Gleason 8: PSA Trend = Recurrence?

There seems to be 2 discussions here. At what point does PSA signal BCR, and at what PSA level do we begin treatment?

I think many oncologists feel that a .05 or .06 is an alarm bell for reoccurrence. By the same token, many feel that waiting until. .2 or .5 is certainly acceptable. There seem to be enough studies indicating that the lower the PSA at commencement of PSA, the higher the success rate.

It is a very personal decision. I for one have decided to jump as soon as we have a good indication of BCR, ( which is .05), and confirmation of the oncologist. I have decided to pursue full pelvic radiation, to give me every chance of hitting the wandering cells.

But I would never recommend what I am doing to any one else. Somehow making my decision now, gives me some comfort and feeling like I am in control.

Goodlife

Hi All.

My PSA has risen to .10 after a stall at 07 for a few readings. At the last reading my rad/onc doc told me I could wait 4 to 6 months for my next reading (vs 2-3 mths). Luckily I checked at 4 months! Doc now says the rise is no big deal and that I can wait, but I've decided to start treatment after I take a 2 week vacation and retest to rule out lab error.

The doc says if the retest drops to .09 I could easily delay RT and says the rise is slow and likened the growth to gossiping women when a friend tells a secret and that one tells another, who tells another, etc., and that it could take forever for the cancer to grow to a meaningful amount. He was clear there's a good chance the cancer is still in the prostate bed and said it would be proven once the PSA starts to decline after starting RT. My wife questioned that statement saying she thought all PSA goes down initially since the bed probably has the most cells, but if some have escaped they will cause a PSA rise eventually. My wife insisted at that point the doc be clear as to whether I had recurrence, not just allude to it. He said absolutely, which was a crushing blow as I have been holding onto the notion it was benign tissue or now, a lab error. Of course that is what the last oncologist told me over 6 months ago and urged immediate radiation (not to wait for.10 for clinical trial of added therapies) based on my Gleason 8, pre-PSA of 30, and a hair from Tb3. I thought that doc was too eager to radiate; if you remember, his report stated I was in denial.

I noticed Piano mentioned how his cancer was contained and said the reason his doctors "think the cancer has escaped is the absolutely clear margins and organ confined". Piano also mentioned SRT/HT combo. First, I'd appreciate comments since his stats are close to mine and would like more info re his docs' concern about escaped cells because I've only seen that mentioned once on the boards. about the SRT/HT, my doctor doesn't believe in the combo saying it's never been proven clinically.

My wife is alarmed by what she says is the doc's laissez-faire attitude about the lack of urgency for treatment after confirming recurrence. She feels he is a pompous and reckless, but I like his positive attitude. She says I picked well for a denier. She may be right. I'm starting to rethink immediate treatment based on his comments. I see RT as one last nail in my penis so I'd like to avoid it if it's not needed.

It keeps asking for my radiation dose. I haven't had it yet. It won't complete the nomogram. How do I proceed?

Benz,
Did you ever have a PAP test? This test is the leading indicator of a primary treatment failure as it looks at the probability of a systemic and not a local reoccurrance. Salvage treatment will do nothing to cure a systemic reoccurrance unless radiation includes the pelvic region and not just the prostate bed. A psa of 30 combined with a high gleason has a much higher probability of being systemic and not local; your clear pathology is another indicator. You should discuss these issues with your doctor and see if there are other ways of determining local or system reoccurrance before proceeding with a treatment that may do more harm than good.

JohnT

I think that you have to be very careful with a G8. Everything I read groups G8 with 9&10 when looking at outcomes of treatment. However, even if it is producing little PSA, the very slow rise in PSA seems pretty encouraging. I seems that your doctor is considering that. Have you thought about a second opinion?

Age at diagnosis 64
PSA 30
RP (robotic) Jan 09
Gleason 8 (4+4) verified
Tumor 3.4 x 1.3 x 1.2 = 5.5 cm3
Tumor focally involves capsule – 0 extension
PT2cN0MX, Stage II
Neg seminal vesicle, lymph nodes and margins
Perineural invasion present
PSA: (3/09 - .04) (5/09 - .02) (9/09 - .<01) (1/10 - .01) (4/10 - .02) (9/10 - .03) (12/10 - .04) (3/11 - .05) (5/11 - .07) (7/11 - .07) (10/11. - 07) (2/12 - .10); (3/12 - .12)

Just received confirmation of previous test taken 3 weeks ago with PSA result of .10. I was hoping for a lab error or that my PSA would be lower or at at this point, stay the same. PSA results: .12.

I plan to meet with the radiologist Tuesday and start treatment next week. I hope it works.

I'll keep you posted.

Take a deep breath and don't rush into anything (IMO). My PSA remained undtectable after surgery for almost 18 months then .12 / .13 so we jumped on RT. Post RT the PSA was .13 and then a year after started doubling and tripling to 3.44 ... HT followed. So I ask myself, was the radiation necessary???  That is the only time in four years I have ever second guessed myself and my treatment.  Now I proceed cautiously and with greater knowledge. Good luck to you whatever your decision.

Skate

Post Edited (Skate) : 3/19/2012 2:33:11 PM (GMT-6)

Benz,

I had a post-op G of 4+5, multiple positive margins, multiple EPE. Lymph nodes and SV clear.

I went straight to adjuvant IGRT (i.e. decided before the first post-op PSA). My PSA was actually undetectable (<0.1, my uro does not do ultra-sensitive) until about 6 months after IGRT. When mine started up, it was .2, .4, .7, now 1.3. I'm now getting ready to make a decision to move on to whatever is next (Likely HT, but my uro is interested in some early chemo options that may come available before decision date).

I have no idea if my RT helped. It was indicated, and I could not find a doctor who advised against it (no, I didn't know about this forum, and no, could not go out of my insurance network due to costs, so Meyers et. al. were not available). It may be that it did nothing, or that I am getting worse more slowly than I would have had I not done it. I'll never know.

My RT journey is linked in my sig. ~20 months post RT I have fatigue, bowel issues, continued incontinence at 2 pads per day more or less, and ED (was not a nerve-sparing surgery).

Benz

Sorry to see your rise in PSA.

Your path report indicates that you had negative surgical margins. Did your RO explain to you his thoughts on where he would target the radiation? From what I have read, if the surgery resulted in nagative margins, then the cancer (if there is in fact any cancer) would most likely not be localised and thus the RO would not know where to target.

Here, the uros prefer not to break the numbers out to two decimal places so I can't track the rise below 0.1. However, once it hit that magic number I started getting mentally ready for SRT. Once I bumped above 0.1 the ways had been greased and it was just a matter of getting the insurance company to finish dotting i's and crossing t's.

Benz,

My apologies if I have offended you with my remarks. You are right of course, I am no doctor and you have 4 saying you have a recurrence.

Best of luck with your treatment.

Benz,
My circumstances were also similar. RP in January 2008, then recurrence June 2010 (detectable at 0.05). Waited 6 months, until it rose to 0.08, then opted for SRT. Fell to 0.05 2 weeks after end of SRT, then to <0.05 (lowest detectable amount at lab I test) and has stayed there so far, with most recent "zero" yesterday, one year after SRT. I do not think I have had a long term side effect, but you know Purgatory (in particular) and I think Compiler and some others did have problems; some major. Whatever you choose, I wish you the best.
Bill