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0.07 to 0.21 in less than 3 months

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Posted 5/5/2014 2:22 PM (GMT 0)

We just got my husbands last PSA score in the mail Friday and it said 0.21.  It was 0.07 on 2/14.  We're scheduled to meet with an RO late this week to discuss adjuvant RT.  But I was shocked to see that last PSA.  I thought it would come back something like 0.05 or maybe even 0.09.  He's been on ADT since dx in Sept.  What does this PSA say about the ADT?  Should we be concerned about hormone refractory already?  Am I overreacting?  I realize RT is supposed to "mop-up" the positive margins and zap the bone mets and should knock the PSA back down.  But I'm confused as to what's happening with the ADT.  Is it working like it's supposed to or is it starting to fail?  Any insight would be very helpful.  I don't think I'm thinking very clearly about this right now because I'm a little scared. 

Thanks for the great support and insight this community provides.  It's truly a blessing to have such wonderful people that will share their experiences to help others. 

Posted 5/5/2014 3:06 PM (GMT 0)
Have you found a medical oncologist yet? A while back you were wondering about the switch from Firmagon to Eligard. That transition has come up in another thread since then and the consensus seems to be that we are all confused about what the expect. Have they been monitoring his testosterone during the transition? Firmagon and Eligard do the same things by opposite means. Firmagon is a GnRH antagonist. It blocks the pituitary from excreting the hormone that causes the testes to produce testosterone, thus causing testosterone levels to drop to castrate levels. Eligard is a GnRH agonist. It tells the pituitary to excrete lots and lots of the hormone and, after a few weeks the pituitary stops listening and stops producing the hormone and the testosterone level also goes to castrate levels and stays there. But during those couple of weeks the testosterone levels go up and sometimes this can cause problems. This initial rise in testosterone is called a flare.

It might be that your husband had a small flare that raised his T levels briefly above castrate levels and made his PSA go in the wrong direction for a few weeks. I dunno. I'll start another thread for that question so the smart guys can offer an opinion.
Posted 5/5/2014 6:20 PM (GMT 0)
my apologies, I thought I checked the box to include the signature.  Let me try again to include it. 

I only have the testosterone level from the last two PSA tests.  13 and 11 respectively.  We have not met with a Medical Oncologist yet.  I've been talking to people in the medical field and friends to find out the best MO in our community. I haven't been able to find anyone that specifically specializes in pca.  I was hoping to find one within a 3 to 5 hour driving distance. But no luck.  Maybe I'm not searching the right way and maybe we should just schedule an appointment with a general MO and go from there. 

The blood test which resulted in the 0.21 was taken the same day he received the second Eligard injection.  Now that I think about it . . . he may have received the shot and then walked straight over to have his blood drawn.  shouldn't the blood have been drawn first, or does it matter? 

Posted 5/5/2014 7:00 PM (GMT 0)
There are only a handful of MOs in the country that specialize in prostate cancer. Mine is moving to a new practice later this year where he will concentrate on PCa but he has been a general MO for over twenty years and I have been sharing him with lots of ladies in hats.

It is good that you have been looking for a rock star MO in your area but don't let "the best be the enemy of the good". Go ahead and get him hooked up with a well-regarded local medical oncologist then keep looking for a world-class expert for an occasional second opinion.
Posted 5/5/2014 7:27 PM (GMT 0)
604:

Where are you located. Maybe we can make some suggestions. Yes, if possible it would be good to get one of those experts specializing in PC.

Mel
Posted 5/5/2014 7:28 PM (GMT 0)
PeterDisAbelard - will do.  Thanks for the advise.  

Also, when we asked my husbands uro about switching from firmagon to eligard he indicated the Firmagon was a short term treatment that would help reduce the flare when treatment was switched to the GnRH agonist treatment.  I did some research and found a couple articles and (as much as I could understand it) felt comfortable that our uro new what he was doing. The following link is the only one article I bookmarked and I can't find the others now.

http://www.onclive.com/publications/urologists-in-cancer-care/2013/December-2013/Study-Degarelix-Before-Leuprolide-Can-Eliminate-Testosterone-Surge

So if this article is true I'm still concerned about the rise in PSA.  The testosterone level was in a good range after the first eligard and has dropped even more.  So that shows no evidence of flare. 

