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Persistent PSA after RALP

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Posted 3/20/2017 3:15 PM (GMT 0)
Hi all,

I've been lurking here for some time as my PCa treatment seemed to be progressing relatively normally, but I've hit a bit of a bump and I'm not sure how big a bump it is and need some thoughts.

As can be seen from my Signature, I was diagnosed with PCa in Dec 2016 following an elevated PSA of 4.3. I pushed things along and had a RALP in the first week of February 2017. Everything seemed ok following nerve sparing surgery. Pathology was negative margins, Gleason 7 (3+4) PT2 stage, PNI+, SVI- Prostate was 35g and there was a single lesion about 5% of the prostate near the apex. Some incontinence and ED but things seem to be improving.

I just had my 6-week PSA and it's 0.050 (test result is 3 decimal places). I think this puts me in the "PSA persistence" category as the current definition according to most of the recent studies that I've read is >= 0.03 The Urologist said its "not good" and to test in 2 weeks time to see if it comes down or there is some test error or variation. It's not a very high level of persistence, but some studies I've seen show significantly worse BCR prognosis compared to 0.03 and 0.04 six weeks post RP.

Was wondering if some of the more experienced folks can chime in about what they think and if there are any others who had 6-week ultrasensitive PSA tests come down over time.
Posted 3/20/2017 3:24 PM (GMT 0)
I'm no expert, but I waited three months before I got my first PSA. I know 6 weeks is common, but it also is too early to panic as it could definitely still be on its way down. All you can do is wait (the worst part imo) and see what future tests show. Good luck to you and let us know how you fare.

Tom
Posted 3/20/2017 4:25 PM (GMT 0)
Welcome to HW.

Six weeks is a bit soon. Retesting is prudent. Current studies are saying that if you get to .03 post RP you should start thinking about SRT, and by .05 you should be arranging for it.

Older standards of treatment said, start worrying at .1 and start SRT by .2.

In your case, I think a bit of watching and waiting are in order. In any case it's too soon after surgery to think about any follow up treatments.

See what the retest says and go from there.
Andrew
Posted 3/20/2017 6:29 PM (GMT 0)
Some studies consider the nadir psa post-surgery to be important. If it reaches undetectable at some point, that is a good sign. But the nadir doesn't have to be at six weeks. It can come later. So be patient. I hope for the best for you.
Posted 3/20/2017 7:02 PM (GMT 0)
My 7 week psa was .01 and 3 mos. later it went down.
Posted 3/20/2017 7:17 PM (GMT 0)
For guys with favorable pathology, you have to wait for a pattern to develop. One reading at 6 weeks is way too little to make an informed decision on.At 6 weeks, you can still have residual benign tissue this early. By 3 months, and with another test at 6 months, you'll have a better idea.

/pcnrv.blogspot.com/2016/08/low-detectable-psa-after-prostatectomy.html
Posted 3/20/2017 10:59 PM (GMT 0)
Thanks all. I do hope the uPSA declines at the next test in 2 weeks time. Will update.

Allen, the links in your blog were very useful. The Kang study is particularly worrisome that any uPSA reading above 0.03 post RP implied 98% BCR, but I do realize that the cohort was PT3/4 and/or +ve margins, while I have favorable pathology. But it's unclear whether her conclusions on >=0.03 would also apply to patients with favorable pathology.

The Veseley study was also interesting to me mainly because they tested uPSA at 14 days, 30 days, 60, 90 and 180 days after surgery. Again this was a higher risk group than me with +ve surgical margins, but had a mix of lower risk patients as well although about half had eventual BCR at 3-years. The 14 day BCR cutoff was not predictive but the rest were. Of interest were the 30 and 60 day cutoffs of .073 and .041 since I'm at 45 days with .050. It gave me some hope that the uPSA might fall between now and my retest, which will be 60 days.

Here's another study that uses uPSA <=0.05 as undetectable and has a 5-year follow up compared to the Veseley studies 3 years. Wonder what you think of it.

/www.ncbi.nlm.nih.gov/pmc/articles/PMC2930030/
Posted 3/20/2017 11:16 PM (GMT 0)

Weightloss said...
But it's unclear whether her conclusions on >=0.03 would also apply to patients with favorable pathology.

