PSA update

Hello all,
I've been off the air for a couple of weeks so I hope you are all traveling well. Had my latest PSA at the end of September and the results were <0.01 undetectable. Well that's good news. This time I had it done by a different lab. As you can see in my signature my PSA in October '07 (8 weeks post surgery) was <0.1 followed by the January '08 result of 0.1 again. Following a bit of research and suggestions here on Healingwell (regarding adjuvent therapy in relation to higher risk prognosis of Gleason 8 and focal extraprostatic extension) I decided that I would go the ultrasensitive route with future testing as well as getting feedback about additional treatment from a radiation oncologist and a medical oncologist (many thanks to TC-LasVegas for his input on this one). My GP requested the ultrasensitive PSA test in April '08 and the result came back as a standard result <0.1. I lodged a complaint that this result was not as per the request. The result was re-issued as <0.001. Wow that's really good news. At the time I thought that reading was a little unusual as I had not seen such a low level posted before. It was about June when I finally saw the oncologists.............their opinion......"yes, studies indicate that prognosis is improved for patients with higher risk factors and have adjuvent therapy over patients who do not". But--------there is a window for this therapy, normally from three to six months following surgery, and as I was now at about 12 months this window had passed. Why had my surgeon not even raised the possibility even if he thought it unwarranted? As the oncologist said, surgeons like to believe their surgery is successful and if you have adjuvent therapy you cannot be counted as a surgical success. I guess it's a little easier to roll the dice when you're not the one at a somewhat increased risk. So the opinion is monitor PSA and do salvage radiation if relapse should occur. At the radiation guy's suggestion I also had the post-surgery slides looked at by the leading lab in my state. The report was basically the same, however the Gleason score was downgraded from an 8 to a 4+3=7 (the same as the original biopsy) with the extraprostatic extension being comprised of grade 3 cells so that is a bit of a plus I suppose......better grade 3 than grade 4 poking their nose out there. The time for the next PSA came in August, again the ultrasensitive test was requested. Again the standard result of <0.1 was issued. Once again I lodged a complaint and again the result was re-issued as <0.001. Although the reading was excellent this level caused me a little disquiet and another member (I can't think who it was at the moment) also raised their eyebrows at the level. This prompted me to find out what equipment the lab used----------it is the Immulite 2000 and this has a lower detection limit of 0.003. I contacted the lab by email and asked "How did you produce a result of <0.001 on equipment whose lowest level of detection is 0.003". There was no response. Of course the actual levels are so low as to be meaningless but I had the suspicion that somebody has (1) made a mistake or (2) fudged the figures following my complaint, both of which are completely unacceptable. I took technical details of the Immulite 2000 to my GP (who has the humility to admit his knowledge of ultrasensitve testing is limited) and he queried the pathology lab on my behalf. A couple of weeks later the lab responded. The lab's explanation was that the local urologists (5 in my city, all housed within the one complex and none of whom are treating me) only required the standard report and that's why they issue them as such. At their (pathology) next monthly meeting with the local specialists the question of ultrasensitve testing was raised as a result of my complaint. The urologists held that they only wanted standard testing following surgery (in spite of the view of a lot of oncologists).............the pathologists replied that they would have to comply with the ultrasensitive requests in future as it was the lab who was on the line. They also admitted that my results were "misreported". What the hell do they mean by "misreported". Needless to say my confidence in them was now shot to pieces. I went on to find a new lab and came across the Tumour Marker Unit in the Biochemistry department at Royal Prince Alfred Hospital in Sydney. What a difference. I contacted the department and spoke to one of the scientists there. He understood my concerns and made an appointment for me to have a new test telling me to contact him when I arrived (he gave me his mobile number). When the day came this wonderful person came down and met me in the hospital lobby and escorted me to the blood collection area. He rang me directly the next day with the result of <0.01 (they record any result under two decimal places as such). I am not hung up on ultrasensitive results but I believe that things should be done correctly, particularly when you are dealing with cancer of any type. I have got to admit that my lifelong automatic respect for the medical community is seriously being challenged as a result of this journey. There are excellent professionals, mediocre professionals, and outright bad professionals out there so you have to sort the chaff from the hay. O.K my rant has ended, I have purged my frustration and am looking forward to posting an excellent score on the golf course this weekend. Spring has just started, the weather is great, my part of the world is renewing itself, so onward and upward.
Bill

Bill,
Your labs look great. On the RT thing, I don't know they can base ther claim of 3 to 6 months on any valid study, except to say that is the window used at Harvard and Stanford in their controlled study that showed a significant improvement in controlling the disease. What I am saying is that there is no study out there yet that compares using RT 12 months after RP and prior to biochemical relapse, thus no one knows if it would produce the same results as the Stanford study. Just a thought. Perhaps you might ask that question of your RO. I just know it looks and sounds right that if you hit it before it spreads, you will get better results.

On the PSA testing, yea I can understand that frustration and tell you that's why I stuck with the Bayer Assay. <0.1 is fine with me. I probably would not make a salvage treatment decision until at least 0.4 anyway. I would rather understand the doubling rate based on the larger numbers. So I guess, I have heard it here several times, those "ultrafines" sure do cause quite a few concerns regularly.

I would rather worry about my putting skills.

Tony

Congratulations on your PSA scores!  Your persistence has paid off in giving you the answers you needed. Take care and be well...Tim

Bill,

It's good to hear your PSA is still "undetectable". As I have posted before, I have also had a few issues with the reporting of my PSA results, but not near the level of issues you have had. Regarding the "window" of adjuvant/salvage therapy, I also see no logic to tying the window to the date of surgery. It's not as if the cancer cells were "spilled" into the prostate bed at the time of surgery; if there are some outside the prostate then they were probably there before the surgery. Dr. Walsh's book mentions that the longer time until a recurrence actually improves the probability that salvage therapy will work. I think the reason given was that this implies a less aggressive cancer and hence more likely to be killed by radiation.

I am coming up on my one year PSA test. As I have mentioned before, I am strongly leaning toward switching from the ultrasensitive to the standard PSA test. Based on my very good final pathology and Gleason score, I statistically have only a 1% chance of recurrence over ten years. I don't want to risk giving this dreaded disease the upper hand, but I know that my personality will cause me to fret over the smallest bit of test noise to the upside. However, I don't want to unnecessarily irradiate my terrifically functioning nerve bundles. My "compromise" for this change is that I am thinking about getting tested every six months for the first five years, as opposed to yearly. That way, if I do reach 0.1, I should know this earlier than otherwise. One thing I do potentially lose is PSA velocity information that could be better gleaned from ultrasensitive testing after surgery. In my case, however, I have a good bit of data regarding my PSA velocity prior to surgery (low). My assumption here is that the aggressiveness of any cells outside the prostate would be the same as those found inside and hence should produce the same velocity. This is just my assumption, though, and is not based on anything I have read or heard.