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Posted 10/18/2019 5:05 PM (GMT 0)
So - 9 years ago I had the prostatectomy and about 3 years ago the PSA started to increase - it was last measured at 0.12

It was “undetectable” for 6 years however that might have been with less sensitive tests

One set of advice is - go ahead and start RT because you are headed there anyway and intuitively why not treat earlier when you can perhaps believe that the cancer cells are localized and haven’t spread - why take a chance

The other advice is to wait till PSA hits 0.2 or even 0.5 then do a PSMA scan then proceed - this is based on the idea that 0.12 is low and why invite complication of treatment before necessary

I’m leaving some details out for brevity’s sake

I was resigned to immediate treatment and then the 3rd opinion said slow down

The doctors are pretty good, 2 of the 3 are well known - of those one said reasonable to treat the other said wait

What does the crowd advise?
Posted 10/18/2019 5:18 PM (GMT 0)
What was your post op Gleason score? The question in my mind is what is your risk group?

If you're in a higher risk group, I'd be talking to an RO and planning treatment.

Not sure I'd recommend slowing down.
Posted 10/18/2019 7:39 PM (GMT 0)
>>The other advice is to wait till PSA hits 0.2 or even 0.5 then do a PSMA scan then proceed - this is based on the idea that 0.12 is low and why invite complication of treatment before necessary<<

this is based on very poor advice. you need to consult with an RO ASAP. good luck.
Posted 10/18/2019 7:45 PM (GMT 0)
You had a pretty long run so hard to know where the PCa is at this point from my limited view. It would be nice if you could summarize your pathology results for reference. Was there anything noted about lymph nodes, margins, etc?

The reasons why are not altogether that important since it is pretty clear that something is going on but slowly. Early salvage radiation has some published benefits but is not real clear where the threshold should be ( >0.03 to <0.50) for maximum benefit other than the earlier, the better it seems. PSA > 0.20 has always been the point where recurrence after surgery has been firmly established so that cutoff would make sense to most urologists.

Regardless, you should be talking with the RO now and exploring their opinions and options. My guess would be that your doctors would all agree at PSA =0.20, a decision should be made. Radiation does not help if the PCa is not in the target area but by the time your PSA is high enough for scans to pick up the location of the cancer, you have lost the advantage of early SRT. Some say that some new fancy scans can find things down to PSA = 0.20 but I am not sure how reliable that is. Having a clear scan does not tell you much early on so you have to wait until something shows up later on which is why some say wait closer to 0.50 to make the call on treatment after a scan at that time.

Tough decisions, no doubt. You can always throw the kitchen sink at it now with ADT and SRT and hope for the best. Or you can wait and do nothing until you can get quality scan results then do whatever that requires.
Posted 10/18/2019 8:39 PM (GMT 0)
I was Gleason 3-4
The advice is coming from 3 radiation oncologists
The original surgery report said margins were clear bur some extra-capsular extension IIRC
Posted 10/18/2019 8:46 PM (GMT 0)
My PSA
5/16 0.03
5/18 0.09
3/19 0.10
7/19 0.12

One RO said numbers can fluctuate Throughout the day no to mention over time so to him this doesn’t indicate steady increase necessarily

To me , I’d buy the fluctuation answer if it ever went down
Posted 10/18/2019 8:50 PM (GMT 0)
There is the possibility that there's some prostate tissue that's regrowing. Given your age and risk factor, I'm inclined to vote to start SRT. SRT is normally tolerated well by most guys. Side effects aren't horrible, but the daily treatments can be a bit of grind.

You could do one more PSA test just to confirm the number, but I'm thinking I wouldn't mess around too much. Scans at that PSA level don't show much and I'd be worried about waiting for higher PSA. If there's any chance it's still in the prostate bed, then now is the time to strike.

Still, it's your choice.

Andrew
Posted 10/18/2019 8:50 PM (GMT 0)
>>One RO said numbers can fluctuate Throughout the day no to mention over time so to him this doesn’t indicate steady increase necessarily<<

the trend is clearly up. i'd be consulting with someone with a greater sense of urgency.
Posted 10/18/2019 9:45 PM (GMT 0)
I could have written your original post. Only difference for me, is when your second post said all 3 Drs were RO’s.
The guy that told me to wait was my surgeon. The two guys that told me to move forward based on recent studies showing earlier is better were RO’s.. I only bring up my own situation because I think it definitely relates to yours. The good news for you though is you’ve had a very long run, and the rate of your rise is extremely slow which works in your favor

I’m not a doctor I’ll just give you my opinion, you’ve got a clear trend it’s time to act. As Andrew/InTheShop said. “ . If there's any chance it's still in the prostate bed, then now is the time to strike. ”

