Wait for 0.2, radiate ?

Hi all.

My psa seems to be on the rise after having prostate removed in 2017. In 12 months it's gone from 0.02 to 0.48 and a further small increase in the last month to 0.059. My urologist has advised me to wait until somewhere close to 0.2, then do a pet psma scan and just target what shows up. There's been no mention of any hormone treatment then.

He mentions recent studies shows no long term benefits to radiating the prostate bed/area not knowing where the cancer is, so not worth it given radiation side effects.

What do others think ? I like the idea of doing nothing to avoid side effects, but wonder if I need a 2nd opinion ?

Any thoughts welcome.

Hey Jasper…you’ve got some G6 growing in you. (If your pathology can be believed.)

I’ve had two opinions from PCa radiologists. John’s Hopkins told me almost 4 years ago, “You need SRT. We’ll get the ball rolling right now.” I’ve not been back. Another RO in Knoxville, TN told me, “Eventually you’ll need radiation but it’s not something that has to be done today.”

I may revisit it if it ever becomes detectable. (>.1)

They’re not the ones with the stricture.

G6 doesn’t metastasize. But it does grow.

I’m not sure I agree with your urologist’s plan. PSMA is changing the rules of the game for sure. But even PMSA will not guarantee anything at these low levels.

.

I would:

(1) Inquire about getting a 2nd opinion on the tissue removed at your RP. Gleason 6 (3+3) doesn't metastasize, so perhaps higher-grade lesions were missed, or perhaps some healthy and/or G6 tissue was left behind.

(2) Have tissue removed at your RP sent for a Decipher genomics test. This test doesn't look at the pathology of your cancer, but rather the RNA of your cancer. It can give you the genetic risk that your cancer had the potential of being or progressing to Grade 4 or 5 (rather than 3) and your theoretical risk of metastases within 5 years of your RP.

If all signs point to you having been a true G6 (3+3), then any remaining growing tissue is very likely confined to your fossa (the bed where your prostate was) and ideal for RT.

Djin

One of my doctor's words of wisdom:

"A great doctor will ALWAYS encourage each patient to seek out a second opinion."

A word to the wise, is always sufficient, as they say!

With my best ~ stay in touch with us here!

CYCLONE - # Iowa State University

Post Edited (Cyclone-ISU) : 2/22/2022 7:26:51 PM (GMT-7)

Thanks for all the replies. Lots of helpful advice.

I honestly don't believe now I'm really "G6 (3+3)" as the post surgery hist report indicates. Prior biopsies say 3+4 so being a cynic, my bet is on that - especially with rise in psa. Not sure if I can get that report relooked at. I'm in Australia but I will ask the next urologist when I get a 2nd opinion on way forward.

So will see another urologist for 2nd opinion before checking out a radiation oncology guy. I know each will be biased to their own domain, so I'll need to see a radiation guy for their perspective. I'll do that after the 2nd uro consult.

My existing urologist did the urethroplasty op but he hasn't mentioned that part re: in his opinion of deferring radiation. I don't think that was part of his decision making - I think he's just recommending against radiation when the specific area is unknown. My worry is I'm rolling the dice at 0.2. It may have spread further, or what if nothing shows again on psma scan ? I'll just be in a deeper hole ?

I think I'll see a 2nd urologist first and mention if there's any the consequences of radiation on repaired stricture. That's a nightmare I don't want to revisit.

Here is a good thread launched by our former member Tall Allen on when to initiate salvage radiation:
https://www.healingwell.com/community/default.aspx?f=35&m=3495340

Hi. Similar situation.

My suggestions mirror DjinTonic.
1. Worth sending the slides (or even better, have the tissue block re-cut) to Johns Hopkins for a pathology review. Might not change treatment but may provide peace of mind if a G6.
2. Definitely get a Decipher test.
3. You need a urologist, period. But your urologist is not guiding you any further on your cancer journey. See a radiation oncologist. it's time to get a consult (he most likely won't suggest treatment until .1).

Best of luck!

