advice request with regards to SRT/similar post-op RP treatment

Any advice, opinion or insight would be greatly appreciated

Questions regarding the when(s), how and where(s) of SRT as my uPSA levels have started to rise post-op RP after 2 years.

A big issue is finding the right health insurance plan in case I need treatment in the coming year which is the issue for guys under 65 and medicare. This means I need to know a few options going forward and if the health insurance plan covers them. Hoping for no treatment in the coming year.

A friend of mine just got treated at Stanford with ADT then SRT with a post-op RP uPSA level of 0.05 after 4 years. Blind shotgun prostate bed and lymph node radiation since nothing showed on MRI imaging.

Is blind shotgun radiation preferred over waiting for higher PSA levels, positive imaging locations and targeted radiation?

My uPSA was first detectable at 17 months (with b vitamin supplements being used).

These b vitamin supplements were subsequently eliminated with uPSA being detected again at 26 months post-op RP

I am 60 years old

Ultrasensitive PSA test results - 17 months clean post op RP until positive at 22 months

Radical Prostatectomy 11/19/2015 with Gleason 3+4 at age 56

uPSA test result history

12/20/19 12/13/19 12/6/19 12/4/19 7/15/19
0.010 0.012 0.011 0.011 <0.006

4/3/19 11/29/18 11/16/18 9/21/18 7/16/18 4/30/18
0.008 0.007 0.009 0.007 0.007 <0.006

2/24/18 1/8/18 11/14/17 10/11/17 9/16/17 9/15/17
<0.006 0.008 <0.006 <0.006 0.009 0.010

6/5/17 3/3/17 12/1/16 8/29/16 5/4/16 1/14/15
<0.006 <0.015 <0.015 <0.015 <0.015 <0.02


my medical history is as follows

Genomic Health Decipher test score 0.22 below-average risk, 0 to 1 scale

Genomic Health Decipher test predicts metastasis risk and longevity for 5, 7 and 10 years out.

11/19/2015 Radical Prostatectomy UCSF Dr Peter Carroll da Vinci robotic surgery

Synoptic Comment for Prostate Tumors
- Type of tumor: Small acinar adenocarcinoma.
- location of tumor: Single tumor. Left posterolateral midgland and base (1.2 cc; slides B10-12).
- Estimated volume of tumor: 1.2 cc.
- Gleason score: 3+4=7; primary pattern 3, secondary pattern 4.
- Estimated volume > Gleason pattern 3: 10%.
- Involvement of capsule: Tumor invades capsule: left posterior midgland (slides B10, B11).
- Extraprostatic extension: None.
- Margin status for tumor: No tumor at ink, but tumor into capsule is less than 0.1 mm from ink; slide B11.
- Margin status for benign prostate glands: No benign glands present at inked excision margins.
- High-grade prostatic intraepithelial neoplasia (HGPIN): Present, extensive.
- Tumor involvement of seminal vesicle: No tumor.
- Perineural infiltration: Present.
- Lymphovascular invasion: None.
- Lymph node status: Negative; total number of nodes examined: 1.
- AJCC/UICC stage: pT2aN0.

Johns Hopkins (Epstein) pathology 10/13/2015
Gleason Score: 3+4=7
Left Base
2 cores (60% + 20%) (30% Gleason pattern 4)

Kaiser pathology, 9/1/2015
STAGE: T1c
Gleason Score: 3+4=7
NUMBER CORES INVOLVED/TOTAL NUMBER CORES: 2 / 14
TOTAL CARCINOMA LENGTH: 10 mm
PSA 3.2 6/10/2014
PSA 4.8 6/8/2015
PSA 4.4 8/10/2015 (free PSA 7%)
PSA 5.0 9/28/2015 (free PSA 8%)

A) PROSTATE, RIGHT APEX, NEEDLE BIOPSY
-- ATYPICAL SMALL ACINAR PROLIFERATION
-- TOTAL SPECIMEN LENGTH, 44 MM

B) PROSTATE, RIGHT MID, NEEDLE BIOPSY
-- FOCAL HIGH GRADE PROSTATIC INTRAEPITHELIAL
NEOPLASIA
-- TOTAL SPECIMEN LENGTH, 30 MM

C) PROSTATE, RIGHT BASE, NEEDLE BIOPSY
-- FOCAL HIGH GRADE PROSTATIC INTRAEPITHELIAL NEOPLASIA
-- TOTAL SPECIMEN LENGTH, 23 MM

D) PROSTATE, LEFT APEX, NEEDLE BIOPSY
-- BENIGN PROSTATIC GLANDS AND STROMA, 43 MM

E) PROSTATE, LEFT MID, NEEDLE BIOPSY
-- BENIGN PROSTATIC GLANDS AND STROMA, 22 MM

F) PROSTATE, LEFT BASE
ADENOCARCINOMA, GLEASON GRADE 3+4 = 7
ADENOCARCINOMA INVOLVES 2 OF 2 CORES AND 10 MM OF 30 MM

The first involved core from the left base contains 3 mm of Gleason grade 3+3=6 adenocarcinoma and the adenocarcinoma is located 6 mm from the presumed peripheral edge (see note).
The total core length is 17 mm.