When HT starts to fail PSA rises, correct?  Does the testosterone level rise too?

Posted 5/5/2014 7:30 PM (GMT 0)
compiler-

We're in MO.
Posted 5/5/2014 7:32 PM (GMT 0)
Are you able to travel out of State?

Mel
Posted 5/5/2014 7:38 PM (GMT 0)
yes, we are able.
Posted 5/5/2014 7:48 PM (GMT 0)
6040poly,

The PSA rise above .2 would have to be confirmed before it is officially deemed castration-resistant. You will have to weigh the risks against the potential for benefits from blind salvage RT, although advanced imaging (e.g., C11 Acetate PET after PSA reaches 2) may reveal specific areas to target. However, given that there were mets in the lymph nodes, bones, seminal vesicles and margins, the odds are not great that that would be effective, and it is expensive.

However, if the cancer is castrate-resistant, there are lots of options to be discussed with his oncologist: second-line hormonal therapies (Zytiga & Xtandi), immunotherapy (Provenge), chemotherapy (Taxotere), and radiotherapy (Xofigo). There are also many combinations of these kinds of therapies and experimental therapies available via clinical trials.

- Allen
Posted 5/5/2014 7:53 PM (GMT 0)
6040poly,

Thanks, that's exactly the information I couldn't find.

Actually, they did see a flare but dismissed it as "clinically" insignificant in all but four patients. Those patients were briefly bumped out of castrate levels of T but returned to castrate levels within a week. My question is whether that one-week vacation for those four guys would be enough to show as a blip on the gradual suppression of PSA. What they were worrying about is gross symptomatic impact (pain, etc.) which sometimes (seldom) happen with a full-flown T flare in men just starting out on Lupron. Clearly that didn't happen, which is good, but it doesn't speak to my question about causing a bump in the PSA scores.

Since the flare only lasts a few days any flare your husband might have seen would be long over before his next bloodwork.

The study said...
Upon the transition from degarelix to leuprolide at day 90, there was a rise in testosterone from the lowest point of 16.5 ng/dl to a peak of 25.8 ng/dl recorded on day 93 (P = .0005), the researchers reported. Four patients (8.9%) experienced a clinically significant surge with a mean peak serum testosterone of 80.7 ng/dl; all four returned to castration levels within 7 days.

Posted 5/5/2014 8:07 PM (GMT 0)
604:

Dr. Lam and Dr. Scholz are among the very best and I've been pleased with them. They practice together in Marina del Rey, Ca.
They do telephone consultations. That might be a way to go. You can call their office (Prostate Oncology Specialists -- do a google search and look at their web-site).

Another good one is Dr. Maha Hussain at U. of Mich in Ann Arbor.

Dr. Myers is another top doctor. I forget where he is located. Maybe someone could post that information.

HOWEVER, nothing has been confirmed. This could be a blip. So, it would be worth researching these doctors, but wait until the next PSA before doing anything.

Mel
Posted 5/5/2014 10:11 PM (GMT 0)
Not a patient of his, but Dr Charles "Snuffy" Myers is in VA, close to Chalottesville and UVA.
Posted 5/6/2014 2:40 AM (GMT 0)
I vote for a retest. I'd want the number confirmed before doing RT. Not saying you don't need it but best to be sure before sitting in front of a radiation machine.

Let us know what the RO says.
Andrew
Posted 5/6/2014 9:45 PM (GMT 0)
6040poly,

If a re-test confirms PSA of .21 or higher, here's a suggestion:

Sorry to hear of the situation.

Google "Memorial sloan kettering prostate cancer nomogram"

find the nomogram that deals with outcomes for salvage radiation after RP

fill in your husbands numbers

that will tell the probability of remission in six years. And that will help you decide whether radiation is worth doing.
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