Recurrence six-years after surgery

[OldTiredSailor]

RALP late August 2018 (age 71) - Pathology Report:

Adenocarcinoma (acinar, not otherwise specified)

Gleason 7 ( 3 + 4 ) Grade Group 2 pT3a pNo

20% of gland involved bilaterally

EPE: Present, Focal Left Posterior Apex

Margins: Involved by invasive carcinoma 2mm Unifocal Gleason 3

Positive Margin: Left Posterior Apex 2mm

Alll other margins: No invasion

Perinuereal Invasion: Present

Four Lymph nodes examined - No involvement

Lynphovascular Invasion: Not Identified

Seminal Vesicle Invasion: Not identified

A Decipher evaluation was done on the tissue removed during surgery and yielded a 0.47 score a a report that told me there was less than a 4% chance of metastasis in five years and 5% chance of Prostate Specific Mortality in 10-years. Most recent research puts the cutoff for low risk as a score of 0.45 compared to my 0.47.

Six-months after surgery PSA was 0.018 and stayed below 0.1 until April 2024 (68 months post surgery) when it hit 0.196 or double the value in June 2023. Then the PSA values decreased slightly for the next four months. The same thing happened in early 2020 and again in all of 2021 when the PSA declined 30% over 18-months.

But, the PSA then jumped to 0.230 in mid-October 2024 and now 0.400 in early December 2024.

ALL PSA tests were done by the same Labcorp location using the same methodology.

I had no additional therapy after the RALP in August 2018. I did see an oncologist every six-months from the surger date until July 2023.

In July 2023 my oncologist took me off the six-month testing schedule saying "nothing interesting happens after five years with a low PSA reading."

Has anyone experienced these big swings in low PSA values post surgery and then a large increase after five or more years?

I am in excellent health and live an independent and active life. I play high level pickleball five-days a week for several hours each day. I have no other health issues and the more sophisticated life expectancy calculators give me another 14 to 17 years on this earth.

I know I probably need treatment. But when and what? I have done a lot of reading on the current protocols for BCR and find the recommendations to be contradictory and not entirely convincing.

I see my oncologist December 12 and have a 2nd opinion appointment at Moffet Cancer Center in Tampa on December 16. Are there any suggestions on what I should talk to them about?

[Justfor_]

Check my bio. Faster progression than yours, on all accounts, but, devised my way to slow it down by a miniscule dosage of Bicalutamide.

[RJAMSG]

Hello, there are a few others in this group similar to you. Check/google “Dan’s Prostate Cancer Journey’ I would see what your Oncologist says and also Moffitt,radiation is probably the next step likely to the bed of prostate and maybe lymph nodes, they may want to do hormones but for a short period too. Prayer for wisdom and health

[marlins1]

If you have a BCR of .4 PSA, you are looking at Salvage RT. I did mine at .34. No complications.

[FlyJ]

See my bio. I had similar hx with T3a but gleason 9 and higher decipher score. Robotic RP and pelvic lymph node dissection primary treatment. BCR in 30 months with psa .21. PSA then dropping to .18 and then further drop to .15 over the next 6 mos. with no SOC Rx. Next PSA rose to .17. Despite negative PMSA scan I went ahead with prostate bed/pelvic lymph node radiation and short term ADT (similar to SPPORT trial group 3 Rx). My psa has been undectable since- now out 2+ years from end of radiation.

[Seve]

OTS - I am experiencing something similar. Had RALP in May 2018. About 18 months after my psa began to slowly rise. Actually would rise and fall over the years. Last 4 readings were (all in 2024) 4/24:.19, 6/10:.16, 8/2:.15, 9/27: .19. I have a January appointment with oncologist, will get another psa test later this month. Have you seen the old paper by Koulikov titled I think: “Low detectable psa after prostatectomy - wait or treat”?

[FlyJ in reply to Seve]

From the paper you reference "These findings do not apply to patients at high risk". I don't see in your bio info to catagorize your clinical situation. High risk would be : PSA level is more than 20 ng/mL, or the cancer is in the T3a stage or Grade Group 4 or 5

[Seve in reply to FlyJ]

FlyJ - psa at treatment was 12.5. Had G7 being 4+3. Lymph nodes taken on each side of prostate were clean.

[j-o-h-n]

BTW If you should need to have Radiation to the bed (frying the groin) here is how I reacted to it.

It was a nothing burger, no pain, no nothing, no nothing and no nothing. However a couple of years later they discovered that my left urinary tract was crimped and they thought it may be from the frying (never proved that it was). So they put a stent up and down my willie (no nothing again) for several years and finally the doctor stopped them. Urine from the left kidney is 15 % and 85% from my right kidney - also nothing.

A few members suggest having a spaceOAR installed before the frying (to protect other parts of your wonderful body). Some members state that you don't need a spaceOAR nowadays That would be you and your doctor's call.

Anyway, you owe me 2 cents,, and best wishes to you and to your pickled balls.

Good Luck, Good Health and Good Humor.

j-o-h-n

[NanoMRI]

It was and continues to be my experience that the definition of BCR and recommendations are contradictory and I agree not entirely convincing. I believe this is largely because this disease is largely seen as a chronic illness with ADT as the medicine of choice. (For ten years my intent has been to defer ADT/CR for as long as possible).

My RP was nine years ago and I chose to reply on <0.010 as best indicator and rejected the concept of recurrence; rather see it as cancer remains. My post RP uPSA nadir was 0.051 - we accepted cancer remained. Eleven months later my uPSA was up to 0.11 and I chose salvage RT to the prostate bed only; I was not willing to give the cancer any more time. I had no imaging at that time, so IMO, we were shooting blind (characterization many docs despise). I was not willing to shoot blind to the pelvic region.

If I had a do-over today, I would have two imaging methods and a liquid blood biopsy before treatment decision. I would also look into salvage extended pelvic lymph node surgery using the frozen section pathology method - I did this after my unsuccessful salvage RT to the prostate bed. Hope this helps. All the best!

PS - are you still sailing? I picked up a new to me daysailer this past summer.

[jctaylor]

I am facing a similar situation. My biopsy was G 4+5, RP was in May of 2019. My path report was not detailed but suggested that the biopsy overstated presence of G 5 tissue and found clean margins, seminal vesicles and lymph nodes. I had no further treatment. My first PSA, 3 months post op was undetectable but gradually increased over the years since. Plotted on a graph it would resemble an ascending saw tooth pattern until December of 2022 it reached a high of .080 but gradually descended after that to a low of .056 in January of this year. My latest test last week more than doubled to .12. I have an appointment scheduled with my URO at the end of January.

[Justfor_ in reply to jctaylor]

You may want to take a look at my bio. Close stages, similar"bumpy" range (0.08-0.15)

PSA