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PSA up to 1.9 after 4yrs RaD

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Posted 1/13/2021 6:16 PM (GMT 0)
My PSA went from nadir of 0.3 two years ago up to 1.9 after 4 years of Rad treatment and now they want to put me on Eligard to bring it back down. Is Eligard one of the best treatments to lower PSA? Is 1.9 too high after 4 years of the last Rad treatment.
Posted 1/13/2021 6:37 PM (GMT 0)
Generally a nadir plus 2.0 is considered cancer recurrence following radiation as the primary treatment. You are not there yet, but apparently your PSA trend is prompting your doctor to act.

Have any scans been ordered to determine if there is PCa growing in the prostate area or pelvic lymph nodes? I would think that should be considered. If there is PCa evidence there, then there are several focal methods of salvage that could be used.

The use of ADT would be for controlling systemic disease, meaning disease that is away from the original site. Eligard, Lupron and a Firmagon are all medications that halt the production of gonadal testosterone, a prime food for PCa. And it will lower the PSA to undetectable unless some of the cancer has developed a resistance, which you won’t know until you are on ADT. Other medications block the PCa receptors from utilizing testosterone and include Casodex, Zytiga and Xtandi.

You have some options. Follow the current advice and get the shot. Or, Ask why now when you haven’t yet reached nadir plus 2.0. After all, you could be experiencing a rather common post-radiation bounce that signals cancer dying, not growing. You would find out more by waiting a while longer to see more of the trend. I would definitely be testing every three months if you aren’t already doing so. Or, Ask why they aren’t pursuing any scans to detect PCa. Your PSA is high enough that if due to PCa might show up on scans. If nothing shows then you might wait before starting ADT. These questions would drive my next discussion with the doctors.
Posted 1/13/2021 6:53 PM (GMT 0)
I think they might be in the process of setting up scans but have not heard back yet. It was Mon I talked to the tech and now it's Wed. I have appointment on Friday so then I will get some answers, hopefully.
Posted 1/13/2021 8:42 PM (GMT 0)
Personally, I would be very reluctant to jump into ADT at this point. Has your PSA the past four years been a steady increase? You are hovering near an "official" recurrence, but even above recurrence doesn't always mean it's time for palliative treatment. At a PSA of 1.9, standard bone/CT scans are unlikely to detect anything.

If you haven't already done so, I encourage you to consider moving your treatment to an MO (medical oncologist) experienced with PCa.

Good luck and please keep us posted.
Posted 1/13/2021 9:24 PM (GMT 0)
Admitting that I do not have the info that your physician (urologist?) has, I concur that ADT appears premature at this point. I As mentioned above, radiation therapy often causes 'bounces' in PSA test results and your test result has not exceeded the guideline (nadir + 2) for further treatment.
Posted 1/14/2021 1:26 AM (GMT 0)
you might be right about that. They said they would like it under one so that is why they want to do the Eligard but I'll ask him about that on the up coming appointment. It looks like they might do it to be on safe side

the last two PSA's were 1.56 to now up to 1.88 exactly .
Posted 1/14/2021 2:19 AM (GMT 0)
This DR , I'm seeing might be a medical oncologist. He was referred to me by my regular Urologist Dr.
I'll have to ask. As for my G score it was 8
Is a MO a medical oncologist DR. that specializes in PCa? If so I'll have to look for one. I have appointment this Friday as the 2nd visit with this Dr. He's supposed to be pretty good at this but I don't know for sure as I have only been to him once.
Posted 1/14/2021 2:22 AM (GMT 0)
What's even worse is I take Sotalol for regulating my heart and Sotalol reacts with Eligart to become dangerous from what I read. I wonder why the Dr didnt check on that? I'm trying to get hold of them before appointment but so far they have not called me back.
Posted 1/14/2021 6:00 AM (GMT 0)
JNF what scan should I take? mattam says that at my level bone/ct scans are unlikely to detect anything.
Posted 1/14/2021 11:49 AM (GMT 0)
psma is state of the art. Recently fda approved.

https://www.cancer.gov/news-events/cancer-currents-blog/2020/prostate-cancer-psma-pet-ct-metastasis

https://www.fda.gov/news-events/press-announcements/fda-approves-first-psma-targeted-pet-imaging-drug-men-prostate-cancer

Im not sure how many places you can get it.

Another test is axumin scan
https://www.axumin.com/patient
Posted 1/14/2021 12:53 PM (GMT 0)
My experience:

My doc waited until my PSA hit 3.0 before he scheduled an axumin PET scan and another bone scan. He said when the PSA was lower there was not enough cancer to see in the scans. When I hit PSA of 3, he put me back on Eligard to stop the cancer from advancing.The bone scan came up empty but the PET scan revealed 3 mets (metastases) in my pelvic lymph glands. I qualified for Xtandi when they found the 3 lymph gland mets, so insurance would pay for the Xtandi (except for the co-pay).

The fact that I have 3 soft tissue mets close to each other and not far from the original tumor site qualified me as "Oligometastatic" so my radiation oncologist says I have a shot at killing it off. I am now 2 weeks + into salvage radiation to the higher-up pelvic lymph nodes and an extra shot of radiation to those 3 hot lymph nodes. I will stay on both Eligard and Xtandi for the rest of this year and have another month of salvage radiation therapy to go yet.

