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PSA going up 15 years after RP

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Posted 4/21/2019 11:25 PM (GMT 0)
I have RP 15 years ago. Now I am 70 years old
I see my PSA go up.
Any advise.

Age 70 as of 2019

G Score 4, RP - radical prostatectomy Dec. 2003
PSA- 2017-06-08 0.66
PSA- 2017-12-12 0.80
PSA- 2018-05-08 1.09
PSA- 2018-09-24 0.98
PSA- 2018-11-13 1.02
PSA- 2018-04-17 1.12
Posted 4/22/2019 12:00 AM (GMT 0)
Looks like its been a relatively slow rise but you might want to see a doctor about it.
Posted 4/22/2019 2:45 AM (GMT 0)
Thankfully you are being monitored. These do happen. One of my clients was PSA undetectable for 16 years after surgery and then his PSA went up. He started on ADT. What is your doctor telling you? My advice is to get with a very good medical oncologist that does a lot of prostate cancer work. Likely it is too late for SRT. It is a little early for any scans to show where the cancer may be. This is the PCa twighlight zone.
Posted 4/22/2019 2:59 AM (GMT 0)
Welcome, Data0011.

I agree with Almost a 10, but probably you're already seeing a doctor, given that you've been undergoing frequent PSA testing the past two years. If so, what kind (uro? PCP? oncologist?), and what advice has the doctor been giving you?

The American Urological Association defines post-surgery biochemical recurrence (BCR) as a PSA > 0.2 ng/mL followed by a subsequent confirmatory PSA at that level. You clearly meet that criterion. Was your PSA stable around 0.6 for years and only started rising in 2017? Perhaps there's a good reason, given your full medical history, that you've been monitoring with no further treatment since surgery. These sorts of missing details make it hard for forum members, who are not doctors, to advise anything other than to see an oncologist who specializes in prostate cancer.
Posted 4/22/2019 11:26 AM (GMT 0)
I'm thinking the last PSA in your sig is April 2019 (not 2018).

That's a very slow rate of change so far. I suggest caution about over-treatment. Maybe find a conservative MO (if you don't have one). I think there's a parallel here to AS for low level biopsy patients. Had you been treated with primary radiation, those numbers wouldn't be considered significant.

Best to you -
Wilderness
Posted 4/22/2019 1:09 PM (GMT 0)
Data - It seems some additional info would help like others have said and to also visit with your doctor about this to get the proper referrals if necessary. Do you have a PSA history other than what you provided in your signature? I would assume you have been doing PSA’s for 15 years but could understand if you stopped at 10 years. I also assume that your PSA was undetectable in the years after surgery so that was your starting point? Just trying to understand your situation since the first PSA result you posted was 0.66.
Posted 4/22/2019 1:40 PM (GMT 0)
Agreeing with previous comments. Although already far beyond any definition of biochemical recurrence, your psa has a doubling time of about 2 years. It means that, with the current exponential increase, it would take 10 or more years to reach a dangerous level. But this rate may change. ADT at some point can give you more extra time or maybe it would be overtreating. Just consult a MO (or a couple of them). I assume you would not mind to be 90 or more and I hope you can. Also consider that new better treatments may be around in a not so far away future.
Posted 4/22/2019 2:58 PM (GMT 0)

jmadrid said...
Agreeing with previous comments. Although already far beyond any definition of biochemical recurrence, your psa has a doubling time of about 2 years. It means that, with the current exponential increase, it would take 10 or more years to reach a dangerous level. But this rate may change. ADT at some point can give you more extra time or maybe it would be overtreating. Just consult a MO (or a couple of them). I assume you would not mind to be 90 or more and I hope you can. Also consider that new better treatments may be around in a not so far away future.

Ditto.
Posted 4/22/2019 3:07 PM (GMT 0)
(Note that I also assumed that your signature had an error, and that your most recent data point was April 2019, not April 2018.)

I took 60-seconds to enter your 5 data points into this handy, free online PSA doubling time calculator: HERE

If you do the same, you will see that your PSA doubling time is greater than 5-years. What this means is that if future values follow the trend of your recently past values, then at age 75 you might expect your PSA to be a little above 2 ng/mL. Extending that for another 5 years, at age 80 you might expect PSA to be, conservatively, around 5 ng/mL. At age 90, your forecasted PSA might be around 20 ng/mL.

