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PSAV 12 months prior to diagonsis

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Posted 9/12/2014 1:32 AM (GMT 0)
I just read tonight that men with a PSAV of more than 2ng/ml in the 12 months prior to diagnosis are 10 times more likely to die from PC than those with PSAV under 2ng/ml. That's reassuring.
The outlook just gets worse and worse for me. First, many tell me I should consider AS, that with a GS 6, 1mm cancer I'm low risk. Then I have mpMRI and the radiologist tells me I might have SV invasion and the 1mm is probably more like 7 mm and needle just got tiny piece, and it's probably GS 7 because GS6's don't usually invade the SV. Now I read that men with PSAV >2 in preceding 12 months is often sign of aggressive cancer and predicts spread. Radiation is not enough. Hormone therapy should be prescribed as well.
Posted 9/12/2014 2:45 AM (GMT 0)
The article you read is very controversial. It is worth noting, but don't be overwhelmed by it. I did a fair bit of research into this several years because I too had a brisk rise prior to treatment.

My PSA went from 2.7 to 5.3 in 12 months. I'm having a biochemical recurrence now, and am about to start salvage radiation but my PSA at this point is only 0.1 and my surgery was 4.5 years ago. So my post-surgery PSA has shown a relatively slow growth rate as these things go. That said, there are other guys here who had high PSAV among other adverse signs that you DON'T have, and they are now fighting a more aggressive cancer. So YMMV.

There is a later research report that found that while a high pre-treatment psav is indeed correlated with a worse outcome, it is also true that a high pre-treatment psav is highly correlated with many other features, for example high PSA in absolute terms, high gleason, positive margins, SV invasion etc. When you do a statistical procedure called "multivariate analysis" it is possible (if the sample has been constructed properly) to tease apart the different variables and assess the impact of each on a man's prognosis. This report found that once the other factors were taken into consideration, high PSAV did NOT have a statistically significant relationship with disease progression and mortality.

You might want to check out memorial sloan kettering nomograms (google: prostate nomogram mskcc) to put in your stats and see what that says about prognosis. I think you'll find it reassuring. it would be very unusual to have one positive core of 3+3 or 3+4 and have seminal vesical invasion. Not impossible but very unlikely.

If you choose to get surgery you will have the pathology report afterwards and that will tell much more about your situation than PSAV. That would tell you whether adjuvant radiation or hormone therapy is needed.
Posted 9/12/2014 3:14 AM (GMT 0)
Myself, and both my urologist and oncologist, both prescribe to the inherent dangers of having a fast PSA rise record, in particular, to the 12 months prior to an actual PC diagnosis. There are doctors that strongly disagree, to be fair.

I have been the poster child for that theory. My PSA rose from 4.x to 12. x in the last 12 months prior to my 3rd and final biopsy. Then in just 2 more months (awaiting surgery) it rose again from 12.x to 16.x.

My surgeon was very troubled by this, and my surgery quickly failed (in 9 months). My first post surgery PSA was .05, and the doctor said it was very troublesome..

Make a long story short, I then underwent salvage radiation. Not only was it administered wrong, which left me disabled, it too failed fast, in less than 9 months.

My PSA has grown since, to above 80.x. It did take an unexpected drop earlier this year for the first time ever, but until it's checked again in December, we are sure if that drop was just a quirk, or more hopefully, the signs that it is indeed dropping on its own.

David
Posted 9/12/2014 3:15 AM (GMT 0)
You have to be more selective in what you read. PSAV is no longer considered prognostic of a worse outcome.

MSK says (Urology, March 2014), "(6) PSA velocity is uninformative of risk at diagnosis; (7) high PSA velocity is not an indication for treatment in men on active surveillance"

A commentary on PSA velocity and doubling time for clinical decisions in prostate cancer.

Harvard/Brigham & Women's says (Urologic Oncology June 2014) "its calculation does not significantly enhance the clinical performance of PSA alone."

PSA velocity: A systematic review of clinical applications

Save the PSA kinetics for after treatment (hopefully, never!).

- Allen
Posted 9/12/2014 12:10 PM (GMT 0)
Thank you all for responding. I had a terrible night last night after doing so much better in the past couple of weeks as I prepare for my trip to UFPTI next week (9/17-9/19) for my consultation and work up for proton therapy.

I had decided to give myself a break from all the internet searches I've done the past 2 months and see what the oncologist has to say when I meet with him next week. I just received my agenda for the work up and notice it doesn't include a biopsy. I had expected that it would since they have my mpMRI report and images and can see that the radiologist noted a 7mm suspicious image near or at SV which he thinks could be the primary tumor from which my positive 1mm biopsy core was taken. He thinks it is a moderate chance that the suspicious area is cancer, and if it is he would not be surprised if it contains some Gleason 4 since my initial grading was 3+4 and was downgraded by Hopkins to 3+3. They're implanting gold markers so it would seem to be convenient to do the biopsy. I'm sure the doctor will explain why he's not doing the biopsy.

I noticed that I'm scheduled for some lab work on my first day which got me to wondering if they would check PSA again. That led me to reading about PSA to see if it's routine to check PSA just prior to treatment. Eventually I wandered into discussions about PSAV rising more than 2.0 in the 12 months preceding diagnosis. I should have stayed away from the internet.

Allen, as usual your knowledge is comprehensive and current. Your comments and links were especially helpful and reduced my anxiety.

Post Edited (hrpufnstuf) : 9/12/2014 8:12:15 AM (GMT-6)

Posted 9/13/2014 3:30 PM (GMT 0)
I had this very worrisome talk with Dr. Grimm, a prominent BT man. Long story short, he and his colleagues do not take PSA kinetics lightly, but hold to PSA as a stronger predictor.

You will hear both sides on this forum and see a ton of clinical trials going both ways. Nevertheless, Tall Allen's info is the latest and has helped to put down a lot of anxiety.

There are some who hold PSA density as a solid predictor of BCR. But, the following trial quote places some doubt on that topic as well.

PSAD was better than PSA in predicting EPE (p<0.001) and BCR (p<0.001) in patients with a biopsy Gleason score ≤ 6. In patients with biopsy Gleason scores of 7, PSA was more predictive than PSAD for SV involvement (p<0.001), LN involvement (p=0.017), and BCR (p<0.001). For men with biopsy Gleason scores ≥ 8, there was no statistical difference between PSA and PSAD in prognostic value for pathological or clinical outcomes.
Posted 9/13/2014 6:04 PM (GMT 0)
It's important to remember, there are experts in the PC field, that feel strongly to the other side of this argument, that do believe that rapid PSA velocity in the 12 preceding months to a PC dx. can be (not always) be predictor of a more serious outcome. As mentioned above, my case has been the perfect example of how this can play out, especially when I "only" had a Gleason 7 case to begin with. My cancer journey has acted aggressive from the start, and continues to do so, despite the numbers, studies, the opinions differing back and forth.

That's why its important, especially to the OP of this thread, to remember to take their medical advice from real life doctors and PC experts, not from internet peer to peer PC patients. All we can do is share our personal experiences, and share what our doctors and experts have told us.

I would never make a medical decision on what I have learned here in nearly 6 years, despite the fact that we do have some posters that are way more knowledgeable than others, it still doesn't make them an experienced medical professional.

This is a good place to bounce off ideas and theories, but not a good place to decide treatments or non-treatments, in my opinion. Plus, of course, its a great place for support.

David in SC
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