I have G7 prostate cancer which is kind-of nasty despite claims that it is borderline. I have an MO - medical oncologist - who supervises the drugs and testing and a RO - radiation oncologist - who supervises my radiation treatments. Those 2 work together to plan and implement my treatment plan. I had a URO - urologist - who did the surgery to remove the cancerous prostate gland.

Personally, I figure that I do whatever I can to kick the can down the road as I go along. Also, I ask any questions I have to the docs about any and all of this stuff so I can make the best decisions I can about my treatment as I am real clear that I am the one actually directing it. I read all that I can on an ongoing basis as the science is constantly evolving. That habit has put me with my current team and my current treatment. smile
Posted 1/14/2021 6:49 PM (GMT 0)
John, if Eligard is a problem, both Lupron and Firmagon accomplish the same result. In fact Firmagon has some distinct advantages-takes as it has been shown to have fewer adverse coronary events than Lupron or Eligard. Research them relative to your condition and medications and specifically ask the oncologist about it.

Where are you located and who is the doctor you will be seeing. There may be members on the board that can provide you information about specialists in your area.
Posted 1/14/2021 8:02 PM (GMT 0)

john said...
Is a MO a medical oncologist DR. that specializes in PCa? If so I'll have to look for one.


Not as simple as it should be. Oncologist is the generic term for doctors who deal with cancer. There are sub specialties within oncology such as Radiation Oncologist (RO), Surgical Oncologist, Pediatric Oncologist, etc that limit their practice to the specialties within the title. There is no Prostate Oncologist title that I have ever seen used.

The term Medical Oncologist refers to doctors who treat cancer with various chemical, hormonal, etc, therapies. Essentially, they are the oncologists who do not practice the specialties thus Oncologist and Medical Oncologist are used interchangeably for the most part.

There is no way to know from common titles whether any doctor specializes in prostate or breast cancer. You have to read their bios or any other information you can find to see if they specialize or limit practice to a certain area like prostate treatment. As an example, Eugene Kwon MD at Mayo is a very well known doctor for advanced prostate cancer treatment but is a urologist with a diverse background who specializes. My wife's oncologist specializes in breast cancer at the university and that is about all she does in addition to teaching and research.

If you indicate what state you live in, some folks here will probably have experience with local MO's that you can seek out. Easy to find some experts scattered around the county but it helps if they are little closer to home for most people.
Posted 1/14/2021 10:58 PM (GMT 0)
I go to Urology of Indiana where all the Dr's are specialist in Prostate Cancer and other urinary problems. I just started going to this Dr so I hope he knows what he is doing.

When the Nurse called me today i ask about the MO and she said I would not need one.
Posted 1/15/2021 12:55 AM (GMT 0)
John - Sounds somewhat similar to the practice I go to in the Twin Cities. I am sure there are some good urologists there that are pretty knowledgeable.

I think the concern I would have is that you have had primary treatment for prostate cancer which may or may not have succeeded depending on where your next few PSA readings go. It would be nice to have a high powered scan that shows where the cancer might be that is causing your PSA to rise before going on hormonal drugs that knock down the PSA activity and make detection difficult. It is possible that a secondary treatment option might be possible if the source is local vs. endless ADT therapies until that fails.

On the other hand, you are 81 so kicking the can down the road might be a reasonable approach with hormonal treatments. My Dad had a PCa recurrence after brachytherapy around 87/88 and he had Lupron shots for a year or two and is still doing well at 93, His PSA is slowly rising again but it will not be what eventually kills him. If it gets worrisome to his doctor, he will just get another shot.

One thing to consider is that you have the Indiana University Melvin and Bren Simon Comprehensive Cancer Center in Indianapolis that would be a good place to get a second opinion from one of their teams. You have plenty of time to do all of this and arrive at the best solution for you. It may be that you just get treatment as recommended by the urologist but at least you will be comfortable that you made the right choice and saw all the best doctors.
Posted 1/15/2021 2:51 AM (GMT 0)
John, a fellow Hoosier. I grew up in New Castle and am a transplant to Georgia.

The IU Medical Center is renowned for urological cancers. It was there that Dr Einhorn wrote the book on testicular cancer and developed very effective treatment that is used worldwide.

Am anxious to see how your visit goes with the new doc and to see how he answers your concerns. Do you have his name?
Posted 1/15/2021 3:18 AM (GMT 0)
ORR
Posted 1/15/2021 12:07 PM (GMT 0)
Thanks John. Very large practice. Looks like Orr is primarily a surgeon first reading his education, training and practice interest he states. It will be interesting for your meeting with him.

You need to ask him about his relevant experience managing men after radiation. How many is he managing? What are his methods? What is their experience? If he is first of all a surgeon, you are not going to have any surgery. Is he a good match for you? If you question that, please ask him, who in the practice specializes in urologic oncology. This would be akin to a medical oncologist, but specializes in urologic cancers. That doctor would primarily manage prostate cancers that were not initially cured by surgery or radiation and would be managed by various medications.
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