Does this study which predicts BCR for all post RP with uPSA of 0.03 apply to intermediate risk RP?

does this apply to low and intermediate-risk post-RP guys?

https://www.ncbi.nlm.nih.gov/pubmed/25463990

"PURPOSE:
Integrating ultrasensitive prostate specific antigen with surveillance in patients at high risk after radical prostatectomy potentially optimizes treatment by correctly identifying recurrence, promoting an early salvage strategy and minimizing overtreatment. We tested the power of postoperative ultrasensitive prostate specific antigen to identify eventual biochemical failure.

MATERIALS AND METHODS:
We identified 247 patients at high risk with a median followup of 44 months who underwent radical prostatectomy from 1991 to 2013. Each patient had extraprostatic extension and/or a positive margin. Surgical technique, initial prostate specific antigen, pathology findings and postoperative prostate specific antigen were analyzed. The ultrasensitive prostate specific antigen assay threshold was 0.01 ng/ml. Conventional biochemical relapse was defined as prostate specific antigen 0.2 ng/ml or greater. Kaplan-Meier and Cox multivariate analyses were done to compare the rates of ultrasensitive prostate specific antigen recurrence and conventional biochemical relapse.

RESULTS:
Sensitivity analysis revealed that ultrasensitive prostate specific antigen 0.03 ng/ml or greater was the optimal threshold to identify recurrence. A first postoperative ultrasensitive value of 0.03 ng/ml or greater, Gleason grade, T stage, initial prostate specific antigen and margin status predicted conventional biochemical relapse. On multivariate analysis only a first postoperative ultrasensitive value of 0.03 ng/ml or greater, Gleason grade and T stage independently predicted conventional biochemical relapse. First postoperative ultrasensitive prostate specific antigen 0.03 ng/ml or greater conferred the highest risk (HR 8.5, p < 0.0001) and identified conventional biochemical relapse with greater sensitivity than undetectable first conventional prostate specific antigen (70% vs 46%). Any postoperative prostate specific antigen 0.03 ng/ml or greater captured all failures missed by the first postoperative value (100% sensitivity) with accuracy (96% specificity). Defining failure at an ultrasensitive value of 0.03 ng/ml or greater yielded a median lead time advantage of 18 months (mean 24) over the conventional definition of prostate specific antigen 0.2 ng/ml or greater.

CONCLUSIONS:
Ultrasensitive prostate specific antigen 0.03 ng/ml or greater is an independent factor that identifies biochemical relapse more accurately than any traditional risk factors and confers a significant lead time advantage. This factor enables critical decisions on the timing of and indication for postoperative radiotherapy in patients at high risk after radical prostatectomy."

Rather good studies that indicate .03 is a good point to treat, the question is where is it at? Yes, I believe intermidiate risk is included.

jronne said...
DjinTonic I wonder if my good gnmemoic health decipher score 0.22 also reduces my BCR risk or just my metastatic risk?

Since BCR can be from (a) local tissue (without any lymph node involvement) and/or (b) metastatic (local and/or distant), if you lower the risk of (a), you logically lower BCR risk.

BUT

Less than half of BCR cases go on to clinical recurrence (even though one often wants to treat for BCR and not run the risk).

Not all rising PSA will go on to a level of 0.2 and rising. Whether you decide to treat earlier or much earlier depends also on your risk status.

A LOW risk of Mets doesn't mean NO risk.

Djin

Post Edited (DjinTonic) : 1/28/2020 4:45:31 AM (GMT-7)

Ultimately, the goal of RP treatment of PC is to see the PSA drop to non-detectable levels. And, with the ever dropping low limit of the uPSA test, there may come a point where non-detectable no longer happens. Imagine that, a test so sensitive that no one would ever be non-detectable.

Using the term "PSA Nadir" post surgery seems odd--until very recently, I had never seen it used in this context--nadir was a term for radiation treated patients--to define the lowest level they achieved so they could judge when BCR started (as in nadir +2).

All that being said, the standard of care guidance as published by the giants in the field such as MSKCC is that BCR should be considered when PSA gets to 0.02 or 0.03--which is 4-5X the detection limit of the most commonly used assay. Along with doubling time--which of course is an exponential function--this defines when treatment should resume. I would still hold on to the guidance that says that BCR exists and needs further treatment when ALL of these conditions are met: Rising PSA from non-detectable to 0.03 OR never going non-detectable, plus doubling time of 6 months or less, plus two successive PSA tests at least 3 months apart that show the rise is continuing.

If all that is happening, then get to the RO and get going. Long doubling time? Stable but elevated PSA? Keep an eye on it.

Djin, it has been reported here by several men that some of the researchers at (among others) MSKCC are recommending BCR treatment at 0.03 for post-RP patients. Whether they have 'officially' redefined it, I can't say. One of the issues has been that has maintained the 0.1 is the uneven dispersal of the ultrasensitive test--it really is not universally available, even in the US, much less so in other parts of the world.

Believe it or not, there are huge swaths of US population that are hundreds of miles from a level 1 cancer center, and live in small enough towns where Labcorp isn't there. Really. I've lived there. I had no idea (except for what others had said here) that the uPSA went down below 0.04 until 3 years ago. I had never had that level of test.

DjinTonic yes your uPSA readings might be slightly worse than mine as they are 0.015 vs 0.012

the good news is that you have been flat for 10 months

what concerns me is that BCR is now effectively defined at 0.03 which we are both to close too at least for my comfort

knowing of anybody or anybody that knows somebody that has been camped out at uPSA of 0.01 to 0.02 for 5 years would be great news

BCR might just be a matter of if not when

DjinTonic said...
Thanks, Hilbert. Yes, I'm familiar with those studies. There is certainly a trend toward early and very early treatment. This year there should be results from several studies specifically designed to answer questions about adjuvant vs. early salvage vs. very early salvage. There is currently distance between how uro's vs radiologists lean on timing. And I've also read that radiologists themselves are divided evenly on the timing issue.

Djin

Very true, and many of those studies are done by radiation oncologists, who just might have a bias. In any event, it fuels much overtreatment, and even more patient obsession, as we see around here all the time. Someday we'll have more accurate data and answers.