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Posted 5/4/2024 12:34 PM (GMT 0)
Hello, lately I have been seeing how my PSA increases, slowly but…. These are the measurements 0.045………..03/02/2021
0.038 ……….03/22/2021
0.036………..09/21/2021
0.037…………03/21/2022
0.041…………09/21/2022
0.042…………03/21/2023
0.054………..10/21/2023
0.068………..02/05/2024.
My pathological examination was PT3a clean margins, seminal vesicles free of cancer and no lymph nodes. 3+4 20% of 4. The doctor tells me that up to 0.2 there is nothing to worry about or act in any way. When it reaches 0.2, will it mean cancer again?
Sorry for my English, I am Spanish and I use a translator. thank you
Posted 5/4/2024 3:38 PM (GMT 0)
I do believe that your doctor is correct. I have read that some doctors like to start treatment at a PSA of 0.1 ng/mL, but I don't know if that has been validated. I have also seen cases where the PSA settled at some low level for quite some time without treatment. Let's hope for that to be the case.
When did you have the surgery?
Since you asked, YES, if your PSA keeps going up it does mean that there is cancer somewhere.
Posted 5/4/2024 4:10 PM (GMT 0)
Hello, I had surgery 11/21/2020. If reaching 0.2 happens late, what percentage is there that he only receives radiotherapy and is in a prostate bed?
The urologist also told me that if it reaches 0.2 they would do a PET scan and if it came out clear they would do nothing.

Post Edited (jotaToledo) : 5/4/2024 8:15:23 AM (GMT-8)

Posted 5/4/2024 6:21 PM (GMT 0)
Hi Jota,

At this point you should start searching for a radiation oncologist that you feel comfortable with.

The standard of care for a recurrence is not this

“ The urologist also told me that if it reaches 0.2 they would do a PET scan and if it came out clear they would do nothing”

My dr’s assumed that the cancer was near where the prostate was. They radiated that area along with 6 months of hormone therapy. In my case that did not work, but they did not wait until my psa reached 0.2.

Some men get a decipher genetic test to get a sense of the chances of the cancer metastasizing.
Posted 5/4/2024 10:00 PM (GMT 0)
Hi Jota - You had an intermediate grade cancer, no other issues noted in post-op pathology, and your doubling time is still pretty long but decreasing. Looks like another year before you get near 0.10. Many doctors would wait until PSA = 0.20 before next steps in this situation. However, you have prostate cancer, not the doctor, so you have reason to ask questions and understand your options fully.

I agree with Stephen and you see a radiation oncologist (RO) to get their opinion of your situation since they would most likely to do secondary treatment. The PSMA PET scan generally does not discover cancer at low PSA so you need to discuss with RO doctor about radiation without a specific target for your situation.
Posted 5/5/2024 9:42 AM (GMT 0)
Joto,

How old are you? Yes, the slowly climbing PSA means that a few cells escaped the scalpel during surgery, and they have started to grow, so it is likely future treatment is coming. As Mumbo said, it's slow, you're at least a year away from further treatment.

The scans that exist today are unlikely to identify the focal point for radiation until your PSA gets above 0.1, or maybe 0.2. The doctor who will know more is a Radiation Oncologist, so it would be good to identify one and visit for a consultation. There isn't anything wrong with setting things up and starting the process now, knowing that it is coming. It's likely your treatment will consist of a series of radiation treatments that will last a few weeks, and then you'll be done with it.
Posted 5/5/2024 12:48 PM (GMT 0)
Your English is fine! I think you should see a radiation oncologist. A lot of doctors and researchers believe that you should initiate radiation at a lower level than 0.2. I started at 0.05. Search for articles about "early salvage radiation."

A recent study concluded "Based on these data, clinicians may offer salvage RT at PSA levels less than 0.2 ng/mL to patients who are assessed as being at high risk of subsequent clinical progression." The study can be found here: https://www.auajournals.org/doi/10.1097/JU.0000000000003892
Posted 5/5/2024 1:20 PM (GMT 0)
fiddlecanoe - It seems that the “really” early salvage philosophy, <0.10, has faded somewhat since I started in 2018. Early salvage seems to be defined as 0.20 - 0.50 as a standard now. High risk cases are still set aside for “special treatment” considerations like adjuvant radiation and really early eSRT.

I think jota’s doctor is following current thinking except for the statement “The urologist also told me that if it reaches 0.2 they would do a PET scan and if it came out clear they would do nothing.” If his PSA > 0.20, the serious treatment discussions should take place, even if scans do not find anything. To treat or not treat is the big decision problem as the scans are far from foolproof.
Posted 5/5/2024 4:00 PM (GMT 0)

Mumbo said...
fiddlecanoe - It seems that the “really” early salvage philosophy, <0.10, has faded somewhat since I started in 2018. Early salvage seems to be defined as 0.20 - 0.50 as a standard now. High risk cases are still set aside for “special treatment” considerations like adjuvant radiation and really early eSRT.

