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Slowly Rising PSA 13 Years After Prostatectomy

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Posted 5/1/2014 1:46 AM (GMT 0)
I had a radical prostatectomy in 2001. My pre-surgery PSA was 11, my Gleason score was 7-8, and there was cancer in the seminal vesicles, but none in the margins or lymph nodes. I've had no post-op treatment of any kind. My post-op PSA went to less than .04, but has gradually crept up over the 13 years since my surgery and is now .31. The increase has been roughly linear. I was at .15 in 2008, and experienced a .03 decrease in 2011. I am not one to pursue aggressive measures to stomp out a condition that may or may not be indicative of a recurrence. And in fact, in a discussion with my urologist two years ago, I was told that based on the very slow progression of my PSA, I may just be harboring some residual condition that's not going anywhere, and that he could see no reason for further treatment unless I were to experience a sudden and significant PSA spike. I am 71 years old, in excellent physical condition, and have no other health issues. What would you recommend?
Posted 5/1/2014 1:51 AM (GMT 0)
I think you should stay the course. You have wonderful stats.
Bob
Posted 5/1/2014 2:41 AM (GMT 0)
Welcome to HW, this is a great place to ask questions like that.

In your place, I'd keep up the annual PSA tests and I'd check in with the Uro to see if he ever changes his opinion. If he does, then you've got a lot of options.

Of course you have to remember that I'm not a doctor, just some random guy on the internet.

Hang in there and keep us updated on your progress.
Andrew
Posted 5/1/2014 3:00 AM (GMT 0)
I agree with your doctor. Unless you suddenly get a huge spike in your PSA at some future date, I would stay the course, and maintain whatever quality of life you currently have.

David
Posted 5/1/2014 6:09 PM (GMT 0)
With your high risk disease (Gleason 8), I think you should at least discuss salvage radiation with a radiation oncologist. Treating it at the earliest possible time has much better outcomes. There is no source for PSA that high post-RP other than PC. One option is to have a multiparametric MRI with a very experienced radiologist to hunt for the site of the cancer.

You are fortunate to have had a lot of healing time since your surgery.

- Allen
Posted 5/1/2014 8:12 PM (GMT 0)
One of my clients had a similar situation to yours. His PSA started rising 16 years after his surgery. He is now 72. His doctors started him on intermitent hormone therapy.
Posted 5/1/2014 8:43 PM (GMT 0)
if you are experiencing BCR the window for optimal results with SRT is rapidly closing -- i.e., the disease could become systemic and could begin progessing at a more rapid pace.

that's the way I would look at it and I probably would already of had SRT because I do believe in stomping it out. at you age I'm not sure what I'd do.

ed
Posted 5/1/2014 8:51 PM (GMT 0)
Clinical trials typically require experience with HT. Most require HT failure except for a few exceptions. Intermittent HT might allow for other options, if needed.

I suppose you could consider Avodart and/or diet changes.
Don't think that I would choose salvage radiation after 13 years.
Posted 5/1/2014 9:15 PM (GMT 0)
With your Gleason 8 disease I'd at least talk to a Radiation and/or Medical Oncologist. If you are going to do radiation, the sooner the better. If you want to manage it with HT the timing is different.
Posted 5/1/2014 11:13 PM (GMT 0)
Hello Bill,

It is a tough call. I am very interested in the responses since I have a similar situation. Surgery in 2005 for gleason 3+4, psa 4. Positive margins, otherwise clear. At 3 years psa was <.03. Then at 5 years .05. Since then it has moved up slowly to 0.12. So now nearly 9 years out I am getting psa checks every 6 months. My uro has encouraged me to consult with an RO but meanwhile supports my "watch and see" approach. I am 66 and in otherwise great health. Like you, the thought of potential side effects from radiation are a real negative. My uro has even said that one option would be to let it go for now and hit it with hormone therapy when/if needed. If my psa takes a spike I will have to rethink things. I do think I will try to get a consultation with Dr. Scholtz or Lam since they are close by.

