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Two and Half years since surgery rising PSA

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Posted 12/27/2016 1:48 PM (GMT 0)
Hi All,

Just learned about this site...I am being treated at the VA.
Diagnosed Jan 2014
4+3 PSA 4.5 age 68
Had Robotic March 2014
No leakage found after surgery....
Been non delectable until
Jan 2016 .026
May .086
MRI and Bone scan Clean
Now .132

Any input would be great....Going to the Urologist this Thursday.

Thanks
Steve
Posted 12/27/2016 2:24 PM (GMT 0)
It looks like the surgery failed as the cancer was probably already out of the area the surgeon could reach. Now it will need to be determined whether you use Salvage Radiation and/or Hormone Therapy to reach the cancer. In addition to the urologist you will need to be speaking with a radiation oncologist.
Posted 12/27/2016 3:09 PM (GMT 0)
I agree with JNF - it's time to see a Radiation Oncologist.

Bobby Mac
Posted 12/27/2016 3:11 PM (GMT 0)
Welcome to HW, sorry you need to be here.

Does look like you'll need more treatment. Standard of care now would be to see a radiation oncologist and get SRT (salvage radiation treatment). If the remaining PC is still in the prostate bed, then SRT can still be curable.

You should be getting a referral from urology to radiation oncology at your next appointment.

Do you also have medicare? If so you might want to get a second opinion from an RO outside the VA system.

Hang in there and keep us updated on your progress,
Andrew
Posted 12/27/2016 7:09 PM (GMT 0)
SteveO
I saw you post on the veterans' site and am glad to see you made it over here. You will see some differences of opinion here about when it is appropriate to start salvage radiation (SRT). When I had mine in 2010 the standard was to consider SRT if PSA climbed to 0.2 after surgery. Most studies at that time showed significantly better outcomes if treatment was begun before a PSA of 0.5 than if started later. Mine hit 0.4 very soon after hitting 0.2 so by the time I began SRT it was 0.44. More recent studies suggest starting even sooner than 0.2, with measurements as low as 0.03 being seen as a trigger point for consulting with an radiation oncologist (RO).

Some patients here agree and some disagree with these lower decision points for further treatment, as may also different doctors. That's one of the problems with this disease. When a bone is broken everyone knows the right thing to do. With a disease as varied as individual cases of prostate cancer (PCa) there is sometimes as much art as science in choosing what to do next.

One thing you may want to ask at your upcoming appointment is to what extent PSA momentum may affect a decision. PSA doubling times at these very low levels can be erratic. My experience was a very slow climb to 0.1 and then holding there for a couple of years. But then it jumped very quickly to .2 and .4 in a matter of only a few months.

I don't know how the VA docs look at this. As InTheShop suggested, an opinion from an RO outside the VA system could be a useful for the sake of comparison. But you may well find different opinions from different doctors both within and outside the VA system. I've used the "civilian" system for my PCa to-date, but use the VA for an annual check-up and vision and hearing tests and have so far been very happy with VA care to the extent I've used it.
Jim
Posted 12/27/2016 7:31 PM (GMT 0)
SteveO - What was your pathology report after surgery? Gleason, stage, margins, SVI, EPE, nodes ...?
Those facts together with PSA-DT will also be considered when deciding if/when to start Salvage RT. Early SRT provides good possibility of cure if local recurrence.
Posted 12/27/2016 7:40 PM (GMT 0)
Here is what I got from doctor notes...

PSA HISTORY:
5/20/16 - 0.086
1/13/16 - 0.064
6/23/15 - 0.023
4/27/15 - <0.1
10/30/14 - < 0.1

S/P robotic radical prostatectomy at Huntersville Medical Center by Dr
Rotch Vick for Gleason 4+3 , tertiary pattern 5, pT2cNxMx with negative
margins on 3/4/2014

I dont also understand what the doubling times mean....
Posted 12/27/2016 10:13 PM (GMT 0)
The PSA Doubling Time is the time in which the PSA has doubled. There is software on the internet to compute it. Yours appears to be doubling pretty quickly.
Good luck.