I think jota’s doctor is following current thinking except for the statement “The urologist also told me that if it reaches 0.2 they would do a PET scan and if it came out clear they would do nothing.” If his PSA > 0.20, the serious treatment discussions should take place, even if scans do not find anything. To treat or not treat is the big decision problem as the scans are far from foolproof.

yeah screw the scans and get treated well before .2
Posted 5/6/2024 1:54 AM (GMT 0)
Jota, I agree with the above comments, you should see a radiation oncologist. A urologist is not the person to make these decisions. They are generally surgeons, and once surgery is done, their job is done.

My PSA started rising 2 years after surgery and at 3 years it reached .08. My surgeon, one of the best in the country, recommended I do nothing, and do a PET scan when it reached .2, then if PET showed noting, still do not treat, and do another PET Scan when PSA reached .4. Sound familiar? I took it on myself to meet with two top radiation oncologists, one at Sloan Kettering in NY and the other at Cleveland Clinic in Florida. They both recommended I treat and not wait, which I did. Both Rad oncologists cited studies, I tried to find them but could not.

This would be a good article for you to read.... Its from the Journal of Urology and is dated April 1st, 2024.
https://www.auajournals.org/doi/10.1097/ju.0000000000003892

Among other important things, the article states : Clinicians should inform patients that salvage radiation for a detectable prostate-specific antigen (PSA) after RP is more effective when given at lower levels of PSA. (Strong Recommendation; Evidence Level: Grade B)"

And also: "12. In a patient with a BCR following RP, clinicians should not withhold salvage prostate bed RT in the setting of a negative PET/CT. (Expert Opinion)
The detection rate of PET/CT, particularly at low PSA levels, is not high enough to determine that patients would not benefit from salvage RT in the setting of a negative PET/CT.42 As such, withholding salvage prostate bed RT in patients without detectable lesions on PET/CT may miss a “window” of opportunity to more effectively treat a minimal amount of recurrent disease.
Posted 5/6/2024 9:59 AM (GMT 0)
I have read the article and I see that RT is offered at <0.2 if it is high risk, I think I do not fall into that group for now. and equal percentages of success in RT are given from 0.2 to 0.5 depending on the article. The new protocols come from meetings of many specialist people and I think we have to trust them. I also think that when they do not do radiotherapy so soon it is in case it stabilizes and you give RT without need, on the opposite side the sooner the better, what is the middle ground? always take risks? but RT is not a game. Thanks
Posted 5/6/2024 10:49 AM (GMT 0)
Jota,

I see your concern. I'd ask, as I am unfamiliar with the system in Spain (I'm assuming you're in Spain from the 'Toledo' in your handle), what is the process for seeing a specialist there for a consultation?

The key point is that your urologist is not the expert here, a radiation oncologist would be. It would be worth your while to arrange a consultation soon, at least to weigh the options carefully and to know who to call when needed.
Posted 5/6/2024 2:47 PM (GMT 0)

gfspain said...
I have read the article and I see that RT is offered at <0.2 if it is high risk, I think I do not fall into that group for now. and equal percentages of success in RT are given from 0.2 to 0.5 depending on the article. The new protocols come from meetings of many specialist people and I think we have to trust them. I also think that when they do not do radiotherapy so soon it is in case it stabilizes and you give RT without need, on the opposite side the sooner the better, what is the middle ground? always take risks? but RT is not a game. Thanks

I agree with your interpretation, Jota. SRT for a BCR of 0.2 to 0.5 is still considered "early" and administering "very early" SRT at 0.1 is more often advised for post-RP men considered to be at high-risk for clinical recurrence. Other factors one may want to consider or bring up for discussion with your docs are post-RP PSA nadir, interval from RP to BCR, rate of PSA rise, the location and extent of one's specific adverse RP path findings (EPE in your case, I believe), and genomic/germline test results.

I have an upcoming PSA test and may be in your position.

Djin
Posted 5/6/2024 8:29 PM (GMT 0)
Being PT3A it is probable that your increase means something. However, it is slow. I would not seriously consider radiation now, but I certainly would if PSA reaches a value close to 0.1.
May I ask you where your tests are made? I am in Madrid and I just get fluctuating numbers below 0.1, always with only two decimal figures. It is out of curiosity, after many tests in the same private hospital I will not change of lab anyway.
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