In an attempt to keep the beast at bay I wach my diet and supplement with many of the products that have shown some effectiveness, i.e. pomegranite, curcumin, vit D, green tea, etc. Could be a waste of $$ but I do believe it has helped to slow the progression.

No one can tell you what to do but, if it were me, I would try everything else to slow it down before getting zapped. Probably set a limit at 0.5 or so. Of course your expected life span is a big factor. Tough call. Good luck with whatever your decision.
Posted 5/2/2014 1:05 AM (GMT 0)
I have to believe that after this long some of those pesky G4 cells are far from the prostate bed and would not be touched by SRT. Problem is that with such a low PSA it is nearly impossible to determine where they are. Thus Hormone Therapy is the systemic clean up routine that attacks them wherever they may be. Not so sure I would go to SRT. Clearly get with a med-onc that specializes in PCa and can show you the work he has done with scores of men in your situation. You need a doctor that has dealt with your situation many times successfully.
Posted 5/2/2014 1:06 AM (GMT 0)
Jmon,
You wrote "Probably set a limit at 0.5 or so."

You should be aware that there may be a cost to waiting that long. After analyzing every study that looked at adjuvant RT vs waiting, Dr. King found that there is a loss in expected biochemical recurrence-free survival of 2.6% for every .1 increase in PSA. So if your odds of recurrence-free survival with SRT at a PSA of .2 is 64%, then waiting to get your SRT until your PSA climbs from .2 to .5, translates to an expected loss of 8% points to 56%.

The Timing of Salvage Radiotherapy After Radical Prostatectomy: A Systematic Review

- Allen
Posted 5/2/2014 2:19 AM (GMT 0)

Bill Moore said...
I had a radical prostatectomy in 2001. My pre-surgery PSA was 11, my Gleason score was 7-8, and there was cancer in the seminal vesicles, but none in the margins or lymph nodes. I've had no post-op treatment of any kind. My post-op PSA went to less than .04, but has gradually crept up over the 13 years since my surgery and is now .31. The increase has been roughly linear. I was at .15 in 2008, and experienced a .03 decrease in 2011. I am not one to pursue aggressive measures to stomp out a condition that may or may not be indicative of a recurrence. And in fact, in a discussion with my urologist two years ago, I was told that based on the very slow progression of my PSA, I may just be harboring some residual condition that's not going anywhere, and that he could see no reason for further treatment unless I were to experience a sudden and significant PSA spike. I am 71 years old, in excellent physical condition, and have no other health issues. What would you recommend?

Just cherry picking from your post, Bill,

"My post-op PSA went to less than .04, but has gradually crept up over the 13 years since my surgery and is now 0.31...I am 71 years old"

I am kind of surprised so many people are recommending something other than careful monitoring. At this PSADT Doubling time, it would take a long time for PSA to get high enough to be any concern.

At that rate in 13 years when you are 71+13=84, your PSA would be 0.31 + 0.27 = 0.58.

Even if it is considered multiplicative rather than additive 0.31*0.27/0.04 is only a PSA of 2.09 at age 84.

Tall Allen posted a tool the other day to calculate PSADT.

nomograms.mskcc.org/Prostate/PsaDoublingTime.aspx

The tool will generate different results depending on how many dates and PSA values you input.

Instead of doing the 12 year result, you can try just the past 2 or 3 PSA measurements and dates to see what it yields.

I am not a medical professional by any means, so do check with a uro and an onco.

Perhaps go to more frequent PSA measurements to see what if any trend develops.

LupronJim
Posted 5/2/2014 3:44 AM (GMT 0)
Bill,
Another Bill here. I don't have any suggestion to offer and am sorry that you are having "anxiety" after all these years. Your situation may affect many of us later in life. If it's been 2 years since discussing your slow rise with a uro, my only recommendation is to see an expert whoever that may be to see what your future holds; I would tend to follow JNF's advice.
I'm not a math major, but my understanding of this "crap" is that 70% of the men projected to die of PCa do so after the age of 75. I am an older man than you and would not be pleased to watch my psa continue to go up without doing something;
Maybe that's my personality, but I would hate to take a "wait & see" approach. I wish you the best. Sorry that I was no help.
Bill idea
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