It's not at all unclear - it does NOT apply to those with favorable pathology. Nor does the Vesely study. For that you have to look at the Koulikov study.
Posted 3/21/2017 12:02 AM (GMT 0)
Don't worry too much if the best uPSA you can get only detects 0.05 or more. It's not much of a difference. The small margin and that it's only G3 at the margin are very favorable.
Posted 3/21/2017 2:10 AM (GMT 0)

Tall Allen said...
....At 6 weeks, you can still have residual benign tissue this early....

Could you perhaps elaborate on that, or provide a link on this specific issue? I am keen to understand:

1. Does the (possible) influence of benign tissue disappear / reduce after a period of time?
2. If such tissue is supplied by blood, why would its possible impact on PSA reduce or disappear?

Thank you,
<D
Posted 3/21/2017 6:08 AM (GMT 0)
Prostate tissue releases a lot of PSA when it is cut. Over time, pretty quickly, it heals and no longer releases much PSA. Over time, benign tissue is no longer a source of PSA.
Posted 3/21/2017 9:29 AM (GMT 0)
The mystery continues, albeit with a potentially good outcome. PSA persistence anxiety led me to test at another independent lab. Result: < 0.008 !! Put me over the moon. I went to a 3rd lab and only after they drew blood, they told me that they don't do uPSA only regular PSA. So I went to a sister hospital of the one that gave me a 0.050 reading, they use the same equipment, and I will find out tomorrow. Keeping my fingers crossed.
Posted 3/21/2017 10:53 AM (GMT 0)
Weightloss, great news. I guess it points out how "off" we are when we react to measurements this low.

Jack/Diane. I think some states allow you to test without subscriptions, you can walk in any time and ask for any test.
Unfortunately for me, NY isn't one of them
Posted 3/21/2017 10:58 AM (GMT 0)

Jack & Diane said...
Hooray!!! Wonderful news!! Fingers crossed for the same results with this test!! Please share the results when you receive them.

How are you able to go wherever you want and get all these tests? Is your doctor ordering them for you? (Also, thanks for your response to me TA)

I'm paying for them myself and presenting as a "walk in" patient. The independent labs here seem to have a nurse on duty drawing blood. For the hospital lab, they don't accept walk in patients, so I called my GP and he phoned in the request. The uPSA test isn't too expensive. about $60
Posted 3/21/2017 11:10 AM (GMT 0)
Jack & Diane- In my case I live pretty far from the surgeon who performed my RALP, so they emailed me a prescription for a uPSA. Took it to a LabCorp 5 minutes from my house. They test to three decimals by the way.
Posted 3/22/2017 1:52 AM (GMT 0)

Tall Allen said...
Prostate tissue releases a lot of PSA when it is cut. Over time, pretty quickly, it heals and no longer releases much PSA. Over time, benign tissue is no longer a source of PSA.

I understand and agree with the first two sentences. But why wouldn't blood-supplied ('alive' for want of a better word) benign tissue continue to be a source of very low amounts of PSA?

Further, I found this from a fairly recent article: "In some patients, residual prostatic tissue (for example, residual apical tissue post robotic prostatectomy) can lead to a measurable PSA after surgery; however, typically this low PSA remains stable over time."

You will understand my interest in this - see signature.

Thanks,
<D

www.ajmc.com/journals/supplement/2014/ace021_dec14_prostate_ce/ace021_dec14_prostatece_kolodziej
Posted 3/22/2017 6:49 AM (GMT 0)
Benign prostate tissue needs a prostate to thrive, so it will atrophy over time. Only damaged prostate tissue adds PSA to the serum. All I can tell you is that isn't the case in general. But "in general" may be different than your case. In any case, your PSA is too low to be of concern.
Posted 3/22/2017 1:22 PM (GMT 0)
Not so good news. The 3rd uPSA test that I had at a sister hospital of the 1st came back 0.054. The two hospitals use identical equipment. Grasping at straws, I went to a the largest teaching hospital here and had a 4th uPSA test. It came back < 0.01 In summary,

3/20 Hospital A: 0.050
3/21 Independent Lab B: < 0.008
3/22 Hospital C: (sister hospital of A): 0.054
3/22 Major Teaching Hospital D: < 0.01

In the end, I'm not sure if my body still generates detectable PSA. Certainly one brand of equipment detects some, but two other brands don't. I can't find any literature that compares the reliability of ultra sensitive PSA test assays when PSA is < 0.1

So what am I to do? I'm actually in Singapore and there is this large Government cancer research and treatment center called the "National Cancer Center" or NCCS, which is like the National Cancer Institute in the US. It's supposed to have the best of everything and the Wiki says it has the "largest concentration of internationally qualified oncologists", but you can't just walk in. Since I will probably have to see an oncologist should my PSA remain detectable, tomorrow, I will start a process of getting referred to an oncologist in the NCCS. I presume that they will give me a uPSA test and that there won't be any question over the veracity of the results there.

