uPSA or PSA

I had one uPSA done which came in <0.006 but the rest of my testing have been regular PSA. My URO prefers regular PSA based on my post op Path. Would you recommend I insist on uPSA.

Most URO sees no reason for further treatment until your PSA rise above 0.1 (and probably it will never do that). Why then measure lower values? With the ultra sensitive PSA test, normally fluctuations will occur. How will you deal with 0.01 at one test and three months later 0.04? You probably becomes anxious! Unnecessarily. With your pathology - avoid PSA stress and anxiety by continuing with the regular test.

Thanks ! But I’m still confused.

TA - you recommend uPSA. My EPE was positive in MRI but negative in the path report. Margins were clear.

NKinney and Gemlin recommend regular PSA.

ddss

It is always good to have choices. To have uPSA in your case might not be what your urologist would recommend- he has his reasons. However, if you want to have a better idea of what is going on, then get the uPSA. When and if there is an upward pattern which reaches .03, then you can make a decision to keep monitoring or take some action. Of course the velocity of the change must be considered as well. Both my urologist and RO had me on uPSA. So when the trend was moving higher and the reading was consistently between .03 and .06, they both suggested that I consider starting salvage radiation. I was eight years past surgery when SRT was started. I am now 35 months past completion of SRT. All of my readings since the end of SRT have been <.006. I still go every six months for uPSA. I will until I reach the five year mark, then annual test after that. RO said after second post SRT test, "I think you are done". I have been very blessed with good doctors and a great God for sure.

Your post-surgical pathology should be the primary determining factor.

Octorobo, you had +EPE in your post-surgical pathology. If you had asked, I would have recommended uPSA for monitoring for you, too.

142, your post-surgical pathology isn't listed here, but in the back of my head I seem to recall that you also had unfavorable post-surgical pathology...in which case I would also have recommended uPSA for monitoring for you.

It's just a tool. I'm certainly in favor of using the appropriate tool for the appropriate situation according to a sensible guideline. (I did, however, take a bit of issue with "insisting," and especially the notion of "demanding." I think, however, that "continuing the conversation" may be appropriate in some situations, even when it is counter-intuitive to the guidelines...I'm personally probably not smarter about medical issues than most doctors.)

Post Edited (NKinney) : 2/27/2018 11:21:16 AM (GMT-7)

It is certainly not true that the only patients who can benefit from a uPSA are those with adverse pathology. The Koulikov study (explained below) found that it is the pattern of PSA when above 0.03 ng/ml that is determinative, even in those with good pathology. Such patients had 'low detectable, unstable PSA" demonstrated by 2 subsequent increases in PSA and/or PSA velocity ≥ 0.05 ng/ml/yr. Those with good pathology were less likely to demonstrate such an unstable pattern, but if they did, most of them went on to progress further. Given what we know - that earlier SRT saves lives - this is important.

/pcnrv.blogspot.com/2016/08/low-detectable-psa-after-prostatectomy.html

How one deals with it is another thing. I have been chagrinned by a few posts on HW where patients reacted when those lines weren't crossed. There is a comfort to knowing the cancer is "undetectable" even if one has to use a less precise test to achieve that status. On the other hand, it is discomfiting to hear that one's PSA is detectable at all. So if a series of 0.01s and 0.02s are going to create anxiety and drive overtreatment, one may decide to forgo that possible early warning system.

Gemlin-

Your conclusion isn't supported by the data. Dr King's meta-analysis did not include studies that used uPSA. You can't extrapolate beyond the dataset. It is very likely that treating at low uPSA can make a huge difference in outcomes, while treating after it becomes detectable on a conventional PSA test confers only an incremental benefit. This is why adjuvant RT beats salvage RT in all major clinical trials, and the differences in outcomes are significant and meaningful. The goal, however, is to avoid the overtreatment that comes with adjuvant treatment. For that reason, Dr King (and most ROs in the US) advocates treatment at the lowest possible PSA of at least 0.03 for those with adverse pathology.

WeightLoss said...
The 5th generation assays can detect PSA down to 0.00005 ng/ml

]

Just what we all need. We'll all be posting in the Anxiety and Depression section if HW.

Pratoman said...

WeightLoss said...
The 5th generation assays can detect PSA down to 0.00005 ng/ml

]

Just what we all need. We'll all be posting in the Anxiety and Depression section if HW.

This is a great point. I agree with this sentiment:

There's likely a place for this in research, but I see virtually no use in the short/intermediate term in a clinical setting (in our doctor's offices), and I hope it is kept OUT.





This discussion helps illustrate another issue/question from an earlier post in this thread.

Tall Allen said...
For that reason, Dr King...advocates treatment at the lowest possible PSA of at least 0.03 for those with adverse pathology.

I know you cannot necessarily speak for Dr King, but maybe you are familiar with whether he's commented on this... If he "advocates treatment at 0.03 for those with adverse pathology", when does he advocate treatment for those who do NOT have adverse pathology?

Trick question? Maybe (to the keen eye). I would ideally hold this follow-up question until after that first question is answered, but in the interest of efficient use of bits and bytes, I would also go ahead and ask the likely-related-but-separate question: "So is he advocating the uPSA test in the clinical setting for ALL surgical PC patients?" The first comment quoted above seems to indicate that he is. I have an opinion on that (which aligns with most other clinicians, based on human factors + common sense principled in relevant facts)...there's a place in research for the uPSA and also for those with adverse/unfavorable post-surgery pathology, but it's not necessary/appropriate in the clinical setting for everyone (or even most) who had favorable pathology.

Post Edited (NKinney) : 2/28/2018 10:47:37 AM (GMT-7)

Thanks, but the information in that link/report appears incomplete to the question at-hand.

There should be one more line in the (blue) table: Pathological Gleason score <=7

(Allow me to go ahead and proactively answer the potential follow-up question: "yes, pathological findings of GS>7 (the "high-risk of recurrence" Gleason scores of 4+4, 4+5, 5+4 and 5+5) are indeed adverse/unfavorable, even in the absence of +SM, +EPE, others."

The paper's abstract doesn't address this, but you have access tot he full text. Does the author address the question at hand (evidence supporting uPSA for men with ZERO adverse post-surgical pathology)?

Actually, the blue table column major-heading in the blue table—to be relevant to the question at-hand—should be: "7-year recurrence-free survival," with the addition of the GS<=7 row added.

• uPSA in research setting (and all adverse surgical pathology findings) -- I'm ok with
  
• uPSA for most^# surgical cases with ZERO adverse pathological findings -- I'm not ok with, and the report does not appear to address

^# I could come up with a short list of exceptions...

Post Edited (NKinney) : 2/28/2018 12:09:34 PM (GMT-7)

Re-checked the table again...still looking for the data on the 5th (missing) row of data isolating outcomes for favorable post-surgical pathology which would support your "all pathology should use uPSA" statement...otherwise, unsupported.

Post Edited (NKinney) : 2/28/2018 3:14:05 PM (GMT-7)

uPSA for EVERYONE after RP, and salvage radiation then for EVERYONE who then surpasses 0.03 ng/mL...that’s wacko.

NKinney said...
and salvage radiation then for EVERYONE who then surpasses 0.03 ng/mL...that’s wacko.

What is whacko is that you think anyone said that.