Post Edited (RobertC) : 12/27/2016 3:16:05 PM (GMT-7)

Posted 12/27/2016 11:01 PM (GMT 0)
see a radiation onc pronto. that's what i'd do. don't let the beast get away.

ed
Posted 12/28/2016 6:02 AM (GMT 0)
Steve - the standard of care use to be to start SRT when PSA hits .2 post RP. However, recent studies show that SRT at much lower PSA, .02, is much better. At this point, I'd be pushing for RT, possibly with some short term HT.

You that the VA often needs to get pushed into doing things. Push for the RO, soon.

Andrew
Posted 12/28/2016 6:09 AM (GMT 0)
You do have a gl9...are you aware of that...the gl4 and tertiary 5 add up to a gl9...this is the way it is classified now by "most" pathologists at this point in time
Posted 12/28/2016 6:12 AM (GMT 0)
in the shop uses a lot of poetic licsense in the shop...its what he does...fear not... he 's happy the bait was taken.. don't you tho..02 ridic-cluess...
Posted 12/28/2016 1:01 PM (GMT 0)
Steve - in this article by Tall Allen you find a nomogram that might be of interest for you.
Probability of remaining recurrence-free after salvage radiation
Posted 12/28/2016 1:39 PM (GMT 0)
I'm in the VA system but I went to MD Anderson for my PCa treatment. Like others have recommended, I would consult with a non-VA radiation oncologist for another opinion. One thing I've discovered with the VA is I have to be my own advocate and not rely solely on my primary care Doc.
Posted 12/28/2016 10:58 PM (GMT 0)
Bohemond, you mentioned a Veterans Site. Do you have a link to it?
Posted 12/28/2016 11:24 PM (GMT 0)
Hey Steve-

Looks like your on the same path I've been on. The tertiary patter 5 is more important than it seems. Bolo is right. I was a 3+4=7 after surgery, T3b, but my PSA came back less than 8 mo after surgery. Go get a radiation oncology consult as soon as ya can. Bone Scan and Contrast CT to check for spread. You can discuss the merits of Hormone Therapy in addition to the Radiation. I did both. Unfortunately for me, mine came back for a third round only 6mo later, so on to long term HT and chemo for me starting next month.

Lot's of good folks here with an amazing amount of knowledge and compassion.

Keep us informed on how you are doing!
Wyo
Posted 12/29/2016 12:53 AM (GMT 0)

bdbbauden said...
Bohemond, you mentioned a Veterans Site. Do you have a link to it?


Here's the site. It's Veterans' Benefits Network, which as named has threads that discuss the intricacies of applying for and managing veterans' benefits.

Are you Vietnam or other vet with Agent Orange exposure? If so you need to apply ASAP because any disability benefits begin to accrue only from the the date of your application.
vets.yuku.com/
Jim
Posted 12/29/2016 6:41 PM (GMT 0)
Jim,

I'm a Vietnam vet. I applied to the VA back in June. Have gotten nothing but the bureaucratic run around for the past six months.

Bruce
Posted 12/29/2016 7:14 PM (GMT 0)
Jim,
Sorry to hear that.....Most important have a good VSO and don't give up.

Just got back from the doctor and he said lets watch and wait another 4 months...

I am going to get a second opinion Jan 25th, so I will update you all then. Thanks for all the input .......Happy New Year and Blessings to you all

Steve Age 71
diagnosed Jan 2014 PSA 4.5
4+3 = 7
robotic March 2014
2016 Jan. .026
May. .086
June had MRI and Bone scan.......Was clean......
Dec .132
Posted 12/29/2016 9:01 PM (GMT 0)
SteveO
Four months seems like too long a wait to me, given the amount of increase you've had over the past year and the newer guidance that suggest earlier treatment than used to be recommended.

Bruce,

bdbbauden said...

I'm a Vietnam vet. I applied to the VA back in June. Have gotten nothing but the bureaucratic run around for the past six months.

Do you have access to the VA's eBenefits site? If you have an account you can track the status of your claim.