I can fully relate now to PSA anxiety and how damaging it can be to one's mental state.
Posted 3/22/2017 2:00 PM (GMT 0)
Are US patients unnecessarily frightened because of unnecessarily sensitive tests? Look here what the latest European PCa guidelines says. It is not so that more patients die from failed treatment in Europe than in US.
I could be ok to react it a little bit slower.

Guideline said...
Biochemical relapse after radical prostatectomy is defined as two consecutive rising PSA values ​​of 0.2 ng / ml. At high risk of local recurrence radiation therapy should be initiated on rising PSA in the range 0.1-0.2 mg / l. PSA values ​​≤ 0.09 mg / l is not infrequently the remaining benign prostate tissue. These values ​​should be listed as <0.1 ng / ml in the response from the laboratory, because the clinical benefit of knowing these low values ​​is insignificant and is not deemed to outweigh the concerns that it may cause to give different values ​​to the patient.

Posted 3/22/2017 2:12 PM (GMT 0)
That guideline certainly applies to me at this point.

To worry myself even further, the latest I could find on 5th gen PSA testing is referenced in this article, which goes to 0.00005

clinchem.aaccjnls.org/content/clinchem/57/12/1712.full.pdf

Seems to indicate, although from a small sample, that above a 0.01 nadir, there isn't much hope...
Posted 3/22/2017 5:10 PM (GMT 0)
As I said, you are testing too soon and much too frequently. Test at 3 months after your RP , and then again at 6 months. You are feeding your own anxiety by doing this. Breathe. Try to be in the present moment. Nothing is on fire.
Posted 3/22/2017 9:02 PM (GMT 0)
Brother, I can relate to your anxiety very well. But - hard as I found to do it - the advice you read above to give it a bit of time is very good. I am no shining example of the calm approach to PSA testing, but I have forced myself onto a two-monthly schedule, and after one more test, the plan is to go to three months.

Your results are curious though - I would consider ignoring those results from the two sister hospitals, pick ONE place based on quality / reputation (the independent lab B?) and stick with it. The key is repeatability and consistency, which allows you to see possible trends over time. You cannot get that from a mixed bag of labs.

So do give yourself a break and try to relax. There are some really good and very simple techniques. Google 'relaxation response' .

Ps. Your pathology is quite good - similar to mine, except I had a small margin.

<D
Posted 3/22/2017 10:16 PM (GMT 0)
Weightloss
you are tying yourself in knots and to no avail. As a 9 year post surgery fella with still undetectable PSA (<.01) I will say what you are doing has no advantage. Six weeks is somewhat early to test your PSA levels and I feel it is rather foolish of your doctor to say "that's not good" and want another test in two weeks.

Tall Allen has given you very good advice.
Test at 3 months and then 3 monthly intervals for at least the first year. If the results are consistent you can push the testing regularity out thereafter, perhaps three times a year during the second year and twice a year thereafter ------ this was my regime.

You cannot jump from lab to lab (having different equipment and different assay conditions) and use those results for a valid comparison. Stick with the teaching hospital results and use the <.01 reading as your base line. The important thing to do thereafter is use with their results only as a valid comparison of your PSA status. I don't think that 3 decimal place results are of any additional value----- rather too sensitive and any minor variations below .01 may cause you unnecessary anxiety.
You want to see a consistent <.01 test result hereafter to indicate that surgery was successful.
My story:
www.yananow.org/display_story.php?id=75
Best of luck with your future tests.
Bill
Posted 3/23/2017 5:40 PM (GMT 0)
Just to show the whole picture.My PSA after a Da Vince radical prostatectomy on 29 March 2014 range from 45 (forty-five 3 weeks post-op, down to 1.24 at 6 months post-op, up to 7.44. at. 9 months post-op, down to 3.9 then my latest 5.7. No sighn of cancer in dissected prostate, scans all clean.
No radiotherapy, no hormone therapy. Try to run 3 times a week 5 km fast.
Posted 3/23/2017 6:38 PM (GMT 0)
Merino-

Why did you make that decision? Are you elderly and have comorbidities?
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