There has been recent interest into the question whether PSMA scanning can be avoided for GGG 1-3 men before starting SRT for BCR after RP. For example:

IDENTIFICATION OF THE BEST CANDIDATES FOR PSMA PET/CT AMONG PATIENTS EXPERIENCING BIOCHEMICAL RECURRENCE AFTER RADICAL PROSTATECTOMY (2021)

"Abstract
INTRODUCTION AND OBJECTIVE:
Although PSMA PET/CT is recommended in the biochemical recurrence (BCR) setting after radical prostatectomy (RP), its impact on clinical management is unclear. This is particularly true when considering prostate cancer (PCa) patients at low risk of metastases who could be managed with salvage radiotherapy (sRT) alone. We aimed at assessing when PSMA PET/CT could be safely avoided or postponed

METHODS:
182 patients evaluated with PSMA PET/CT for BCR after RP between 2016 and 2020 were evaluated. The outcome was a distant metastasis (i.e., retroperitoneal, skeletal or visceral) at PSMA PET/CT. Multivariable logistic regression analyses assessed predictors of distant spots (i.e., pathological stage, grade group, sRT and ADT). The model based on the regression coefficients was internally validated. An interaction analysis tested whether the association between PSA at PET/CT and distant spots varied according to the risk calculated using the model. Patients were stratified according to the model-derived risk (<30 vs. ≥30%) and the rate of distant spots at PET/CT was plotted against PSA values

RESULTS:
Median PSA at PET/CT scan was 0.7 ng/ml. Overall, 76 (41.5%) and 57 (31.1%) had grade group 4-5 and seminal vesicle invasion (SVI). Overall, 60 (32.8%) and 24 (13.1%) patients received sRT and ADT before PSMA PET/CT. Overall, 59 (32.2%) patients had distant spots at PSMA PET/CT. Concomitant ADT (Hazard Ratio [HR]: 5.5; p=0.02), SVI (HR:3.5; p=0.005) and grade group 4-5 (HR:3.7; p=0.01) predicted distant spots at PET/CT (AUC: 80%). The rate of distant positive spots in men with grade group 1-3, no SVI and no ADT (n=34, 18.6%) was 12%. This increased to 41% in patients with adverse factors (p<0.001). The impact of PSA values at PSMA PET/CT varied according to the novel risk score (p=0.03 by interaction test). While in men with a calculated risk <30% increasing PSA values at PSMA PET/CT did not impact on the risk of distant metastases at PSMA PET/CT, in those with worse characteristics it increased according to PSA levels.

CONCLUSIONS:
The use of PSMA PET/CT can be safely avoided or postponed in individuals with grade group 1-3, no SVI and who did not receive previous salvage therapies. These patients can be considered candidates to sRT without a previous PSMA PET/CT."

(See graph)

I would think a Decipher test on the RP tissue would be helpful in the decision-making.

Djin

We pulled the trigger at .13. Clearly you have a BCR. .2 is the max you should wait. We knew where we were headed, so didn't want to risk it. Takes time to get things going and didn't want to risk it. Didn't bother with scans. PSA is too low to show anything. It's an educated guess. BTW, 6 weeks after radiation completed, my boyfriend was back to undetectable...so we are happy with our decision and result. Oh, and we opted for no ADT.

Post Edited (teddydog) : 2/24/2022 4:17:20 AM (GMT-7)

Good move, great plan ...

I can honestly state that the day that I added an oncologist to my medical team was a pivotal, impactful day!

He opened doors, where my original urologist had only seen brick walls.

I met my oncologist on a Monday, for the first time, and we got a new treatment going that same Wednesday that had a positive impact on my health, in terms of cancer treatment.

He is originally from Kenya, and we now have a bond that is akin to brotherhood. Truly one of the best individuals I have ever known!

He moved HEAVEN & EARTH to get new treatments going for me, in the months following a tough diagnosis, & his initial decisions continue to pay dividends.

Great decision on your part --- consulting with an ONCOLOGIST.

Cheering you on ~ sending my support & encouragement ~

CYCLONE - # Iowa State University