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I've Made Myself a Victim of PSA Anxiety

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Posted 5/11/2010 11:31 AM (GMT 0)
Just when I thought my life was getting back to normal, I have disovered the famous PSA anxiety.  The last 4 & 1/2 years have been an interesting journey, but other than severe incontinence for 4 months post surgery, I've been much luckier than a lot of guys here.  I did deal with 4 biopsies over 4 years with a PSA that kept rising till it reached 18 shortly before the last biopsy found cancer.  I chose surgery over radiation since my biopsy results of Gleason 6 in only 5% of one core (after 3 negative biopsies) just didn't correlate in my mind with such a high PSA.  The pathology report after surgery found clear margins & no lymph node involvement.

My first PSA 6 weeks post-op was <.1 but last week, at 6 months post-op was .1.  My surgeon says we are going to monitor my PSA every 6 weeks now & that if it rises to .3 I will need radiation.  In addition, he says that since I've had pretty bad incontinence (5 to 7 pads a day) until a month ago when it went down to 2 to 3 pads a day), I will need hormones first.  The reason is that radiation stops all progress on incontinece & that the hormones will pause cancer growth until I am 1 year post surgery when it is likely that there will be no more improvement in incontinence.  He did say though, that there is a good chance that my PSA will not rise further.  He says that with my clear margins, it is unlikely that there is cancer left.  He also said that my prostate was stuck to the rectal wall pretty badly as a result of the 4 biopsies & that it took him an extra hour to peel the prostate away & that some benign prostate tissue could have been left behind.  So here are my questions:

1.  Has anyone else had a similar situation?

2.  Has anyone else had their second PSA be .1 then stay under .3?

3.  How high can PSA go from residual benign tissue?

Thanks in advance for any help.  I had started feeling really good about this journey as my pad usuage has been reduced almost overnight & now I am dwelling on this PSA situation.  Also, thanks for all the help you guys have given me!

Posted 5/11/2010 12:42 PM (GMT 0)
HL, take a look at my signature and you'll see that my husband had a very similar situation. The difference in his case was that his final path report showed EPE but negative margins. When his PSA began to climb last summer, we all assumed that the single focus of EPE was coming back to haunt us. As you can see, his PSA went back down - and has stayed there - but we were ready to pull the trigger on SRT.

In my husband's case, after the first detectable PSA (which was in August), the urologist chose to do another test in 1 month. The September test came back at 0.3, which was when we met with a radiation oncologist. My husband, the urologist and the radiation oncologist all advised for waiting for the 3rd PSA test (which was 1 month after that) before starting treatment. On a Saturday afternoon, the urologist called us at home to tell us the wonderful news that John's PSA was back down to undetectable. We were cautiously optimistic. Doc said come in for another PSA test in 6 weeks - that too came back at zero.

The only major difference I can see between your situation and John's is that your PSA became detectable 6 months after surgery whereas John's took 17 months. I suggest you stay on top of your PSA and watch it closely. Hopefully your doctor is correct and you won't see any further elevation.
Posted 5/11/2010 12:48 PM (GMT 0)
I had my fourth PSA at .16 with a retest of .17 and am doing radiation as we speak - one year from surgery.

My surgeron also said he had to peel the prostate away from the surrounding tissue - and it was an extra hour or so.

I wonder if radiation kills the residual tissue?? I will be interested in others response to this thread.
Posted 5/11/2010 4:40 PM (GMT 0)
My father had some benign tissue left after his RP.
25 years later he developed cancer in that bit that was left and was treated with proton beam radiation. I don't know his PSA progression over that time but it suggests where there's tissue there's a risk.
Posted 5/12/2010 2:42 AM (GMT 0)

Heavy Leaker said...
...He also said that my prostate was stuck to the rectal wall pretty badly as a result of the 4 biopsies & that it took him an extra hour to peel the prostate away & that some benign prostate tissue could have been left behind...

3.  How high can PSA go from residual benign tissue?

Hi, and first of all I'm glad to hear of recent improvements in continence.  Keep working at it.

To your question above, the situation your surgeon described ("peel the prostate away") gives a potentially plausible scenario to extra-ordinarily high amount of benign tissue remaining behind yielding detectible PSA (with "standard PSA" test). 

Normally, the remaining benign tissue would be below the LDL (lower detection limit) of the standard PSA test (one decimal place of significance), although it might register in the hundredths place of the ultra-sensitive PSA test (two decimal places of significance).  The more commonly seen variation in the hundredths position is where the original "PSA Anxiety" term comes from.  (see the article in yellow, at the bottom of this web page:  http://www.phoenix5.org/Basics/psaPostSurgery.html)

I think you are on the right path to monitor more frequently now.  You may also consider a switch to the ultra-sensitive test, now that you've had this "yellow flag" go up...but do keep in mind that by switching tests you will want several data points with the new method (because you cannot compare one method's results to the other method's results).

Hoping that this works out for you and your results drop back below 0.1 ng/mL going forward.

-------------------------------

Regarding Tim-from-Maine's question:  "I wonder if radiation kills the residual tissue??"