That very slow doubling time is very good news and can help to provide clear-headed guidance into next steps. It's always be imperative for you to continue monitoring your post-treatment PSA as you have been doing, but any decision to possibly consider additional treatment should be tempered with the understanding that cancer metastasis does not typically appear until PSA is well into the hundreds, and side effects of metastasis typically does not occur until well after that. The best decision for someone in your situation may be to do nothing except continue to monitor...and be wary of overtreatment which may introduce additional side effect worse than the disease.

Good luck.
Posted 4/22/2019 4:14 PM (GMT 0)
I would not trust the statement that metastasis doesn't appear until the PSA is in the hundreds. We have had many men here demonstrate mets with little PSA expression. It just depends on the person and the cancer. Also as the PCa advances it may actually express less PSA so you can't categorically straight-line a PSA forecast based on the past trend. The past trend is an indicator of what has happened and not necessarily a predictor of what will happen. That is why it must continue to be monitored and supplement by other investigative tools to determine that cancer advancement and what to do about it.

I would not conclude that with the slow doubling time that you are perfectly clear for the next 20 years and stop measuring the PSA. It is just not that simple. The client I mentioned in my earlier post that had a recurrence after 16 years of being undetectable unfortunately passed away from his PCa last fall. This was about six years after his recurrence. ADT and other treatments didn't solve the problem and his PSA never went above 10.
Posted 4/22/2019 4:40 PM (GMT 0)

JNF said...
I would not trust the statement that metastasis doesn't appear until the PSA is in the hundreds.

If someone had said that, I wouldn't trust it either. By contrast, this is exactly what "typically" happens; not always, but 70% of the time (according to the study titled "Predictive value of serum prostate specific antigen in detecting metastasis in prostate cancer patients"). 28% of the time, mets appear at PSA between 20-100ng/mL, and rarely (less than 2%) below 20 ng/mL.


JNF said...
I would not conclude that with the slow doubling time that you are perfectly clear for the next 20 years and stop measuring the PSA.

Prostate cancer—and most other cancers—often (not always) follow very predictable patterns of growth (of course, there's always outlier anecdotal cases, but not typically), but as I said previously, it is "...imperative for you to continue monitoring your post-treatment PSA as you have been doing...". Let there be no misunderstanding or obfuscation of this important point.

Many seniors with very slow-growing PC take the common-sense approach to "spot-treat" only as needed in order to maintain high quality-of-life, and avoid the systemic treatments which are filled with side effects...be aware of this strategy because some doctors (particularly if their doctor/patient relationship is not deep) may nudge patients into an over-kill recommendation.

Let the data be your guide...not anecdotes (stories about "I knew someone once who...").

Post Edited (Blackjack) : 4/22/2019 11:32:53 AM (GMT-6)

Posted 4/22/2019 8:52 PM (GMT 0)
Ahem . . .

Blackjack said...
By contrast, this is exactly what "typically" happens; not always, but 70% of the time (according to the study titled "Predictive value of serum prostate specific antigen in detecting metastasis in prostate cancer patients"). 28% of the time, mets appear at PSA between 20-100ng/mL, and rarely (less than 2%) below 20 ng/mL.


https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3665151/

In reviewing the information in the link, it appears that the stats that you speak of are from a study for determining whether or not a bonescan would be an appropriate diagnostic tool based upon a patient's PSA. They don't even encompass lymph node mets and there are also other caveats to the selection of subjects for the study. Improper stats for the original poster to consider.

Make sure that the data that you are using as a guide fully pertains to your situation.

Post Edited (farmanerd) : 4/22/2019 2:57:29 PM (GMT-6)

Posted 4/23/2019 3:36 PM (GMT 0)
This is a cruel disease - looks like it never leaves you. Do you have access to your post operative pathology report that you can share. It would shed more light on your case.

