PSA Rising After HDR Brachytherapy

In 2019 I had HDR Brachy + 3 wks general beam

Last week (June 7, 2022) I had a phone call with my oncologist. My latest PSA in June was 2.4 so it has now risen steadily since my low point of 0.73 in Dec 2020. He said it is most likely a return of my PC and it is growing slowly.

He said in Ontario I would need to have a PSA of 2.73 in order to have a PSMA test. However he did say he could order an MRI to do more diagnostic testing. He said I could wait until Sept for the MRI.

Should I get the MRI done as as soon as possible?

Should I try and get a PSMA test soon elsewhere rather than waiting for my PSA to rise?

What are the most likely treatment options of a reoccurrence after HDR?

Thanks!

Thanks Mumbo - I appreciate your response:>)

TWF, The Vic Hardy tread is worth reading and following. If you look at my signature you’ll find my PSA was also bouncing; but, appears to have settled down. Be sure to stick with the same assay and following normal cautions such as no sex prior to blood draw etc. Good luck and keep us posted since we learn from one another’s experiences. Terry

Vic Hardy link if you need it. It is still on first page.

https://www.healingwell.com/community/default.aspx?f=35&m=4293892

TWF,

don't panic. The thread I started is pretty long but the upshot is that I had SBRT/Cyberknife therapy 18 mo. ago and my PSA started rising, from 0.7 to 1.46 and my docs, URO and RO both were nudging me to pick a therapy, RP or cryotherapy, neither of which I liked. My URO in particular did not recommend AS, so I started researching other therapies and in the course of that came across a well-respected HDR/LDR doc in Detroit (Alvaro Martinez) that JNF recommended. I sent him my records and his first words were, "Why are you thinking about therapies now, when what you have is almost certainly a PSA bounce?" Just wait and monitor your PSA".

Another doc at Sloan Kettering (James Eastham) who was doing a photodynamic therapy study said essentially the same thing.

My situation is a bit different than yours in that my URO had me do a PSMA, MRI and a biopsy so we had more data. The biopsy from my understanding is not usually done post radiation and mine showed 80% volume of adenocarcinoma, 'however' the caveat was that it showed 'radiation effect' which implies that it's old cancer cells still in the process of dying as JNF points out. Also, looking at Terry's signature where he peaked at 2.7 before coming back down was a 'a-ha' moment for me. Dr. Martinez said he's seen bounces up in the 4's and 5's.

All data is good and I'd recommend a contrast MRI if your system will allow that now. Mine came back with a PI-RADS score of 2. Do the PSMA as soon as you are eligible of course. And since I'm a data nerd, I'm having a PSA draw monthly until I'm confident that it's really a bounce. Mine did actually go down from 1.46 to 1.09 after the initial scare but I would not be surprised if it goes back up... This really is stressful!

Good luck and keep us posted.

Mel the two are unrelated.

When radiation is used as the initial treatment most all the cancer cells are left in the area, albeit damaged by the radiation in such a way they can not repair themselves and get back to the business of dividing and multiplying and spreading and mutating and wreaking havoc. However, they don’t all die at once. Some die when ionized, some are already near death naturally and die off soon and gradually, hence the normal downtrend in PSA, and many hold on for a long while. That cell death (apoptosis) can take a long time as the prostate cells are among the longest lived in our body, 2-2&1/2 years. It is generally held that there is a mass dying of most the remaining radiated cells in the 18-36 month range and in about 65% of men creates an extra expression of PSA. Hence the bounce. The dead cells then no longer express PSA and are eliminated from the body and the reduced PSA remains from what is left of the prostate continues and is usually very low. When that PSA stabilizes at a low value over time we have a complete remission of the cancer. It is not being treated and there is no measurable evidence of cancer. Any PSA is coming from what is left of the prostate.

In your situation, the prostate and the bulk of the cancer was removed. You obviously had some cancer outside the surgical and SRT fields that has persisted and has been growing. When you find and hit these Mets with radiation, it knocks them down and kills many cells so the tumor is smaller and expresses less PSA. Then the remaining cells divide and multiply and Mets grow in volume and express proportionately more PSA. So your PSA up and down is proportionate to reducing some tumors but then those and others growing. Since you are systemic and radiating only some of the cancer the focused radiation is less likely to be curative. However it is of good value as it debulks the overall tumor load and controls sources of growth and spread. It can also alleviate the problems of tumors as they grow and encroach on organs and bones causing pain and dis-function.

That doesn't look like a PSA bounce to me. As you surmise, the question is where the recurrence is located. I would try to get a PSMA as soon as your insurance will cover it.

Djin