.2. If PSA is 0.2, then it’s also greater than 0.1. Alternatively, if BCR is PSA>=0.2, then salvage treatment given at 0.1 is before BCR.
That's right, each of the 3 trials had slightly different definitions of how they defined biochemical recurrence. The goal of each study was the same: is there any risk in waiting until BCR (however it was defined) rather than adjuvant (immediately after prostatectomy) radiation. They all came up with the same answer - there is no risk in waiting.
Thanks. 12 years out I think the adjuvant RT horse has left the barn. Is there any guidance about when a rising PSA should trigger concern? I’m not worried about the uptick from .008 to .009, but was wondering is there any consensus about what level should trigger concern.
OK, and since different studies use different definitions of BCR, the short answer is there is no way to definitively answer at what level one should be concerned. For example, this study done at UCSF - a center of excellence — uses PSA>= 0.03 as BCR. I believe MSKCC uses 0.2 as BCR.
No. there are 3 and only those 3 randomized clinical trials discussed in my article that all had the same purpose: to find out if men could wait, without risk, until reached BCR before getting salvage radiation. The only 3 definitions used were:
RADICALS-RT: 0.1 ng/ml
GETUG-AFU-17: 0.2 ng/ml
RAVES: 0.2 ng/ml
So, if you want to quibble about whether 0.1 or 0.2 is a better number, it doesn't make much difference because the results were the same - there is no risk in waiting until PSA gets that high.
That now defines the standard-of-care. You or I do not get to make up our own numbers or put some lower level-of-evidence retrospective study just because it appeals to your or my intuitions.
Yes, a randomized controlled prospective study may be the gold standard, but that doesn’t mean that in this case a retrospective analysis is invalid. Statistics was my worst grade in undergrad, but even I know that statistics can be manipulated and are often biased, such as selection bias. If I recall correctly, at one time Johns Hopkins wanted to use .4 or higher as BCR. The so called SOC of .2 was not based on anything other than educated guesses, albeit by top doctors and researchers. If UCSF feels that .03 is a reasonable definition, then it probably is. That doesn’t mean that I would blindly decide to spring into action at that level. Many times in my life I’ve had doctors tell me that based upon their experience they would or wouldn’t follow the SOC (or there is no agreed SOC). If I trust the doctor, I often follow their clinical advice.
Thanks for the debate. Certainly helps me to think more clearly about this. One conclusion I can’t shake is that the concept of informed consent is basically illusory. The average person, myself included, is in no position to to fully appreciate the nuances of the information we’re given, nor do we have the background to completely understand what we’re told.
"Yes, a randomized controlled prospective study may be the gold standard, but that doesn’t mean that in this case a retrospective analysis is invalid." Yes, that's exactly what it means. There is such a thing as "levels of evidence." If you want to understand more, read this:
"Statistics was my worst grade in undergrad, but even I know that statistics can be manipulated and are often biased, such as selection bias."
The top peer-reviewed journals are reliable. Only nutty conspiracy theorists put their intuitions above medical science. Selection bias only applies to retrospective studies, not randomized clinical trials. 3 separate RCTs came to the same conclusion, so it is now accepted as fact by all clinicians.
It doesn't matter what definition of BCR you or UCSF thinks is reasonable. Don't call it BCR then. But the 3 RCTs prove that waiting until PSA reaches 0.1 or 0.2 (whether you want to call that level BCR or not) confers no extra risk. It makes the decision quite straightforward.
Of course there can be selection bias in a RCT. Inclusion and exclusion criteria create bias. The randomization is merely a matter of being randomized to the variable treatments or modalities being tested.
To clear up any misapprehension, I did not select or even have a basis to have an opinion as to whether .03 should be considered BCR. UCSF, a well regarded center of excellence chose that number. I’m not privy as to why.
Things that are “proven” in medicine are often later found to be wrong.
Moreover, the study I think we’d want to see is comparing those who started SRT at 0.03 vs 0.1 or 0.2.
(1) "Of course there can be selection bias in a RCT. Inclusion and exclusion criteria create bias. The randomization is merely a matter of being randomized to the variable treatments or modalities being tested."
The term "selection bias" has a very specific meaning that we do not get to redefine. It refers to a source of confounding in retrospective studies whose magnitude cannot be determined. Inclusion and exclusion criteria in a clinical trial are not a bias - they define the patient selection criteria for whom that trial is relevant.
If you want to see how selection bias can mislead in retrospective studies, see this, which was the only info on debulking the primary that we had in 2016:
When selection bias was eliminated in two RCTs investigating the same subject two years later, it provided the opposite conclusion (except for the oligometastatic subgroup):
(2) "To clear up any misapprehension, I did not select or even have a basis to have an opinion as to whether .03 should be considered BCR. UCSF, a well regarded center of excellence chose that number. I’m not privy as to why."
You are confusing biochemical recurrence, an arbitrary PSA level, with your original question. Your original question was whether your low PSA level is concerning. As I've repeatedly said, 3 RCTs have proved that a patient need not be concerned until PSA reaches 0.1-0.2. It does not matter if UCSF wants to call some earlier PSA "biochemical recurrence." You are confusing nomenclature with an appropriate PSA trigger. It doesn't matter what you call it - only the trigger PSA level is meaningful.
