PSA increase after 11 years.

Hi Ed. I wouldn't be overly concerned. Do you know your actual previous values or where they simply reported as <0.1? In the latter case, it is possible your value(s) were close to 0.1, in which case your current values may well be within the range of normal physiological fluctuations coupled with assay imprecision.

Your three-decimal value (0.126, 0.137) make me think you last two tests were done with Labcorp's ultrasensitive PSA test (uPSA). If your values prior to those were reported as <0.1, they were done with a less sensitive PSA test usually performed for men with prostates (pre-treatment). Results done with different methodologies (and perhaps at different labs to boot) are not generally comparable. I think it would be reasonable for the same blood sample to test 0.137 with a uPSA test and as <0.1 with a standard PSA test.

If you are concerned, I would wait a longer time (perhaps 2 or 3 months) and retest at the same lab and with the exact same PSA test as your last two tests. It takes a number of data points to determine a trend. There are many intrinsic (you) and extrinsic (the test) sources of fluctuation.

Your values of 0.126 and 0.137 are insufficient data to establish a rising PSA. See my recent thread about an unexpectedly high uPSA value I had. I went from <0.014 to 0.037 six months later, followed by 0.020 three months after that! It will take more results for me to know whether my PSA is actually still sable or is slowly creeping up. I'll do my next test in 3 months and, depending on the results, either go back to 6-month testing, or stay at a 3-month interval if my trend still isn't clear or may be going up.

Hope that helps,

Djin

Post Edited (DjinTonic) : 4/9/2021 3:32:04 PM (GMT-6)

Ed, was your 2/15/19 value 0.009 or 0.09? It's impossible to know from something like .009 whether the the leading zero is just missing or the decimal point was misplaced in error.

A change from 0.009 to 0.126 is fairly large; that from 0.09 to 0.126 not so big.

Just a note that no lab will ever report .009 as a medical lab result -- it's best not to write decimal values below 1 without a zero in front of the decimal point (except for gun calibers, baseball hitting averages, and a couple of other conventions). Omitting the leading zero always opens the door to the above-mentioned ambiguity. (Similarly we don't put unnecessary leading zeros before values of 1 or higher, except, perhaps for James Bond and colleagues.)

Further, the fact that some of your values have 2 decimal places and some have 3 would indicate that, although these are all what we now call ultrasensitive, different uPSA methods were used, making comparisons harder. For example, Quest's "post-prostatectomy" PSA test has 2 decimal places, while Labcorp's "ultrasensitive" test has 3.

Did you skip a PSA test in 2020?

Djin

Post Edited (DjinTonic) : 4/9/2021 3:33:07 PM (GMT-6)

I'm few months short of being 80 years old. I'm physically in very good health, I exercise regularly and the only medication I take is 20 mg of a cholesterol medication. The 2019 Ultra sensitive PSA report states ,009. it states that values between 0.006 and 0.014 are near the limit of detection and may show relative imprecision.

Edc,

You are a health conscious fit guy. You have alot of living left to do. You have been diligently keeping an eye out since 2009 and these last few tests have increased your alertness level.

I am relatively new to all of this but for someone who has had their renegade prostate removed the official psa you would need to have to call it a recurrence is 0.20 or higher.

Looking through your old posts you indicate you were a G8.

So if it were me I would start investigating radiation oncologists in your area (gathering names etc...) and like djin said retest in a few months at the same lab. So if the psa continues to increase you are ahead of the curve, if things dont you would be slightly over prepared, which never hurt anyone.

Thank you all for responding. The latest PSA of 1.26 which was confirmed with a retest 10 days later woke me up. 11 years had passed with my PSA being undetectable, so you can imagine what kind of a shock that was. I'm seeing my Urologist in 10 days and will see what he might suggest. He may want me to retest in 3-6 months. I'll keep you posted.

Ed, regarding Medicare, are you on traditional Medicare and a MediGap Supplement? If so the Supplement picks up part or all of the 20% depending on the Supplement Plan Letter. If you are on a Medicare Advantage Plan there is no claim with Medicare, only the insurance company. In that case you have to read your schedule of benefits to determine the applicable deductibles, copays and network information specific to your plan.

A long passage of time between surgery and salvage radiation often diminishes the success as there is a greater probability of PCa being outside the radiation field. Generally, you will have some scans to try to determine this before SRT would be started. I had a client that had RP and was undetectable for 16 years when his PSA started climbing. His doctors suggested against SRT and went to ADT for him. Every case is different and there is no way of knowing what may be in store for you yet.

For SRT it is almost always IMRT/IGRT, never SBRT. Very rarely Proton, but some centers have begun offering it for salvage radiation. Radiation to the prostate as initial treatment is an entirely different situation than radiating the area absent the prostate. That is why radiation treatment side effects are often more significant with SRT than radiation and an initial treatment.