To me that statement right there says it all
Posted 10/18/2019 10:38 PM (GMT 0)
My only question would be after 6 yrs where do you know where to radiate? I probably should explain why I was asking this question. When I was considering Radiation I was emailing back and forth with Tall Allen concerning just radiating just the prostate bed area or the whole pelvic area as he had posted many times on HW about unnecessary radiation and the SE's that came with it. That's why I am asking without any type of scan where would you know where to radiate? Would you do the pelvic area or the bed area? I'm also wondering concerning scans that are available in the USA and that an insurance company would pay for how high the psa would have to be before you could get a scan? Also as Mumbo brought up would a person want to look a hormone treatment option?
Posted 10/18/2019 10:50 PM (GMT 0)
My oncology urologist trained at MD Anderson told me to wait until I hit the magic 0.2 ng/ml number. So after another year I hit the number and underwent SRT. The RO said the same thing. Both said not to rush into unless the numbers kept climbing to the 0.2 ng/ml level.
Posted 10/18/2019 11:08 PM (GMT 0)
It’s probably debatable whether doing SRT at 0.03 gives a Significant advantage over doing it at the 0.2 threshold. But, in my view this is possibly the only area where the highly sensitive PSA tests are advantageous. If you have several PSA tests that are clearly trending up without exception - even if by small amounts - what sense does it make to wait until the PSA reaches 0.2 when you could already be treating with SRT?
Posted 10/18/2019 11:51 PM (GMT 0)
Thanks for the add'l information, you seem to be doing all the right things. The only thing I can think of is to consult a MO that is experienced in prostate cancer to get a possibly a different viewpoint.

I might also be inclined to see if the PSA goes up a couple of hundredths again at the next PSA test (about now?) which should be enough verification that it is not going the other way and put that to rest.

The people here tend to be pretty proactive about treatment and were that way when I was wrestling with the decision to go with adjuvant radiation without measurable PSA earlier in the year. My Uro and RO were no help as they just laid out the choices and said it was up to me based on my consideration of side effect potential and long term probabilities of recurrence. They could argue for both sides of the equation.

As a G9, I just could not get comfortable with waiting and went with ART in the hopes that I improved my odds. I may have over treated myself and/or did no good for the long run but I figure it is better to have played the game and lost than never tried at all. Radiation occupied a lot of time but I survived so far without any lasting side effects so doing ok. You will just have to do some soul searching and decide what is best for you and move ahead. Good luck with a difficult decision.
Posted 10/19/2019 12:37 AM (GMT 0)
>>It’s probably debatable whether doing SRT at 0.03 gives a Significant advantage over doing it at the 0.2 threshold.<<

really? I think .2 is late and the advantage of initiating SRT at .03 is significant.
Posted 10/19/2019 12:43 AM (GMT 0)
F8,
I don’t disagree with you.
Posted 10/19/2019 1:48 AM (GMT 0)
I am just finishing up SRT. I go with doing it now. I was at PSA .18, and the RO said it was time. He also said not to bother doing any scans, even the newer ones won't show anything definite at .18. I have found the side effects are minimal and won't slow you down much. Most of the studies I found say waiting until PSA .5 will considerably increase your chances of future recurrence.
Posted 10/19/2019 6:04 AM (GMT 0)
My first thought was, this is a clear trend of the PSA value, one could already radiate now.

However, after I calculated your PSA doubling time I recommend to wait. You have a doubling time of 33.7 months or 2.8 years. So you will reach the PSA value of 0.2 in August 2021. If you want to do a PSMA PET/CT you will have to wait until April 2025 when you reach 0.5.

So I do not know what the objective of this salvage radiation shall be. If you do nothing and just observe, you will have a PSA value of 8 ng/ml in 2036 when you are 94 years old. You will have no symptoms until then. And it is likely that you will die for other reasons until that time. In 2036 you could start with ADT, if required.

I calculated the PSADT from 5/18 - 0.09 to 7/19 - 0.12.
Posted 10/19/2019 4:31 PM (GMT 0)
I'm in a Very similar wait and see situation. Mine has started creeping a bit. I was 47 at time of surgery. My Dr said they see this occasionally happen and he predicted it will stay there and move little or very slowly (may represent a few benign glands around the urethra or bladder neck. Either way,he thought a significant recurrence is rare at this point and it is unlikely that they are going to do anything but watch. See how mine has creeped up below.... Any thoughts?

