PSA rising after 6 years

Hi,
I had a prostate removal in nov 2009.
For the first 3 years all psa's where <.03 and done at the hospital.
I was then released to my GP and the subsequent reporting was <.1 as they didn't have the ultra sensitive test available until this summer.
The test in May came in at .041 so I was retested in July which was .03.
I was retested last week and the result is .09. and I presume this is recurrence?
What do I need to ask my GP?
I presume a referral to an oncologist and if so what questions do I ask the oncologist?

Thanks,
Mike

Hi Bob

Age 51 at diagnosis.
PSA 5.5 june 09 biopsy july 09 gleason 3+3 = 6 5% and 50% in 2 of 12 cores
robotic prostatectomy nov 7 prostate weight 45gm
path report gleason 3+4 = 7 (yukk)
clear margins.

Hi Mike

Yes, it looks like recurrence to me. Sorry! I had a similar path. I was also Gleason 3 + 4 and with a somewhat greater tumor burden than you report above. I was about seven years below or at 0.1 and then had a sudden rise to 0.4. I then had SRT which pushed my PSA back to undetectable (0.00) for another 5 years. I'm now seeing measurable PSA, but it has now remained steady at 0.05 for almost a year, so no need to to anything further yet.

So, based on my own experience, I say don't panic. You will probably need further treatment - most likely SRT, but that could have a high probability of long-term success. You will likely be sent for a consult with a radiation oncologist, but also get a consult with a medical oncologist. If you end up going for SRT you will need to ask and consider whether short-term hormone deprivation would also improve the likelihood of successful treatment. In my case I had Casodex for 3 months beginning just before and ending a few weeks after my SRT. This is unusual -- from what I read, most RO's prefer using Lupron and probably for a somewhat longer time.

Please keep us posted and best of luck.

Jim

Once a PSA relapse has been diagnosed, it is important to determine whether the recurrence has developed
at local or distant sites:
High risk is characterised by a PSA-DT < 3 months, seminal vesicle invasion,
Gleason score 8-10, time to PSA-recurrence < 3 years.
Low-risk is characterised by PSA-recurrence > 3 years , specimen Gleason score < 7, organ
confined disease and PSA-DT > 12 months.
As other have said, no panic. You are hopefully a low risk, likely to have a slow-growing local recurrence that will respond well to salvage RT.

Your Gp was following the guidelines of the predominant ,in the pcs community, definition, of recurrence and did not deserve it, Imo. Im sure you are aware of what that is{.2 with 3 consecutive rises} You have chosen to rely on a minority, but possibly true, definition of recurrence{ its all case by case}.. most likely gleaned, arguably, from this site.. This is of course, your prerogative. If you want to make a Gp for doing his job, and in his mind, save you from OT, the "bad guy"that is also your prerogative. I trust you will pay more attention to my words than to a disagreement of my interpretation of the data presented, Regards....

My timing is similar to yours. My PSA went from 0 to detectible in 6 years as well. I definitely think a retest is in order. Also, it could be stable and increasing at a slow rate of hopefully will go down after a retest. I know you are diligent and doing your homework so hang in there.

Mike

I commend you for paying attention, even at these low numbers of PSA. I am one that has made decisions based on newer standards of when to get treatment. I was seven and half years out from surgery. When PSA hit .03 my urologist started talking about SRT. When it hit .06 he said time to pull the trigger. Referred me to M D Anderson. RO agreed that it was time. I am now six months past SRT. My latest PSA was <.006. Everyone is excited- come back in six months.

This Thursday, I am going to the funeral of a good friend who did not pay attention and stayed with his original doctor as every step of his PC treatment failed. The out come might have been different had my friend sought the world class treatment available just forty minutes away! Choose wisely!

I had a retest done and the result came back as 0.08.
Any views on this?
Thanks,
Mike

Sadly, I think you need to start the conversation with the onco and maybe an RO. You may or may not need treatment now, but you should start looking at it.

Also a retest in a month or two might be prudent.

Andrew

Mike,
Older guidelines placed biochemical recurrence (BCR) after you have a PSA of 0.2 after primary treatment with prostatectomy. That was the guideline when I had my salvage radiation 5 years ago, and may still be the guideline recognized by many doctors. But the newer guidance from the National Comprehensive Cancer Network (NCCN) is to assume BCR at a lower PSA reading of >0.03 or increases twice in a row after PSA having fallen to near zero. See the link below to page 66 of the NCCN Guidelines for Cancer Patients PDF booklet. If any of your doctors still follow the 0.2 guideline I'd suggest asking them to discuss if they have considered the newer guidelines, and nonetheless believe the 0.2 guideline is still a better demarcation before considering further treatment. They may well have good reason based on experience or other published studies, or because they may weigh the risks of treatment against the risks of side-effects differently for different patients, based on each patient's particular medical history.

But based on the newer criteria your oncologist will probably recommend further treatment based on your current PSA readings of 0.08 and 0.09. The jump in 3 months may be less significant, because measurements at these low numbers may not indicate actual future doubling time. My own experience when I was tracking my PSA at these low levels before SRT was that I stayed below 0.04 for several years and then jumped to 0.1 and remained at 0.1 for another three years before suddenly jumping to 0.2 and then 0.4 within a few months.

Here's a link to the NCCN Guidelines document I mentioned above. See page 66 if the link doesn't take you there directly.

www.nccn.org/patients/guidelines/prostate/index.html#66

Jim

Fairwind you said "I would not consider radiation until they can positively locate any cancer"

How is that done with such a small psa number, some type of scan?

Thanks,
Mike