You can still use the various nomograms to estimate probabilities of SRT success as part of your planning process.

ed -- if your PSA is .126 i would not wait till july to retest. with as long as you've been undetectable i think there's a strong likelihood the cancer is local.

i think the time to see an oncologist is NOW. there's a good chance you won't have to do anything! anyhow man i wish you the best!

JNF said...

...
A long passage of time between surgery and salvage radiation often diminishes the success as there is a greater probability of PCa being outside the radiation field.
...

JFN, this runs counter to every statement I've read about the rate of PSA rise (slow prognosticates better) and how long after treatment the rise begins (longer prognosticates better) as well as what I've been told by doctors. For example:

Biochemical recurrence after radical prostatectomy: what does it mean?

"Short time from RP to BCR has also been associated with poor clinical prognosis. Ten-year rate of PCa systemic progression ranges from 10% to 19% for patients who experienced BCR >6 years or <1.2 year after RP, respectively. Although the time interval from RP to BCR is not an independent variable related to prognosis, patients with early BCR have higher GS, greater preoperative PSA levels, faster PSA-DT and more advanced tumor stage, factors associated to systemic progression and PCa mortality (19)."

which cites

Long-term risk of clinical progression after biochemical recurrence following radical prostatectomy: the impact of time from surgery to recurrence (2011)

This study looked at the time from RP to BCR for 14,632 patients and outcomes and found:

"Cancer-specific mortality 10 yr after BCR was 9.9%, 9.3%, 7.8%, and 4.7% for patients who experienced BCR <1.2 yr, 1.2-3.1 yr, 3.1-5.9 yr, and >5.9 yr after RRP, respectively (p=0.10). On multivariate analysis, time from RRP to BCR was not significantly associated with the risk of systemic progression (p=0.50) or cancer-specific mortality (p=0.81)."

Djin

Djin, good information regarding most recurrences. But we still know that, while uncommon, there are recurrences after 10 or more years of a complete remission with no chemical or physical evidence of cancer.

After my wife completed her initial treatment for BCa she was put on a series of aromatase inhibitors and told she would likely be on them for 10 or more years. We questioned this and her medical oncologist and my urologist discussed the long term possibilities of BCa and PCa recurrence after all very long remission based on their knowledge and experience. Independently they both explained that these cancers have a proclivity to form micromets in the ends of long bones, like the femur, and go dormant for a long time. During this time there is no chemical expressions of activity so they are undetected by common markers like PSA, and too small to show on any type of scan. Then, something happens to awaken them and they start activity, express the chemical markers and can damage again.

This was also the explanation given to my client by his medical oncologist at Winship/Emory Cancer Institure here in Atlanta, that had the long remission span when PSA became detectable and increased. The scans showed nothing to shoot for in the prostate bed where SRT would be administered. Due to these factors they administered systemic treatment instead of 45 or so fractions that would may not solve the issue, but subject an older individual to the treatment rigor and potential side effects of the radiation.

I have read other specialists explain this recurrence following very long remission phenomena, but don’t have the references at hand. It is well established that both BCa and PCa are very bold-borne cancers and by that means spread easily to bones distant from the primary tumor. Being essentially hormone based cancers they are also affected by hormonal changes that can both fuel the cancer like the inappropriate application of estrogen replacement practice in menopausal women, and can suppress cancer like the often used chemical castration of ADT in men. Changes in the hormonal balance, natural weakening of the immune system with age, some shock to the system brought on be other disease, treatment or stress can all be contributors.

And as I said earlier, I think the prudent practitioner would be guided by scans before submitting an 80 year old to the rigors and potential urinary and bowel side effects of SRT just hoping the cancer has been undetectable and dormant in only that one small place for all these years.

Thank you all for your input and advice. As I mentioned, I decided to retest in mid May which is 6 weeks after my last one so my Oncologist can see the acceleration. I’ll post my results.

To show how insidious some cancer can be I just received an update from a high school friend. She had breast cancer in 1998 and suffered a double mastectomy, chemotherapy and radiation therapy; which at the time looked successful. She then appropriately monitored and managed the disease and used tamoxifen for several years and then an aromatase inhibitor for several years. Symptom free and all regular scans, CT’s, and blood markers showed no evidence of cancer. Then in 2017 she suffered a pathological break of a rib bone caused by a BCa tumor that had been dormant and undetected for 20 years. More chemo and radiation and a very diligent management of regular scans and blood tests on a quarterly basis. And then just last month they find BCa lesions in her liver. So now more chemo for that.

Events like this and what Ed is experiencing are all too common with BCa and PCa and illustrate why the intermediate and high risk situations can not turn their back on the disease.

My PSA on 3/30/2021 was 0.126 up from 0.042 on 3/2020. I retested on 4/30/2021 and it was down to 0.12.
My Urologist wants me to wait and retest again at the end of June before I see an Oncologist. However, I did see an Oncologist and she recommended that I should get a PET scan and an MRI to be followed by ADT and IMRT. She thinks that my PSA has gone up the last few years and treating early is better than waiting. I trust my Urologist, he has been with me since the surgery. What do you suggest? all opinions are welcome.