Salvage Radiation Therapy (SRT) is intended to kill the cancerous cells that were left behind in the prostate bed during surgery, but it will also affect normal cells in the area as well...it simply is not focused enough to get only the cancerous cells.   Does this answer your question?

-------------------------------

Regarding STW's comment "My father had some benign tissue left after his RP.  25 years later he developed cancer in that bit that was left...".  

Unfortunately, but obviously, there was also some cancercous cells left behind after his RP.  Since 25 years went by, it would have been only a small amount and it took years for the slowly growing PC cells to multiply enough times to become detectible in a PSA test (thereby leading to his SRT).  Sounds like his SRT cleaned things up, as it usually will.

Posted 5/12/2010 4:18 AM (GMT 0)
Regarding post above: your last statement regarding STW's comment regarding have a recurrence at 25 years...you are suggesting the only way he had a recurrence was that cancer was left behind 25 years earlier. I do not believe you are correct about this. Actually, I believe STW is the one who is correct. Non-cancerous prostate tissue left behind absolutely can turn cancerous later. It is one of the inherent risks of radiation as a primary form of treatment...with radiation, benign prostate tissue remains which is why there is still a PSA level. Recurrence can happen when benign tissue left behind from radiation again goes haywire and becomes cancerous. So same would be true for missed tissue post surgery.

Regarding STW's comment "My father had some benign tissue left after his RP. 25 years later he developed cancer in that bit that was left...".

Unfortunately, but obviously, there was also some cancercous cells left behind after his RP. Since 25 years went by, it would have been only a small amount and it took years for the slowly growing PC cells to multiply enough times to become detectible in a PSA test (thereby leading to his SRT). Sounds like his SRT cleaned things up, as it usually will.
Posted 5/12/2010 11:41 AM (GMT 0)
41diagnosed said... Non-cancerous prostate tissue left behind absolutely can turn cancerous later. It is one of the inherent risks of radiation as a primary form of treatment...with radiation, benign prostate tissue remains which is why there is still a PSA level. Respectfully disagree with how you have extended a situation following Radiation Therapy (with a fully intact prostate) to a very different situation after Radical Prostatectomy.  Quite simply, the feeding of prostate cancer cells does not work that way. Please do refer to Dr Patrick Walsh's book "Guide to Surviving Prostate Cancer", Chapter 10 "How Successful is Treatment of Localized Prostate Cancer", subsection "Cancer Control after Radical Prostatectomy." You are correct about RT; but it is not the same after RP. By the way, the longer the amount of time that goes by after RP before those pesky residual PC cells show themselves in a PSA test, the better the likelihood for favorable outcome of Salvage Radiation Therapy (SRT).  Twenty-five years is not unheard of, but is atypical. edit:  typo Post Edited (Casey59) : 5/12/2010 7:58:37 AM (GMT-6)
Posted 5/12/2010 4:32 PM (GMT 0)
The reason radiation sometime fails is that the dose was not high enough to kill all the cancer or that there were dead spots in delivering the radiation. Getting PC in tissues that have been previously radiatied is extremely rare. The radiated tissue becomes fallow. The newer forms of radiation deliver 81 gy' vs the old 65gy protocols and and much more effective. A seed and external combination deliver 140gy and unlikely to leave any living PC within the prostate. In rare cases some PC cells can develop a resistance to radiation, using two different types of radiation can eliminate this.
There is always some prostate tissue left behind in a surgery, good surgeons leave less. If these contain cancer cells reoccurranc may occurr.
JT
Posted 5/12/2010 6:08 PM (GMT 0)
Leaker,
As I recall you had a large transition zone tumor. These are difficult to operate on and invaribly leave some prostate tissue behind. You can image or rebiopsy the area before you get salvage RT to confirm if it is still local or is benign prostate tissue that was left.
JT
Posted 5/12/2010 6:18 PM (GMT 0)

John T said...
Leaker,
As I recall you had a large transition zone tumor. These are difficult to operate on and invaribly leave some prostate tissue behind. You can image or rebiopsy the area before you get salvage RT to confirm if it is still local or is benign prostate tissue that was left.
JT

John T,

 

I don't ever ecall that terminology (large transition tuymor) being used.  My pathology report is summarrized in my signature.  Is it possible that this amount of PSA is coming from benign tissue?  How much PSA does benign tissue generate & is there anything else that can generate PSA other than benign or cancerous prostate tissue?

Posted 5/12/2010 9:08 PM (GMT 0)
Other organs produce psa, but not in measurable amounts. It's either PC or benign prostate cells. If it is benign psa will stabalize while pc will keep rising. The only way to tell early on is with scans like Color Doppler or MRIS and a biopsy of the suspected area.
When post surgery psa reaches .2 it is commonly called a reoccurrance and salvage radiation is recommended. There is evidence that salvage radiation works better at the .2 level than waiting for it to go higher. There is also evidence that three succesive rises on the ultrasensitive psa test indicate a reoccurrance much earlier than waiting until it hits .2. The earlier salvage radiation is given the higher the chances for a cure.
JohnT
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