If you are otherwise healthy, as others have suggested get scanned soon and I would go see an RO to see if cure is still in the cards. Why not. There is always a risk of Side effects but I would take that gamble.
Posted 4/23/2019 5:34 PM (GMT 0)
It’s obvious that your current docs didn’t do a great job by only monitoring PSA and doing nothing about it when they could have acted when your PSA was low.
Posted 4/23/2019 5:41 PM (GMT 0)
"It’s obvious that your current docs didn’t do a great job by only monitoring PSA and doing nothing about it when they could have acted when your PSA was low."

that's the problem with the back-up plan; it's often not implemented in time.
Posted 4/23/2019 6:03 PM (GMT 0)
farmanerd, you have missed the forest through the trees...


70 YO, 15-years post-treatment, PSA only now at about 1ng/mL, PSADT (the most important datapoint for post-treatment monitoring, and most predictive metric post-RP for future outcomes) indicates 5+ year doubling time. That's pretty darned good, and I would say "good job" staying on top of the situation.

The best decision for someone in your situation may be to do nothing except continue to monitor...and I would be wary of aggressive secondary treatment recommendations which would introduce significant additional side effect, likely much worse than the nominal disease you appear to be carrying around. [This may be highly dependent on your personal relationship with your doctor and/or how effectively you communicate with him or her. Those who have a weaker relationship with their caregivers tend to get pushed into unnecessary treatments more often than those with good relations/communications.] Spot treatment may, however, be in your future...likely in a decade or two from now, but my well-informed, educated guess is "probably not."

The sky is definitely not falling.

Post Edited (Blackjack) : 4/23/2019 12:28:34 PM (GMT-6)

Posted 4/23/2019 6:56 PM (GMT 0)
Blackjack,
Hmmmmm . . . I was expecting some possible spinning, but not avoidance of addressing the incorrect statistics on mets that you have presented. For clarity, you quoted statistics for mets from an article fully titled "Predictive value of serum prostate specific antigen in detecting bone metastasis in prostate cancer patients using bone scintigraphy". You seem to have morphed these statistics into standing for those for overall mets, which is quite incorrect.

Please everybody, verify sources of stats and data.

Post Edited (farmanerd) : 4/23/2019 1:26:16 PM (GMT-6)

Posted 4/23/2019 8:03 PM (GMT 0)

farmanerd said...

Please everybody, verify sources of stats and data.

I fear you ask the unattainable, if not the impossible, farmanerd. ;-(
Posted 4/23/2019 8:10 PM (GMT 0)
Thanks so much for the kind and valuable suggestions about my case.
I did see the Urology doctor at Keck Medicine of USC, University of Southern Cal Yesterday. This is my first visit with him. Since the Urology doctor who operated on me on 2003 has retired 5 year ago.

After review my test result and previous surgery report. The doctor suggests.
(1) Do no procedure at this time except on 6 months PSA watch and continue for years.
(2) If there is surprise PSA change take action depend upon the best solution or technology at that time.
(3) If there is just slow PSA grow, just continually watching PSA as long as it is reasonable safe.

G Score 6, RP - radical prostatectomy Dec. 2003
PSA- 2014-07-23 0.50
PSA- 2016-04-16 0.70
PSA- 2017-06-08 0.66
PSA- 2017-12-12 0.80
PSA- 2018-05-08 1.09
PSA- 2018-09-24 0.98
PSA- 2018-11-13 1.02
PSA- 2019-04-17 1.12
Posted 4/23/2019 8:21 PM (GMT 0)
Lucky you, Data0011. You found a knowledgeable and reasonable Uro!

Monitor your PSA as he instructs, relax and enjoy a good life....
Posted 4/23/2019 8:33 PM (GMT 0)
Sounds like you’re in good hands.
Doubling time 5 years from 2014 to 2019. Many of us would kill for that. Another followup in 6 months is fine.
Thanks for shopping at HealingWell!
Posted 4/23/2019 8:57 PM (GMT 0)
Congratulations for having to do essentially nothing!
Posted 4/24/2019 12:58 AM (GMT 0)
If I were you I'd be going out for Handel's Ice Cream.
Posted 4/24/2019 10:16 AM (GMT 0)
Great Job! you found a good team in your choice of facility's and doctors and then proceeded and thankfully it looks pretty good at this time. It's always interesting to see our forum members here relate their experiences and we hope that we can offer support and encouragement but ultimately it comes down to you and your team of experienced doctors to lay out your plan of treatment. Wishing you the best in your journey.

Larry
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