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PSA increase 4 months after RP

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Posted 11/23/2017 1:34 PM (GMT 0)
I have an update. My father, who had Gleason 9 diagnosis and then a RP in May just had his first PSA test since his initial post op PSA check in July. It increased from .036 to .106, which, although small is the equivalent of more than doubling.

What are your thoughts for a plan of attack? Until this point he has been seeing his surgeon but I think the time has come to see one of the Big Dogs - maybe a specialist at John Hopkins?

And supposedly he cannot receive any treatment until the PSA increases to 5.0 when the location can be detectable. I would imagine that rule would apply to radiation but not hormone therapy?

Further, my dad and mother would like to proceed and plan trips as normally as possible but truly cannot anticipate when this might not be feasible. What are your thoughts for a timeline? We are basically all hoping for the best but bracing ourselves.

73 year old father has prostate cancer
3/17 Gleason 9 core biopsies
5/17 RP
6/17 pathology T2CN0, perineural invasion
7/17 PSA .036
10/17 PSA .106
Posted 11/23/2017 2:14 PM (GMT 0)
What am I missing? Why does he need to wait until PSA gets to 5? He's only had surgery, correct?
It's time to see a Radiation Oncologist. Conventional wisdom is .2 defines biochemical recurrence, but many of most Drs today will take action at around .1.

It's true that at these levels of PSA, scans will very likely detect nothing. But if you wait for it to go high enough to detect location, it will be too late for cure. That's the big conundrum with Salvage Radiation. You are flying blind, making an assumption that it's in the prostate bed.

Re hormone therapy, if he starts HT, it will prevent PSA from getting to .5, but won't cure him. so what's the point.

Get thee to an RO.
Good luck. He'll be fine. But while an RO will probably want one more rise in PSA to confirm the trend, it's pretty much time to act, especially with a G9
Posted 11/23/2017 3:15 PM (GMT 0)
I'd get to JH soon. You need a second opinion on that recommendation.

The only reason I can see for waiting till 5.0 is that the doc is assuming the PC is already metastatic and is only going to do palliative treatments.

If the PC is still confined to the prostate bed then a combo of SRT+HT might be curative.

It's worth getting another medical opinion.
Andrew
Posted 11/23/2017 3:36 PM (GMT 0)
From my limited experience this is the way I would view your father's situation.

If he is truly having a rise in his PSA ( another test or two will confirm the trend if there is one ) then one of two things happened when he had the RP. Either the surgeon missed some PCa she/he could have cut out or the PCa had spread beyond the areas the surgeon could cut out. IMHO that throws some serious doubt the surgeons direction so I certainly would not be basing future treatment decisions based upon his/her advice.

May all beings be well

Roger
Posted 11/23/2017 3:51 PM (GMT 0)
Thank you both! I was thinking that he should see a RI and visit JH ASAP but wanted to hear your advice also. Thankful for each day with him and thankful you all are here to support each other! God bless.
Posted 11/23/2017 5:40 PM (GMT 0)
The surgery failed. The urologists job is done unless there are urological issues. You need to consult with both a MO and RO to help you plan future treatment. The G-9 finding puts him at high risk so starting ADT right now followed up by salvage radiation (SRT) as soon as the RO feels he is ready for it would be standard treatment at this point....They may ad chemo at some point. Make no mistake, your Dad is in a fight for his life and his treatment will be as aggressive as he is willing to endure and can tolerate...But it's not hopeless..He can still beat this thing....Best of luck to you !
Posted 11/24/2017 4:04 AM (GMT 0)
That is a very big, sudden jump in PSA, indicating that his cancer is no longer indolent. He should be talking to an RO right away. The big guns are not at Johns Hopkins - they can probably do a decent job with salvage radiation, but that is not what they are known for. And salvage radiation is about 35-40 daily treatments, so you want a place nearby. If you give his city, someone may be able to suggest an appropriate doctor nearby.

There is absolutely no point, and quite a lot of risk, in waiting for the PSA to rise that much. The cancer is in his prostate bed - that's where it always goes first. So the best he can do is make the assumption that it has not yet spread to distant sites and that he can still be cured. the most curative option is salvage radiation with adjuvant ADT and treating the pelvic lymph nodes as well. Hopefully, that is all he will ever need.
Posted 11/24/2017 7:47 AM (GMT 0)
jmc...I'm going through the same situation right now. More PSA's are a waste of time at this point.

You need to get your dad to a local RO, experienced in prostate cancer immediately. He can beat this thing but immediate intervention is required. Salvage IMGT plus hormones, starting ASAP.

I've made the trip to JHMI serveral times, and as Tall Allen says, they are surgery experts, but not "top dog" radiologists, which is what your dad requires.

Best of luck and keep us posted.

Posted 11/24/2017 3:04 PM (GMT 0)
Time to move. My PSA increased from .10 to .13, radiation starts in 2 days. Hit it now, don’t wait. Once you know it’s increasing there is no need to wait.
Posted 11/24/2017 9:40 PM (GMT 0)
Was there any concern sbout not knowing where to focus radiation?
Posted 11/24/2017 9:43 PM (GMT 0)
So grateful for your responses! What is an MO? They live in Richmond, Va - any advice on who are the experts to call ASAP?
Posted 11/24/2017 11:02 PM (GMT 0)
At age 73 I would watch PSA for a year or longer and then consider ADT in the future and skip radiation therapy altogether. My 2 cents.
Posted 11/25/2017 3:04 AM (GMT 0)

jmc said...
Was there any concern about not knowing where to focus radiation?

Radiation isn't "focused" in one place. They radiate the entire prostate bad, and maybe the entire pelvic lymph node area too. They have to treat what they can't see as well as what they can see.

jmc said...
What is an MO?

MO=medical oncologist
RO=radiation oncologist

While it is still curable, an RO is the kind of doctor he needs. Sorry, I can't recall an RO in the richmond area.
Posted 11/25/2017 5:43 AM (GMT 0)
You might get some referral/treatment leads here:

/www.massey.vcu.edu/patient-care/therapies/radiation/

Charles
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