My initial claim took a year or so. I filed and then got a request from the VA for further information about time in-country (I was boots on ground for a year, but Navy), then nothing heard for another 4 or 5 months, then a C&P exam, then another long wait. Eventually I got a decision letter and back-payments to my filing date. More recently,I filed in October for reclassification to 100% due to return of active PCa. I submitted the VA's DBQ form signed by my uro with the all the requested medical details and affirming my PCa is active. But nonetheless they called me in for a C&P with one of their docs -- who confirmed what my own doc had already told them. My claim has now returned to wait its turn in the pile. My eBenefits account tells me the VA has completed "gathering of evidence" and status is now "recommended for decision" but even so they show an estimated completion date of sometime between Jan 30 and March 20. The wheels turn slowly.
Jim
Posted 12/29/2016 11:43 PM (GMT 0)
Jim,

I have jumped through all the appropriate hoops, furnished information, seen the VA doctor, sent more information. Got a letter last week requesting information they already have.

I'm sorry about your active PCa. Best wishes to you on your treatment and your reclassification with the VA.

Bruce
Posted 12/30/2016 10:32 PM (GMT 0)
SteveO,
Your case is a classic example of the benefit of ultrasensitive testing. Many here oppose it, preferring the one decimal place result, but ultrasensitive can give up to an 18 month advance warning re. what is going on.
For example, your first two PSA results (standard test) post surgery (Oct '14, Apr '15) were <0.1 (less than 0.1) which is a good result with the standard test and what you want to see.
Your next three results were done at the ultrasensive level,
(6/23/15 - 0.023) (1/13/16 - 0.064) (5/20/16 - 0.086) which, had they been reported using the standard result, would also have been <0 .1, falsely indicating all was still going well.
But the ultrasensitive results indicate a steadily rising PSA from at least June 2015 through to May 2016 and this is confirmed by your latest reading (of 0.132 in Dec 2016)

PSA doubling time is a proxy for the speed of tumour growth. As the cells divide they double in number and therefore double in PSA ouitput. Slow doubling time is what you want to see for it means the tumour is growing relatively slowly.
Your doubling time seems to be about 8-9 months which is fairly slow. At that rate your PSA should hit the probable additional therapy trigger figure of 0.2 about May 2017. (which may be what your doctor is looking at)

Here is a doubling time calculator:
www.doubling-time.com/compute-PSA-doubling-time.php

And here is some interesting reading:
/www.pcf.org/c/radiation-therapy-following-prostatectomy/
Posted 12/31/2016 1:04 AM (GMT 0)
So crazy question. At what point after surgery with your PSA rising and if you didn't get treatment the cancer metastasis. according to the calculator says my PSA would be at around 0.3 middle of 2018?

June 2015 0.023
Jan 2016 0.064
May 0.086
Dec 0.132

The surgery was robotic and performed outside of the VA. Good doctor, but after 1 year I went back to the VA for follow up, and this is the blood test results from the VA. The three I had from my outside doctor were <0.1 all the time.

I am going back to my outside doctor for a second opinion.
Thanks,
Steve
Posted 12/31/2016 2:01 AM (GMT 0)
I don't think there is any particular point or PSA level at which the tumour will magically metastize. Theoretically it could do so at any time. However common sense dictates that the risk of a tumour spreading distantly (lymph nodes, bone etc) increases with time. I believe one of the points the link I posted was making was that earlier intervention has been shown to increase the success rate of any additional therapies, especially with the lower Gleason grades. However nothing is set in stone.
I think that "TallAllen" has posted a few studies on the benefit of earlier intervention.
Posted 12/31/2016 3:39 PM (GMT 0)
Steve
I'm linking an article below that gives a broad overview of the treatment options and controversies relating to what is considered biochemical recurrence (BCR) and when or how to treat it. This is not a medical study, but as a review it is written pretty much in layman's English and discusses the results of various medical studies. Please note that this article was published in 2012 and many of the published medical papers it cites are older still. Not discussed here are some more recent studies that suggest earlier salvage treatment than proposed in the article I've linked here. That said, this article is worth reading because it offers a lucid discussion of the kinds of issues patients and doctors need to consider when deciding when or if to begin further treatment after PSA begins to rise after having surgery or radiation as initial treatment.
Jim
www.hematologyandoncology.net/files/2013/02/ho1112_bruce1.pdf
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