When the ultra-sensitive PSA test might make sense

I have previously been an advocate for using the ultra-sensitive test, primarily for folks with aggressive PCa trying to determine if they should pursue adjuvant or salvage RT. I base my advocacy on the following article: "Adjuvant Radiotherapy After Prostatectomy: Does Waiting for a Detectable Prostate-Specific Antigen Level Make Sense?,"

www.redjournal.org/article/S0360-3016%2810%2903669-2/fulltext

I found the following statement relevant:

Article said...
Perhaps the most compelling argument is that there are simply no data that compare truly adjuvant RT (with PSA <0.01 ng/mL) vs. salvage RT at the first indication of a measurable PSA level. Interestingly, even though all patients in the ARO trial had pre-RT PSA strictly <0.1 ng/mL (compared with the higher threshold levels of 0.2 ng/mL for the EORTC trial [with 9% of their patients >0.2 ng/mL] and the SWOG trial [with 35% of their patients >0.2 ng/mL]), they achieved equivalent 5-year bNED rates within their 95% confidence intervals (72% vs. 74% vs. 77%, respectively). This supports the hypothesis that, within a narrow “window of opportunity,” successful postoperative RT will be equally accomplished whether PSA is undetectable or whether it is barely detectable. That window of opportunity might be a postoperative PSA level within the range of 0.05–0.1 ng/mL.

Now I realize that many will not find this article sufficiently compelling to overcome their objections to the ultra-sensitive PSA test, or to base a decision about RT. I, however, have found it useful in my own case, and offer it to those who might find it useful as well.

Nellie

My real concern, based on this article, was that waiting until my PSA rose even to the traditional .2 trigger for recurrence might compromise the effectiveness of RT, so I pulled the trigger very quickly - at .03.

[Edited to add:] And now I remember through the fog that the reason I didn't even wait for my PSA to go above .05 was because my oncologists felt I had recurred, and things looked shaky at work so I wanted to make sure I still had insurance.

Of course the article is in no way definitive. I just decided not to take a chance.

In your case, perhaps the ultra-sensitive test is superfluous, since you don't plan to act until your PSA is within the range of the standard test.

Best wishes,
Nellie

Post Edited (Riviere) : 10/5/2012 10:29:30 AM (GMT-6)

Because my uro does not do ultrasensitive, I really don't know what my first post-op PSA was, beyond being <.1. I pulled the trigger on ART based on the post-op pathology, not the PSA.

I did start ultra-sensitive with my GP after RT. Only one was <.01, just after ART finished. From there on out, it was rising. And  I didn't pull the trigger on HT until PSA hit 5.2.

Startech - I guess that would depend on the cost of the tests at your lab. I've discovered that my real cost for the two types of test is less than $10 difference. It is a little hard to sort out from the billings, but I did get one standalone a few weeks back, which cleared that up. Of course over 3 years, things change -

Hi HD,

Since you are Gleason 6, I'm not sure you would need to jump to RT like I did with Gleason 9. Such a low PSA could quite easily be from benign sources. Plus, it is rising so slowly (that's assuming that this isn't just a blip) that you have plenty of time to see if the PSA doesn't decide to go down again. You might even decide to switch to the regular PSA test, since Gleason 6 cancer tends to be indolent and not go metastatic, so you could wait to see if you really need RT.

I posted a link to this article mainly for folks like me who have aggressive cancer. In my case I felt delay could make a meaningful difference. If I were Gleason 6, I'd probably switch to the regular PSA test and not act until my doctor thought it wise.

Hope that helps.
Nellie

Logo,

My urologist feels that I should have been graded a pT3a because of the positive surgical margin (focal) and the extraprostatic extension.  Here is the text of the pathology report:

Diagnosis:
A. Prostate, radical prostatectomy (44 grams):
Bilateral well-differentiated prostatic adenocarcinoma, predominantly right lobe with a small amount in the left lobe; involving about 20% of the total gland; Gleason score 6/10 (3+3); showing perineural invasion , but no definite lymphovascular invasion; showing focal extraprostatic extension; showing wide involvement of the posterior surface of the right lobe; no evidence of seminal vesicle involvement.
B. Preprostatic tissue, excisional biopsy:
Adipose tissue with no evidence of tumor or lymph nodes.
C. Right pelvic lymph node, excisional biopsy:
One lymph node showing no evidence of mestastic tumor (0/1).
D. Left pelvic lymph node, excisional biopsy:
Two lymph nodes showing no evidence of mestastic tumor (0/2).

• Pathologic staging: pT2cpN0
• Specimen: Prostate and seminal vesicles (44 gm)
• Procedure: Radical prostatectomy and lymphadenectomy
• Prostate size: 3.2 x 3.5 x 3.0 cm
• Lymph node sampling: Bilateral pelvic nodes negative (R 0/1, L 0/2)
• Histologic Type: Adenocarcinoma
• Histologic Grade: Well differentiated
• Primary Pattern: 3
• Secondary Pattern: 3
• Teritary Pattern: N/A
• Total Gleason Score: 6
• Tumor Quantitation: Bilateral, approximately 20% of total gland
• Extraprostatic Extension: Focally present
• Seminal Vesicle Invasion: Not identified
• Margins: Right posterior surface, rest of margins clear
• Lymph-Vascular Invasion: No identified
• Comments: EPE is difficult to judge because tumor extends to the outer surface of the specimen. The right side of the prostate shows infiltrating small to medium sized glands, extending to the posterior surface of the right lobe and focally appearing to extend beyond the prostatic capsule. There is local slight involvement of the left side. Preprostatic tissue and lymph nodes are free of tumor.

I agree with you that RT is a lot like shooting a needle in a haystack; that's what scares me so most about it.  I was under the impression that Gleason 6 has a difficult time surviving outside of the prostate so I'm hoping that my two recent PSA tests of .03 are the result of benign prostate tissue left behind as both of my nerves were spared.

I guess there is really nothing I can do about it and just ride it out.  I know I should not be so hung up on this as there are folks that are far worse along than me, but it does weigh heavily on my mind.  I am a serious control freak and not being able to put a handle on this drives me crazy.

I feel your pain, controller was in my job title. A positive margin would indicate t3a, I believe, but they "can" be insignificant, as do walsh and Scardino. your report was hedging its bet on the epe. As a post op 6 you are as golden as it gets. Live your life, ride free and keep that head on a swivel. regards Logo