don’t make any rash decisions. My went up gradually for 3 years before trending down to acceptable levels, 5 years out from proton an still going down. Enjoy life. I wasted those three stressed and worried I was dying “tomorrow” the whole time.
Thanks. My 2 RO's said that while I was an "outlier" I wasn't as unusual as people think. It just seemed like I see other people have very rapid declines.
just giving you my "thoughts." I know with a PSA that high they could probably justify it and if it came back clean, that would be a good feeling and if it didn't, it would tell you where to possibly hit with SBRT. But of course they doctors have the final say and in this case, I guess their say is just don't worry about it. So that's your final answer. Stop worrying about it.
Based on the information provided, your PSA kinetics after SBRT (stereotactic body radiation therapy) appear to follow a **common and reassuring pattern**, even if the decline is slower than you hoped. Here’s a breakdown of key points to consider:
---
### **1. PSA Trends Post-SBRT**
- **Initial Rise (Bounce):** Your PSA increased temporarily after treatment (8.6 → 11.96 at 12/23). This is a well-documented "PSA bounce" seen in **~30% of patients after radiation therapy** (including SBRT). Bounces typically resolve within 12-24 months and are **not necessarily linked to recurrence**.
- **Downward Trajectory:** Since the bounce, your PSA has steadily declined (11.96 → 5.4 over 12 months). This downward trend is **encouraging** and aligns with the gradual response expected after radiation (PSA nadir often occurs 18-24+ months post-treatment).
---
### **2. Prostatitis as a Confounding Factor**
- Inflammation (prostatitis) can persistently elevate PSA and create "noise" in interpreting results. If your RO suspects this, it might explain the slower decline. Antibiotics (if infection is present) or anti-inflammatory strategies (e.g., NSAIDs) could help lower PSA further.
---
### **3. Realistic Expectations for PSA Nadir**
- **SBRT typically achieves a PSA nadir of 0.5–2.0 ng/mL**, but this varies based on:
- Baseline PSA (yours was elevated at diagnosis: 8.6).
- Prostate size (larger glands may take longer to decline).
- Presence of inflammation (prostatitis).
- Your current PSA (5.4 at 14 months) is still within the range of a **slow responder**, especially with confounding factors like prostatitis. Many patients see continued declines beyond 2 years.
---
### **4. Next Steps**
- **Monitor Trends, Not Absolute Values:** Focus on the **direction** (downward trend) rather than the absolute number. A rise of ≥2 ng/mL above the nadir (Phoenix criteria) is the threshold for concern about recurrence, which you haven’t reached.
- **Rule Out Prostatitis:** If not already done, consider:
- Urinalysis/culture to check for infection.
- Trial of antibiotics (e.g., ciprofloxacin) to see if PSA drops further.
- Prostate MRI to assess for residual inflammation or recurrence.
- **Patience:** Radiation works slowly—your PSA may continue to decline for another 6–12 months.
---
### **5. Reassurance from Your RO**
Your radiation oncologist’s perspective aligns with current evidence: **a gradual decline is acceptable**, especially with prostatitis complicating the picture. Unless there’s a sustained rise, there’s no clear indication of treatment failure.
---
### **Bottom Line**
Your PSA trajectory is **moving in the right direction**, albeit slowly. Prostatitis likely contributes to the "plateau," and continued monitoring (every 3–6 months) is reasonable. If PSA stabilizes or rises in the future, advanced imaging (PSMA PET) or biomarkers (e.g., 4Kscore) could clarify next steps—but for now, cautious optimism is warranted.
The **4Kscore** is a blood test designed to help assess the risk of **aggressive prostate cancer** (specifically, high-grade Gleason score ≥7) in individuals with an elevated PSA or other prostate cancer concerns. It combines measurements of four prostate-related proteins (kallikreins) with clinical factors to provide a personalized risk assessment. Here’s a breakdown:
---
### **What Does the 4Kscore Measure?**
1. **Four Kallikrein Proteins** (hence "4K"):
- **Total PSA**: The standard PSA in your blood.
- **Free PSA**: PSA not bound to proteins (low levels are associated with cancer).
- **Intact PSA**: A specific form of PSA linked to prostate cancer.
- **Human Kallikrein 2 (hK2)**: An enzyme related to PSA that’s elevated in aggressive cancer.
2. **Clinical Factors**:
- Age
- Results of a digital rectal exam (DRE)
- Prior prostate biopsy history.
These factors are analyzed using an algorithm to generate a **percentage risk** of finding aggressive prostate cancer on biopsy.
---
### **How Is It Used?**
- **Purpose**: To determine whether a prostate biopsy is necessary in men with:
- Elevated PSA.
- A suspicious DRE.
- Uncertainty about prostate cancer risk (e.g., after prior negative biopsies).
- **Strengths**:
- Reduces unnecessary biopsies by distinguishing between **aggressive cancer** and benign conditions (e.g., prostatitis, BPH).
- More accurate than PSA alone for predicting high-grade cancer.
---
### **Why Is It Relevant to You?**
In your case, the 4Kscore could help clarify whether:
- A rising or persistent PSA after SBRT is due to **cancer recurrence** (vs. prostatitis or radiation-induced inflammation).
- Additional testing (e.g., biopsy, PSMA PET scan) is warranted if PSA trends become concerning.
---
### **Key Points About the 4Kscore**
- **Not a Standalone Test**: It complements—not replaces—PSA, imaging, or biopsy.
- **Prognostic Value**: Studies show it reliably predicts the likelihood of aggressive cancer, even in men with PSA "gray zone" values (4–10 ng/mL).
- **Clinical Validation**: Validated in over 25,000 patients, including those with prior negative biopsies.
- **Limitations**:
- Does not diagnose cancer; it estimates risk.
- Less studied in post-radiation patients (like you), though some clinicians use it in this context.
- Insurance coverage varies (check with your provider).
---
### **When Might Your RO Recommend It?**
If your PSA starts rising again or fails to decline further, the 4Kscore could help guide decisions about:
- Whether to pursue advanced imaging (e.g., PSMA PET).
- The need for salvage therapies (e.g., ADT, focal therapy).
- Re-biopsy (if prostate remains intact).
---
### **Bottom Line**
The 4Kscore is a **risk-stratification tool** that adds nuance to PSA interpretation. For you, it could help rule out (or flag) aggressive disease if PSA trends become ambiguous. However, your RO would likely recommend it only if your PSA trajectory raises new concerns. For now, your downward trend remains reassuring!
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SBRT v. Brachytherapy for Favorable Intermediate Risk 