Diagnosed in February 2011 at 47
Clinical Report: PSA 3.7 Gleason 7, 3+3 and 3+4, T2C, 8 out 12 cores positive
Davinci Robotic Surgery in August 2011 at University of Ky
Path Report: pT3a, 3+4 and 4+3, no radiation
Negative Lymph Nodes, Margins and Vesicles
Extensive Perineural Invasion
Both nerves spared except 15% on one side, still some ED
Undetectable PSA since at <0.03
UNTIL...July 2018 0.04
January 2019 0.05
July 2019 0.07
Posted 10/19/2019 6:12 PM (GMT 0)
I’ve been undetectable for 11 years, if I ever become detectable again (like I thought I was 5 months ago) I would get treatment because I’m paranoid as all hell but that’s me, I didn’t say it was logical...
Posted 10/19/2019 6:46 PM (GMT 0)

F8 said...


really? I think .2 is late and the advantage of initiating SRT at .03 is significant.

Look who thinks he's smarter than the doctors now...LOL
Posted 10/19/2019 6:54 PM (GMT 0)
I think this is the conundrum, if the agressivity changes you may wish you’d treated
If you are sure doubling time is constant- better not to treat

George_ said...
My first thought was, this is a clear trend of the PSA value, one could already radiate now.

However, after I calculated your PSA doubling time I recommend to wait. You have a doubling time of 33.7 months or 2.8 years. So you will reach the PSA value of 0.2 in August 2021. If you want to do a PSMA PET/CT you will have to wait until April 2025 when you reach 0.5.

So I do not know what the objective of this salvage radiation shall be. If you do nothing and just observe, you will have a PSA value of 8 ng/ml in 2036 when you are 94 years old. You will have no symptoms until then. And it is likely that you will die for other reasons until that time. In 2036 you could start with ADT, if required.

I calculated the PSADT from 5/18 - 0.09 to 7/19 - 0.12.

Posted 10/19/2019 8:03 PM (GMT 0)

garyi said...

F8 said...


really? I think .2 is late and the advantage of initiating SRT at .03 is significant.

Look who thinks he's smarter than the doctors now...LOL

do you think there is no advantage to initiating SRT earlier than .2?
Posted 10/19/2019 10:18 PM (GMT 0)
sfigato - George is on the right track and makes a good point but be careful of working with hundredths with low PSA's. The results are probably ±0.02 so a 0.09 to 0.12 in a year plus could easily be off and the projections quite misleading. Your last PSA's were 0.10 and 0.12 in a 4 month period which would provide a much different extrapolation but could also be no increase in reality. More points are better so confidence in the extrapolation can be gained.

The good news is you have some time to keep an eye on the situation. The 0.03 value is long past so now you are looking at the 0.10 - 0.20 range. I think I might stay on a 3 month testing cycle and do something when the numbers seem to demand it. Only you can determine when the time is right.
Posted 10/20/2019 1:45 AM (GMT 0)
sfigato,

Well, your case is really a tough one, and I'm not sure what I'd do in your case -- I'd be kinda "on the fence".

Can tell you what I've done since my uPSA started going detectable a few years ago. I've kept up my 6 mth appts. with urologist I've had all along. I've closely monitored my uPSA and tried to do everything I can to make each test meaningful (avoid biotin, keep similarly hydrated before blood draw, etc.). I even went off TRT, probably forever, Dec. of last year when I thought I was getting a spike in uPSA. You can see this in the last half of 2018 readings in this uPSA chart I keep:

https://i.imgur.com/ogdl0hc.jpg

Since then, I've kinda seemed to stabilize. If I see a definite trend up, that doesn't seem to be just month to month variation, then, yes, I will start pushing ahead with an RO. Probably in the .10 to .15 range, I dunno. My urologist says unless I was in the .4 range, the current scans would not be of much help. So guys like us are just flying blind as regards knowing what is really going on. Fact of life. But really unsettling. I am just trying to get used to it.

I suppose you could try closely monitoring for a short period and see if you are going to stabilize. Some studies show that a certain percentage of recurring men have this happen. I am age 70, so as things stand now, I'm likely to die of something else. My uro last visit said exactly that.

Please keep us posted of what happens. It will help others.

Robert
Posted 10/20/2019 3:20 PM (GMT 0)
Robert,

your URO tells you 0.4 because this study determined that the PSA value of about half of the patients stabilized at 0.4 ng/ml: https://www.ncbi.nlm.nih.gov/pubmed/11257657

For me you are an example that ultrasensitive PSA tests do have no additional diagnostic value, they just make the patients nervous. When I calculate from 3-17 with 0.027 to 10-19 with 0.035 you have a doubling time of 6.9 years. With other words, you will reach 0.4 ng/ml in 24 years. You are cured, that's all!

George
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