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Reconciling theory with observation

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Posted 1/2/2013 6:23 PM (GMT 0)
It is not a study, but simply my observation that there are many men who have untypical stats, latest one camerabug6´s husband, with PSA 5 and cancer in lymph nodes, which is considered systemic. There are a few posters here, who have bone mets with PSA < 10. There are many more posters who had a radical prostatectomy with PSA < 10, yet their PSA continued to climb after the surgery.

Books on PC, guidelines, nomograms, etc. express strong views/links that PC with PSA<10 is a localized disease, and term those that are not as "rare variants", but my observation has been, to a large degree, quite the opposite.

It seems common that a guy with PSA 7 can have lymph node and bone mets (my Dad one of them). It makes my faith in PSA a bit more shaky. If I were a man on AS, I would certainly use means other than PSA to make sure that the cancer is localized. Interested in how many guys here had further problems with PSA less than 10 before local therapy. Not that it solves any problems, just exchanging thoughts. And Happy New Year to all of you out there, the true heros!
Posted 1/2/2013 7:24 PM (GMT 0)
yes the PSA test has it's problems and should really be viewed an indicator of what is going on - not an absolute measurement. I view it this way: Falling PSA good, rising PSA bad.
Posted 1/2/2013 7:30 PM (GMT 0)
SpecialLady,
Poorly differentiated prostate cancer produce less PSA per tumor volume than well differentiated PCa. Localized treatment failure is common because of the uncertainty that exists at diagnosis. A biopsy result is representative of the sample but not necessarily of the cancer present in the prostate gland. Occult prostate cancer can progress from a larger majority of androgen dependent cancer cells to one of androgen independent cells.

When the ratio of androgen independent cells to the androgen dependent cells in the tumor load increases, the cancer becomes resistant and is able to progress using various growth sources other than androgen. PSA level is not representative depending of the degree of dedifferentiation present in the tumor volume. Other markers, like PAP, AlkP, CGA and NSE are available to support PSA monitoring.

How to explain what happen to men who are diagnosed with very advanced disease before the disease is detected? Their response to androgen deprivation is usually poor or not existent. In other words, in such cases through a process of dedifferentiation the cancer, before being detected or any treatment applied(including androgen deprivation), has mutated causing chromosomal gains or depletions that makes it very difficult to treat with our current forms of treatment. Hence, until the present, the high disease mortality in these men. New hormonal treatments have shown that what was considered androgen independence can be still treated with some survival benefits.

The rare variant forms of prostate cancer constitute a very small component of PCa diagnosed these days. The most common variant forms: Signet ring cell, Mucinous, Ductal or Intraductal, Squamous cell and Neuroendocrine. These constitute 1.6% of all the PCa diagnosed while plain old adenocarcinoma of the prostate makes the great majority of cases. Yes, these variants are rare and have a higher mortality rate than the common form of the disease.

Source: http://www.medscape.com/viewarticle/769835

D M Marcus et al. A Comprehensive Review of Incidence and Survival in Patients With Rare Histological Variants of Prostate Cancer in the United States From 1973 to 2008
Prostate Cancer Prostatic Dis. 2012;15(3):283-288.

RalphV
Posted 1/2/2013 7:47 PM (GMT 0)
SpecialLady -

You are absolutely right when you suggest that PSA alone should not be used as any kind of single, definitive guide to treatment, or anything else. Too many variables.

I am one more case in point. When my prostate troubles began last year (as per my signature below), my uro told me following his first exam of me that my prostate, sized at 156 grams (!), was "...one of the top 5 or 6 biggest I have ever seen," as he put it. He said that my PSA test results at that time, which were running 13-something and 14-something, were driven much more by my enlarged prostate size than by any PCa I might be having. It turned out that I did indeed have a case of PCa, as determined by a later biopsy, but he said the PSA numbers in my case were so badly skewed by my prostate size that they were unreliable as indicators of the PCa I had.

Clearly, PSA is only one tool in the toolbox, and must be used along with other measures to determine an accurate diagnosis and treatment plan.

Having said that, though, let's give credit where credit is due. The presence and use of the PSA test result in PCa diagnosis and treatment decisions over, what is it, the past 30 years or so, has been a tool of MAJOR significance in the fight against PCa.

Stop and imagine for a moment just where we would all be if the PSA test, with all of its warts, wasn't available to us. Think of all the posts here on the list over the years in which the term "PSA" appears, and what if all those posts just suddenly vanished. It's not a perfect tool by any means, but I know we'd all rather have it than not have it.

Think of it another way. Think of all the other cancers there are out there that do not have the kind of early warning detection system like the PSA that we have. If those cancers had something like the PSA, what an improvement it would be for all of them.

So I agree with you that a person's PSA score has to be interpreted properly, and in context, but on the whole let's remember that we are lucky to have it available to us, warts and all.
Posted 1/2/2013 8:18 PM (GMT 0)
It's easy to find fault with the PSA test.  We all know it's less than perfect.  I can honestly say, though, that the PSA test was THE FACTOR that led my family physician to recommend I see a urologist, which led to the detection of a nodule, which led to a biospy, which led to.........where I am now, as opposed to where I would have been without the PSA test.

