First psa test post surgery: 0.05. Still anxious!

I posted last week about my husband who is a G9, just had RP in mid December. We had our first follow up with surgeon at MSK on Wednesday. We were happy to learn that is psa is undetectable. Dr. said that we will continue to monitor psa and next visit is in June, putting us at the six month mark. I thought that my husband would have additional treatment right away given his Gleason score but doctor said they do not want to overtreat. I know we are at one of the best cancer centers but I can't help after reading so much on the internet that maybe we should be doing more...but what, since he is undetectable at the moment? Pathology did show one lymph node positive and dr. mentioned it was not in the usual place, it was in the peri prostatic fat.
I will be emailing him to ask about two things regarding lymph node: what is the significance of the fact that there was no extranodal extension (meaning cancer did not pop out of node), as I have
read in Peter Scardino's cancer book that this is more favorable (without explanation of why). Also, I have read in same book and on internet that's men with just one lymph node involved have a more favorable outcome.

Of course we all want the best outcome and my husband choose RP with the hope of avoiding ht for as long as possible. Is it standard procedure to just wait for psa to rise at this point? ..I don't mean to be questioning surgeon--we have great faith in him and he is among the best at one of the best hospitals. I'm just like most other people who's loved one was diagnosed with a despicable disease - I just can't seem to stop reading in the hope that something else may help!

Your thread title says PSA "0.05"; your text "undetectable" - maybe clarify that?

With G9, ECE and node positive maybe time to leave urologist for RO & MO team?

I am so with you on postponing HT as long as possible - doubled by how young he is!

Best to you -
Wilderness.

It is early and the low PSA looks encouraging at this point. I am concerned by the number of positive cores and G 9, but it looks like a favorable surgical pathology. Just in case, I would be interviewing radiation oncologists and identifying medical oncologists that are very experienced and successful treating high risk PCa such as this. Do the research and consultations before you actually need to be making decisions and you will significantly reduce the stress of the situation. I would also be testing PSA every 3 months for now.

It has often been said that the low risk PCa is usually over-treated and the high risk PCa is usually under-treated. You are looking for treatment appropriate with the risk level and evidence based practice standards. I don't remember seeing a G9 on this board that didn't have some period of ADT as part of the initial treatment. Best to join the G9 thread and get some of their experiences. Some PCa specialists treat by responding to changes, others take a more aggressive approach and treat anticipating what the cancer is likely to do trying to get ahead of it. You have to get some different opinions and see what fits your situation the best. I think it would be very difficult to over-treat a G9 with 11/12 cores positive. But, if you can avoid ADT or SRT for a long time it could be good for you.

Revisit the nomograms and seek some more opinions so that you are very well informed and understand the treatment path with confidence.

A slight correction for Gemlin is that some men with high grade PCa show very low levels of PSA making it unreliable for determining whether the cancer is gaining. PSA is very good, but not perfect.

Dr. Eastham at MSK also performed my surgery and my post-op pathology also indicated G9(4+5). My PSA has remained undetectable for 3 years and Dr. Eastham also advised me against overtreatment. I get my PSA checked 3 times a year; twice a year at MSK and once for my annual physical with my GP. After studying this forum since my surgery, I've considered ADT but have decided to follow my doctor's advice.

JNF's reply to this thread is making me reconsider my decision.

Walt

Remember Walt, I am not a doc just giving my opinion. You are doing well so far and that is great. Always strive to improve your knowledge to know your options and keep in close touch with your doctors.

To me it would be interesting to estimate the tumor load for schoolpsych, Walt, and InThisTogether. Based on the PSA one would surmise that Walt may have had a significantly greater tumor load then the others. PSA can be used to estimate the load as we know generally how each G grade affects it.

Though each is a G9, Walt's significantly higher PSA should be taken into account and may have indicated a higher probability of cancer escape which would indicate the use of ADT. That was a strong reason for me using ADT based on the nomograms showing a nearly 100% probability of escape mainly due to the high PSA.

Just shows that each case is individual and needs to be treated as such.

JNF, looks like Walt's highest PSA was 4.8 and mine was 47. Maybe you meant me instead of Walt when talking about higher PSA? Yes, I think that is an interesting point too. My PSA was much higher than the single-digit PSAs of the guys here where ADT was not suggested so that very well could be the difference.

Sorry I mixed the two up. Thanks for the correction.

Dr. Strum published the general ranges several years ago. Basically G6 give off the most PSA for the volume and G10 gives off the least. He Used an average scale that went 4,3,2,1, and.5 for G6 through G10. A benign prostate gives off .066 per cc of volume.

For example a man with a 30cc prostate should give a PSA of about 1.98. Let's say he had a PSA of 5 and was G7. This would mean the PSA from cancer is 3 and using the scale would indicate about 1cc in volume. Maybe the size of a pea. If it were a G9 it would result in about 3cc of volume, three times the tumor load. My docs estimated about 19cc based on the PSA, G of each core and involvement of each core. They backed off this a bit as my white blood count was high and could indicate some prostatitis. In any event the PSA indicated a significant tumor load.

Tall Allen:
The surgeon removed seven lymph nodes; three on each side of pelvis. The 7th was found in the peri prostatic fatty tissue. Per the pathology report: "size of the lymph node involved by tumor: 0.4cm
Size of the largest metastatic focus: 0.02 cm. Extranodal extension not identified."

After reading the link you provided I am not sure why the surgeon said that they don't like to overtreat. We will be reaching out to him this week the more questions.

Can't seem to open the link!