PSA After Triple Play

So you are just about 3 years from radiation therapy and no longer on ADT. That is still in the time frame where a radiation bounce is common and for you wouldn’t be masked by ADT. Remember, you have a prostate and should expect a detectable PSA. You can still have prostate inflammation that expresses PSA. For some men the radiation contributes to such expressions.

The nadir plus 2.0 for recurrence is a a guideline, but is not a singular proof of cancer being active. When you use ADT and go to an undetectable nadir, it was due to the ADT, not the radiation. So you really don’t know what your radiation based nadir would have been. When radiation is used without ADT we want to see a nadir of <0.50 as a preferred indicator of best results. Many men never get that low but do not ever have a recurrence. Thus, as I understand, you would have a little more space before getting overly concerned.

However, you were a very high risk diagnosis and at great risk to systemic disease early on that the radiation, nor surgery, would have affected, and none of the scans might have detected. So with your risk profile you do want to stay on top of this. I certainly hope you are testing PSA at least quarterly. I am a bit surprised that you only did 24 months of ADT given the G10. I certainly hope you have aligned with a top medical oncologist that specializes in PCa like Eugene Kwon or Oliver Sartor. For you I would think that another increase may trigger a return to ADT. If it brings down the PSA then that could indicate the PCa is still active somewhere. Or, if another increase, start doing some scans and see if any hot spots are found that could help in disease management.

Thus, in my opinion, it is time to start considering strategies based on future PSA changes. With high risk disease it is always better to be proactive, not reactive. Now is the time to hire a top medical oncologist and get assessed and start considering future options. Get prepared.

My doc told me that he wouldn't start to get concerned about my PSA after ending my ADT until it got north of 0.5. And even then, he said that I could still have a good outcome. As to my personal PSA following the Triple Play, as expected it drifted up once I finished my ADT, with a peak of 0.2 after two years. Anecdotally, that seems lower than most radiation guys I've read here.

When is your next PSA test? I'd think that would be important in determining if the 0.4 is one of those PSA fluctuations that are fairly common or if it's a sign that it's trending up further. Overall, I think you'll need more time in determining how you're faring.

Are you referring to Nancy Wiggers, the radiation oncologist? Is that who did your radiation? I have always considered Dr Sartor at Tulane if I had a recurrence. He has a great reputation, plus a visit to NOLA is always fun. I know a few men that see him and are pleased.

Different specialties........radiation oncologist, urologist, medical oncologist. Generally if your frontline treatment fails, then that specialty is basically done with the treatment. An exception would be if the radiation oncologist comes back in to treat Mets or do focal radiation in the prostate area. Otherwise you move on to the medical oncologists.

Question......did you receive radiation to the pelvic lymph nodes?

We live in Swee***er, near the dam.

Thanks Sr Sailor, can you talk about the progression to 1.3 ng/ml ? Did it slowly inch up while you sweated bullets and then leveled off....or was it more like a step function ? That's the toughest thing I see about my situation, how to balance increasing PSA to see if it levels off vs when do I give up and engage treatment.

DaysBetween said...
Thanks Sr Sailor, can you talk about the progression to 1.3 ng/ml ? Did it slowly inch up while you sweated bullets and then leveled off....or was it more like a step function ? That's the toughest thing I see about my situation, how to balance increasing PSA to see if it levels off vs when do I give up and engage treatment.

Hi there, DaysBetween. I just saw this post. I was on ADT for 3 years, and saw my testosterone and PSA both rise pretty quickly after it "released", the term for when the Lupron finally wears off.

This alarmed me at the time, but it seems some of us experience this. Here's my understanding of what happens. If you didn't have ADT, your PSA would follow a trend after radiation. It would typically rise a bit, then fall, with a bounce or two along the way, down to some ultimate stable level, say 1.3 for example. If it stays there, then all is well. This could take a couple of years, but eventually it would just stay around 1.3 with some test-to-test variations up and down.

Now if you have ADT, that squashes the PSA down to nearly zero. That's generally done along with the initial radiation therapy, so all you see for a couple of years is undetectable PSA. Again, without the ADT you'd see the post-radiation trend, but it's suppressed due to the ADT.

When ADT releases, the testosterone recovers, and the PSA rises with it (and quickly). But it is just popping up to what it would have been after radiation anyway. So the rate-of-rise after ADT releases can be scary, but it's really rather meaningless. Once it gets back to the post-radiation trendline level, it should stop rising and just hang out at that level.

If it keeps on rising, well, maybe then there is reason for concern. But that "step function" characteristic rise after ADT isn't necessarily trouble in and of itself. That whole thing can take months to a couple of years to work through, as a lot of guys take a long time to recover testosterone after ADT.

[Edit to add: One of my oncologists didn't buy this theory at all, so I would be remiss if I didn't mention it. He was alarmed that my PSA had risen at all after testosterone recovery. He wanted it to stay undetectable, which is the case for many guys (forum member JNF for example), after primary radiation/ADT therapy. So, as with everything in this disease, there isn't a really clear answer. We all have to talk to doctors, research, and derive our own conclusions.]

Post Edited (Redwing57) : 4/5/2021 12:15:24 PM (GMT-6)