After 6 years PSA shows small rise from .01 to .02 to.03

I have been reading this forum for six years and have decided to take the plunge as a poster. The impetus to do so is my first detectable PSA reading of .02 at 75 months (early December, 2014) and another of .03 at 77 months (this week). I have read so many studies my head is spinning and I am not sure I know much more than when I started. Since many of you seem to be able to take complicated concepts and simplify them I hoped you could keep me going down a logical path.

My oncologist (the same one who did the surgery) said he wasn't too worried about the results because I have been less than or equal to .01 for so long. He thought there was a strong chance the readings were just some healthy prostate tissue left behind that has grown and that the likelihood of a recurrence was less than 10%. Even if there was a recurrence he felt that it would likely be an indolent form of the cancer. The Sloan Kettering nomogram suggests about a 3%-9% chance of recurrence, depending what numbers I use for Gleason score and months before rising PSA. I'll be taking another PSA test in four months. He said the key to further decisions is what my PSADT is and that he may need a few more readings before making that determination.

So, here are my questions.
1. Is there any literature out there specifically on recurrence rates for people who show slight PSA elevations after this long a period after surgery?
2. Some of my prior readings were <.01, others =.01. Is there a difference? And if there is a difference, then have I actually been undetectable until recently or does a score of .01 say something other than undetectable? I've been using the same lab for every reading.
3. My post surgery Gleason grade was listed as 3+3 tertiary 4. What is the consensus these days - is my Gleason grade 3+4 or more of a 3+3 and a half?
4. I haven't been able to pin down what happens if the cancer can't be killed. Does everyone with a recurrence where radiation fails eventually metastasize if something else doesn't kill them first?
5. Besides calming down (which I have read as advice on here a lot and I know is good advice) what else should I be doing to get more informed about this?

Sorry for the length of the post. Thanks for reading. Any comments would be highly appreciated.

Doug, thanks for the welcome. I had surgery at the age of 59 and turn 66 in a few weeks. I am not sure I understand your comment about benign cells. I thought positive margins meant cancerous cells at the margins. Are you talking about the difference between Gleason 3 (which as I understand it cannot cause recurrence) and Gleason 4 cells?

Also, thanks for the advice on not jumping into anything. I intend to see what the next PSA test looks like before doing anything. My guess is that unless the test comes back with a big jump that's what the doctor will recommend. He said normally he wants to see a few PSA test before making any decisions.

Funny thing is for the last few years I haven't been nervous at all about upcoming PSA tests. And I wasn't for my annual test in December. After five years of clean PSA tests the odds were all on my side. Now I'm a little hyper even though I know it doesn't do any good to worry. One of the nice things about this site is that you can vent a little with people who share your situation.

Ah, OK, I understand. Again, thanks for responding. I'll be interested to see what comes next for both of us.

Bucky,
Thanks for coming out of the closet and into the light.
You'll notice my numbers look similar to yours And being a high risk guy I watch them like a hawk.
There is a difference between <0.01 and 0.01. The former means your PSA was below their level of detection which they have currently set at 0.01. The latter means they were able to get a reading. You number could actually be anywhere from 0.01 to 0.015. If you are a data freak and like to plot stuff call it 0.012. The most common current analyzer has a resolution of 0.003. eg, 0.003 0.006, 0.009, 0.012 etc. They round the result to the 2nd digit. Depending upon lab controls, they might consider their reliable minimum to be 0.01. If you had a 0.006 it would be reported as <0.01. The lab I use decided it was too difficult to maintain zero down at that point and now calls 0.02 their minimum. A 0.006 is called <0.02. Unfortunately a 0.018 would also be called <0.02.

My point is, something is happening. There are guys still using stone age labs that report diagnostic PSA results to one digit. The text books written 10-15 years ago (likely on papyrus) state that say anything below 0.1 is zero and treatment should be considered if PSA exceeds 0.2 for 2 consecutive readings.

We've come a long way. If you want to start making a chart to calculate your PSADT figure the first time you had a reading that didn't have a "<" sign and call it 0.012. Then start plotting your results.
As a high risk guy my threshold for action is 0.05, not two consecutive 0.2.