Shortly after I discovered HealingWell, someone posted that the only rule about prostate cancer is that there are no rules.  That may be a bit of an overstatement, but not by much.

Posted 1/2/2013 8:39 PM (GMT 0)
SpecialLady,

PSA may be an imperfect tool, but as far as I know it is the only one that yields a reasonably reliable "numeric score" that cancer and danger are present  In my case my PSA had hovered in the 3.0 range for several years, before leaping in four months to 6.0.  As Holmes said to Waston "Something was afoot."  Biopsy revealed a Gleason 7 PSA, later upgraded to Gleason 8 on post surgery pathology.  Contrast this easy scoring and detection system with breast cancer, as an example. (My wife was first diagnosed with breast cancer nine years ago).  Women have to rely on physical exams, mamograms, and MRIs to know if something is going on. These tests are all open to interpretation.  Sometimes they lead to biopsy, sometimes not. If recurrence arises, the tools for diagnosis are still relatively "clumsy," time consuming, and expensive compared to PSA.  By contrast PSA exams are quick, cheap, and pretty much on the money.  That is, a man initially found with a PSA above 4.0 often has something going on.  A man who has had a radical prostatectomy, and sees his PSA emerge again a few years later, probably has had a recurrence.  Again, I think this is the only cancer that can be tracked so reliably with a simple numeric score.   Best wishes!

Newspaper Lover

Age 68

DaVinci surgery 11/09. Clean margins, clean seminal vessels.

Rising PSA noted 06/11

Gleason 8

Time to recurrrence 18 months

Three month doubling time (summer 2011).

PSA rose from .07 on 06/11 to .17 on 11/11.

MRIs and bone scans negative so far.

Started hormone therapy (Lupron/Casodex) 12/11

Began radiation (SRT) 02/20/12.

Finished SRT 04/16/12

Last Lupron shot 03/12

PSA and testostorone "undetectable"  07/12

Next PSA and testostorone test early January

 

 

Posted 1/2/2013 9:07 PM (GMT 0)
Odds of anyone who comes and stays here being "typical" is very small.

shakehead  

Posted 1/2/2013 9:59 PM (GMT 0)
words like "normal" and "typical" don't mean much, when one is in the exceptions of the rule, for sure.

you make a good point. just like there are a handful of us here - with failed surgery/radiation with rising PSA'a >30, with no indications of mets or physical problems.

sometimes, the PSA, to me, is just a reference point, not a true indicator of what is actually going on with one's cancer itself. just another tool, but only a tool

david
Posted 1/3/2013 1:12 AM (GMT 0)
Special Lady,

I am probably the best example on this site for having a low PSA and mets (.09). Given that, it is still used as a marker, but with several grains of salt. Other markers are used in conjunction with PSA to monitor moving forward.

Before RP it was 4 at age 44. .75 at age 40. The more I type this the more I get upset. Because I fell into the trap of listening to the media, etc. that said that PSA testing causes more harm than good. I also believed someone that said to check back at 45 since I established a baseline. What a load of crap.

I' m generally over my anger and deal with the cards I' 've been dealt the best I know how.

PSA not perfect, true. But, it is valuable to most PC guys in varying degrees, even me.

Sorry for the little rant there.

Jerry L.
Posted 1/3/2013 3:22 AM (GMT 0)

I see your point. The PSA is very confusing for me as well.

I have a PSA of 164 with no signs of bone or lymph cancer

and like you say others with PSA under 10 who do causes me

to wonder also.

It was pointed out to me that I could have micrometastasis

somewhere in the body. Problem is finding out if it is systemic

or focal.

Have no symtoms or problems other than high anxiety.

Will be having a 3.0 Tesla endorectal coil MRI next weak to try

and ascertain what is producing the through the roof PSA.

Think our best hope might be with the C11 Choline Petscan which

shows prostate cancer anywhere in the body. Tried to get it but you

have to have failed treatment to be eligible.

Posted 1/3/2013 3:00 PM (GMT 0)
Special Lady....As has been said PSA is not a determinant, but can be a very good indicator, particularly as it changes.    However there are the variants, usually very aggressive, that don't express PSA.   A friend passed away a year ago after a seven year PCa fight during which absolutely everything was thrown at him.  Finally, the small cell cancer in the lungs prevailed....his PSA was never as high as 10.   My brother's brother-in-law has been treated for ten years with surgery, SRT, and two periods on HT....he was PSA 1 and G9 at diagnosis and has been consistently below PSA 1 for ten years, but is fighting an aggressive strain.

Quick Learner, according the the PSA/Gleason conversion tables PSA 164 and G6 indicates tumor volume of about 35cc, about the size of a normal prostate.   I have seen it reported that it is unusual for G6 to become systemic, but not impossible.   Another aspect is that if your cancer is in the transition zone, the normal biopsy will not find it and you could have a sizable tumor that isn't being hit by the biopsy needle.   Thus more testing.   Of course you could have other issues that would raise the PSA, but 164 seems like a lot

Posted 1/4/2013 6:16 AM (GMT 0)

JNF,

One of the best advisers, mentors, and posters, JohnT, told me that transition zone tumor volume does NOT correspond to PSA.  He also said lymph node tumors don't either. In other words the 35cc size does not apply. 

Thanks for your input.

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