The second involved core from the left base contains 7 mm of adenocarcinoma. Greater than 6 mm of the adenocarcinoma is Gleason grade 3 and less than 1 mm is Gleason grade 4. The Gleason grade 4
adenocarcinoma is located approximately 2 mm from the presumed peripheral edge (see note).
The total core length is 13 mm.

NO PERINEURAL INVASION IDENTIFIED

Well, your PSA has been floating around the lower end of the tests. It's not absolutely clear to me that you're having a recurrence.

With the newer, more sensitive scans, I sense the emergence of a new controversy in PCa treatment. For SRT, it used to be just radiate the prostate bed and nodes somewhere between PSA 0.03 - 0.2 and hope for the best.

Now, there seems to be the idea of letting the PSA go higher, pick up it's location with a sensitive scan, and do targeted therapy. I'm not certain if my understanding is correct, but I have two questions:
What is the risk of delayed treatment leading to mets? And what about smaller targets the sensitive scans miss?

Jronne: I must be missing something...what is it u are worried about? I would disagree with the 2nd poster who says u have persistent uPSA....your readings for 2019 are all 0.01 or less, is that correct? Did u make a typo? uPSA is measured in the trillionths, I believe. Not quite sure I understand what u are saying....U look pretty good to me so far. Good Luck, MM

Having just completed SRT, I will comment on this. Nowhere in any current studies and standards have I found that PSAs as low as yours are to be considered anywhere near BCR. If your PSA goes up to the .05-.10 range, then you can start to worry a little. IMHO, for now you look in great shape.

I had persistent PSA. It's my observation you've been blessed, should take a deep breath, enjoy the Holidays, and forget SRT for the time being. SRT, especially with ADT, is no picnic.

A mild, pathology and profile like yours' isn't even close to requiring SRT at this time. Sometimes doing nothing takes more faith and courage than doing just for the sake of doing!

Relax jronne!

This is clearly just noise. In a 3 digit uPSA result, you can generally disregard the last digit. In other words, you're at .01, and as Island Time said, its very probable that nobody is going to treat you at that level. I think it would border on malpractice. It would certainly be the height of overtreatment.

I have to ask, why did you have 4 psa tests, at one week intervals, in December? Seems a little OCD to me, no offense intended.

Bobbiesan / Robert

You have traveled the long path of uncertainty with regards to measurable but possibly long term stable uPSA levels.

I wonder if I am on step one of your journey.

How many guys are like that similar to you?

I looked at and saved the picture of your uPSA levels measured monthly from 1/17 which seems sensible even if it is 5 years post RP. If my levels stay stable I will drop back to every two weeks and then monthly.

What was your uPSA in 2016? Was it always just a blind < 0.015?

I can actually see values that are 0.006 and above. Noisy but something is there.

One guy that was knowledgeable stated the small PSA regions go dormant and then go back on.

If your PSA reaches 0.1 will you act?

Jeff

Bobbiesan said...
.....You are just in a really, really good position right now.

He certainly is...physically. Emotionally, IMO, not so much. More than a "bit of OCD" in my observation, and all over the net with the same story.

Relax Jeff, you are in an excellent medical spot. Just control looking for absolute answers where none exist.

Bobbiesan thx for the perspective. I am hoping to do nothing for years to come and possibly decades.

Trying to collect data and experiences but the forums are filled with guys that all have questions, issues and perspectives to varying extents. I agree with you that the huge selection bias is a key issue.

My background is a 21 year old scientist from CalTech with no job skills that had to make living after college so I taught myself Software in 1981 and worked at 22 companies in 32 years in Silicon Valley. My last stint was in BigData and machine learning.

Our situations are pretty similar separated by a few years. I wonder if my risk profile is perhaps slightly greater than yours simply because I was treated at age 56. I was 20% Gleason 4. My Genomic Health Decipher test score 0.22 below-average risk, 0 to 1 scale

I wish there was a current study after 2014 because things change and move forward.

"Low detectable prostate-specific antigen after radical prostatectomy--treat or watch?"

There are many differing opinions these days.and perhaps the best path chosen depends highly on the medical condition and risk profile of each patient.

Stephen S

My uPSA test results on 9/16/17 9/15/17 were suspect because of the large vitamin b7 biotin supplements I was taking daily as vitamin b7 inflates uPSA test results. The soy protein powder I take also has biotin. So I have cut these out 4 days before each test for the last 2+ years after I learned of this in 10/17.

The 1st real measurement without vitamin b7 was 1/8/18 at 0.008.

The vitamin b7 factor is probably insignificant for PSA tests just uPSA it impacts.

The uPSA test has error margins but in my opinion (and others) the biggest source of variance is that small PSA regions likely produce PSA at an irregular rate sort of fast and slow.

The uPSA test is still new and it's measurements are still yet to be fully understood.

Greetings,

From what I have observed the lower end uPSA triggers get used when there is some adverse pathology alongside a couple/few consecutive rises to ensure a trend is in place.

All the best to you.

There's a reason the Mayo Clinic doesn't use the ultra sensitive tests and I think your's is a prime example. Like the guys have said go enjoy the holidays with your family!


Larry