(3) "Things that are “proven” in medicine are often later found to be wrong."
Your use of the word "often" makes your statement incorrect, at least in present day. Are they "sometimes" later found to be incorrect - of course! That is exactly why all medical researchers now adhere to "levels of evidence" and the GRADE system. It's been found that research findings are seldom ever wrong the higher the level of evidence and GRADE. Only Level 1 high GRADE evidence is practice-changing. Anything less is only hypothesis-generating. Because of the internet, many patients think they understand the information they are seeing without having the context for interpreting that information.
surgeon at Kaiser showed me a chart of your percent cure with radiation versus the PSA at time of Radiation, mine was .5 and reduced by chances of the cure by 20% versus starting at .1 PSA. I started the ADT with cassidyx then in 2 wks Lupron and the radiation. I took two three months shots of Lupron would prefer a single 6-month shot. It was curative the PSA stayed undetectable even 9 years after I stopped the Lupron. I had radiation that has a prostate-bed position tracking function like image guided radiotherapy. They also sent me up stairs to take gas tabs and water when there was too much intestinal gas to do the radiation. Once I was rid of the gas I would ask them to take me in at the next opening usually an hour later.
That’s really interesting and certainly appeals to common sense, although if I’m reading this right, that information is 10 years old. In any event, congratulations and continued good health!
The issue for me is really at what PSA level should one be concerned and what level is optimal to initiate salvage treatment. I read studies defining PSA=.03 as BCR. Still other studies continue to define BCR using the old criteria of 0.2.
For the first few years, the hospital that did my surgery used an assay or equipment with a lower limit of detection of .04. So all I know is that my PSA was less than that. It could have been .03, but I wouldn’t know. They then switched to an assay with a lower limit of detection of .01, so my nadir was <.01. Even now at .009, I’m still less than .01. As I understand it, some of the new ultra sensitive assays go so low that even women would show detectable PSA due to non-prostatic sources.
Seems to me that uniform definitions are needed. It makes little sense to me that I’m detectable at .009, but would be undetectable if the assay had a lower limit of detection of .01.
The Kaiser doc said he would start treatment as early as .03 but getting to point one doesn't hurt your chances very much. I don't know of any PSA test that goes down to 009 so you may be at .09 so you might already be nearly .1
Nice I'll check out labcorp.com or LEF.org for ultrasensitive PSA post-prostatectomy. I've been ordering their blood test outside of Kaiser for a really thorough complete blood count that includes iron, glucose and blood chem using just one or two vials of blood. I also got a fasting insulin test (8.2) because high fasting insulin levels (15+) drive cancer growth. Kaiser uses quest for post prostatectomy PSA and Quests limit of detection is <.01 so they won't show anything below 0.01 even though it is ultra sensitive. They used to go down much lower. I think they stopped because people were getting too anxious about the fluctuations.On the insulin/glucose blood sugar I have prediabetes which is worse after the 6 months of Lupron in 2014 and so I'm on the maximum dose of metformin 500mg 5x/day with food. It's a good thing because it's turns out to be a life extending drug and it may have some anti-cancer effect. Even with that my blood sugar is averaging 120. My Desired glucose goal is around 90. I got an inaccurate (often low by 20) $26 glucose watch but it does track the changes after a meal pretty well. I'll experiment with adding extra extra virgin olive oil to my lentil soup and steel cut oats to reduce glucose/insulin spikes. Extra virgin olive oil is interesting in that it makes you less hungry so it doesn't make you fat (in 1 large trial with unlimited Extra virgin olive oil). I am still avoiding dairy. milk often has natural and added growth hormones BGH that can speed cancer growth. I remember stopping folate supplement that was causing my PSA to go up before I had the radiation. Dr. Steve Scholz at prostate cancer specialists in CA has noticed his patients that were taking B vitamins got a rise in their PSA. folate is usually one of those in B complex. It's DNA repair function is bad especially if you're getting radiation or chemo. I used to like the B complex because it seemed to give me more energy. I just take the centrum men's 50 plus multivitamins now, moderate B vitamin levels. I'm in full remission no current radiation or chemo or ADT (no androgen deprivation therapy like lupron). Undetectable PSA on the quest test.
Good morning, not familiar with your history or if any other treatment besides prostate removal have been done, but if it has been 12 years since any treatment and it is rising so slowly depending on your age etc. there is a possibility that no more treatment is required just to follow psa since it is still so low.
Hi. I’m 66 and have had no further treatment. Thanks for your reply. I’m not really worried about it. In fact, given margins of error in testing, I don’t think there’s any difference between .008 and .009.
I have a problem with PSA measurements provided to that kind of resolution (1/1000) without an accompanying accuracy figure. Does your lab give you that information or or are they just trying to impress patients with glitter (not to say BS) ? Unless the accuracy is +/-0.001 then the difference between your readings is within the band of systematic measurement errors. Ask your Oncologist what the real reading is, I would find it hard to believe that in reality the result should be presented as anything but <0.1 undetectable. You may be paying more for an ultra sensitive test that provides no added value.
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