My answer about whether or not you need to do something about it depends upon your age and overall general health. If you are a 300+ pound, diabetic, 86 year old, your slightly rising PSA numbers are the least of your worries.
If you are an otherwise healthy 55 year old in good shape I'd jump on it so fast my prostate would spin.

If you fill out your profile we can give you better answers.
Good luck.

Jeff

Bucky, regarding your next PSA. Why, realistically, worry about it? It's only an indicator if anything might have to be done and I'm sure you've been (relunctaly) prepared for that for years. Focus on what your next step might be, if any. It's working for me at least.

Cheers, Doug

Shaba.Doug said...
Bucky, regarding your next PSA. Why, realistically, worry about it? It's only an indicator if anything might have to be done and I'm sure you've been (relunctaly) prepared for that for years. Focus on what your next step might be, if any. It's working for me at least.

Cheers, Doug

Hey Doug,

I know that is good advice. I think what is affecting me is that after five years with clean tests I pretty much felt I had this beat. Certainly the odds were with me. So even though the probability tables still look pretty good I am kind of going through the same stages of shock and worry that I went through after the initial prognosis, albeit at a lower level of anxiety.

Again, thanks for responding.

PSADT has not been validated for ultrasensitive PSA, so be careful about drawing any conclusions from that.

Logo, hear you, but I was quite clear knowing definitive answers would follow.

Cheers, Doug

Bucky,

<--- See my name?
A couple of points. Speaking from a purely mathematical basis you cannot calculate a doubling time using zero points. You need to calculate it using the points with actual values. If you call your first positive number from Nov 13 0.012 and average the test and retest from 12/14 0.02 and 1/15 0.03 = ~0.025 on 1/15 that gives yo a doubling time of a year, not 6 years.
Tall Allen brings up a good point to question the validity of using numbers that small to predict PSADT. Small variations are overblown. But, being an engineer I'd use it with caution and still look at it. If 6 months from now your PSA is tracking the curve (0.04 7/15 0.06 1/16) I'd be jumping on it.
The excellent paper referenced by Tall Alen above would put it firmly in the “Low detectable, unstable PSA” (54 patients)
PSA greater than 0.03 and less than 0.2 ng/ml
Two subsequent increases in PSA, and/or
PSA velocity of 0.05 ng/ml/yr or greater

With the result: "The 7-year recurrence-free survival rates for the three groups were found to be:
95 percent in the “undetectable PSA” group
94 percent in the “low detectable, stable PSA” group
37 percent in the “low detectable, unstable PSA” group"

That means 63% in the last group had biochemical recurrence.

"Fewer than a third of patients with a post-prostatectomy biochemical recurrence experienced systemic progression, and it takes a median of 8 years for distant metastatic progression, and 13 years for mortality to occur, according to a Johns Hopkins study (by Pound et al.)."

And that is why I'm called Worried Guy!

Jeff

Jeff, I should have mentioned I just read a study that suggests PSADT projections using ultrasensitive results grossly underestimates real PSADT a large percentage of the time. One more reason to get a few more results before pulling the trigger, I guess. But like a lot of the stuff we read, it's just one study and I am sure if I dig around long enough I'd bet I can find something that contradicts it.

I hear you, Doug. Sometimes I think the more studies I read the less I understand. Treating prostate cancer is a developing science, and so I guess large variations in results of individual research studies are to be expected.

Bucky,
the "low detectable unstable" group most likely consists of a wide variety of people some maybe at the low end above 0.03 but possibly many more at the high end just below 0.2. It is hard to tell how many of each without seeing the data. Also, there would be differences in Gleason and other factors. There is most likely a big difference among the outcomes of such men that does not show up in this rough summary. You are not even in this category yet.

Tom

Hey Tom, thanks for responding. The Koulikov study based its conclusions on PSA readings from the first three years after RP. Thus that study would always assign people with my history as part of the undetectable group no matter what their PSA readings were once the first three years after RP ended. I do think your point about the unstable group being a wide segment of men in different situations is true. As it was their sample for that group of more heterogeneous PSA scores lumped together was only 54.

Another interesting thing about that study is how low the overall BCR rate was. If I did the math right only about 60 of the 556 people experienced BCR within seven years. That's about 11%. Of course, the sample is skewed in that they excluded anyone with BCR within three years.