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Prostate size and PSA after radiation

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Posted 5/19/2015 3:02 PM (GMT 0)
It’s my understanding that a larger prostate will generate more PSA than a smaller one. When my PSA had steadily increased to 5.3 a few years ago I had a biopsy which was negative and the ultrasound showed a gland size of 60 grams. My urologist attributed a large part of my PSA to the gland size. He estimated that at 60 grams, it was contributing almost 4.0 of the PSA. I goggled to find a calculator which shows this correlation and sure enough the calculator confirmed his estimate.
A couple of years later my PSA had continued to rise and another biopsy found cancer. I decided on radiation treatment at the University of Florida Proton Center. I completed my 8 weeks of treatment in January, 2015.
My hope is that my PSA will eventually fall to < 1.0 like so many of my radiation brethren. Most of the men I’ve talked with who finished their proton treatments 2+ years ago are well below 1.0.
What’s bugging me a little is my RO there said that my prostate may not shrink at all and if it did it wouldn’t shrink more than 25% of its pretreatment size. I asked him how I could expect my PSA to fall to the low levels most other men experience if I still have a larger prostate. With a pretreatment prostate of 60 grams generating 4.0 PSA that would mean even after a 25% reduction in gland size to 45 grams, I should logically expect at least a PSA of 3.0. His answer was that there is no correlation of PSA to prostate size following radiation treatment.
Anyone ever considered this question or had radiation with a large prostate and had your PSA fall to the low levels of <1.0?
Posted 5/19/2015 3:55 PM (GMT 0)
Well that is a head scratcher. First I've heard about that. So the external radiation (not seeds right?) does not kill off normal prostate cells? Or at least not most of them?

If he is correct, then it must still hurt prostate function. Which must include the ability of normal prostate cells to generate PSA. But, actually I have no clue.
Posted 5/19/2015 4:12 PM (GMT 0)
The theory behind RT is that it affects the PC cells far more than normal cells so it mostly kills PC. Still normal cells do get damaged and prostate function is hurt.

Most of the PSA drop is due to killing the PC, not reducing the size of the prostate.
Posted 5/19/2015 5:23 PM (GMT 0)
The reason the enlarged prostate puts out more PSA is that BPH makes the prostate cells leaky. BPH is fixed by the radiation, at least to the extent that the cells don't leak much PSA anymore. My prostate did reduce in size by about half. Yours may too. It takes some time, though.
Posted 5/20/2015 4:17 PM (GMT 0)
Thanks to all, especially Allen. I knew you had larger prostate and hoped you had some knowledge on the subject. Not surprised at all that you do. Wish my RO had given me the same explanation. I may have asked my quota of questions long before my treatment ended and by the time I got to this question he was only giving abbreviated responses.

I did ask him early on if the non cancer cells would survive the radiation and he said a lot of them would. So I followed with the logical next question of could I get new case of prostate cancer in the future. He answered yes it would be possible. How can doctors tell if it's the old or new, I asked. No way as practical matter. There would have to be some genetic testing to make that determination, he said. Another reason perhaps in favor of surgery.
Posted 5/20/2015 4:36 PM (GMT 0)
Had wondered if my prostate would shrink some in the week after doing my first HDR Brachy treatment before coming in for my second procedure, one week later. When I asked the doctor if that would happen he told me it might shrink, or it might even enlarge - but that the goal was to kill off cancerous cells, not specifically to shrink the prostate. We didn't discuss size changes expected in the long term.
Posted 5/20/2015 6:20 PM (GMT 0)
WorksOut, you're right that it's a different situation short term after brachy. I think the reason Demanes prefers the week-apart approach is that it gives the inflamed tissues a chance to settle down some. This is especially an issue with LDR brachy because with up to 100 seeds pushed in with needles, there's a lot of inflammation. In the long-term urinary QOL meets or exceeds baseline, probably indicating some repair of BPH.

Second primary prostate cancer has never been reported. It takes 5-15 years for a second primary cancer to develop, while local recurrences almost always show up within the first 5 years. Radiation seems to cull the most cancer-susceptible prostate cells.

- Allen
Posted 5/20/2015 6:53 PM (GMT 0)
hrpufnstuf -

I want to weigh in here because the basics of my situation were similar to yours: large prostate, primary treatment through radiation (IMRT in my case), concern with similar issues, etc.

There is one thing my RO stressed to me that I think needs to be mentioned here. And that is that following radiation it is the pattern of successive PSA test readings (specifically rises) that needs to be carefully observed. As you probably know, following radiation as primary treatment the patient's PSA does not go to zero, but it will continue to have a numerical value.

The important thing is to see if it continues to rise in successive PSA tests. I believe the traditional standard is still "three consecutive rises" in PSA test results following radiation may indicate recurrence. (Tall Allen, is that still the standard, do you know?)

The point: rather than have a great concern over a single initial or early PSA test result, wait and see what kind of movement in the test numbers occurs over a few subsequent tests. That would be more likely to give indication if there is a problem, especially if there is a consistent rise.
Posted 5/20/2015 6:56 PM (GMT 0)
81guy, why did you need HT with Gleason 6?
Posted 5/20/2015 7:04 PM (GMT 0)
No, that hasn't been the standard for over 10 years now. Nadir+2 (the Phoenix definition) is what's used. But hrpufnstuf's wasn't really asking about biochemical recurrence.

- Allen
Posted 5/20/2015 7:10 PM (GMT 0)
Allen's right; failure wasn't my question. Having my PSA reach a nadir of say 3.0 and stay there because of a large prostate would be a disappointment, to put it mildly. It would very difficult not to think that there might be some cancer there causing a PSA that high.
Posted 5/20/2015 7:18 PM (GMT 0)
hrpufnstuf -

The plan, as my RO expressed it to me, was to hit the PCa with two weapons: first the Lupron would shrink the prostate and make it a better target for the radiation, as well as having an effect on the PCa cells; then after that hit it again with the radiation. She noted that this combination statistically produced better long-term outcomes for being disease-free in the future, even for G6's like me.

I know there is some debate about the point at which this kind of trigger needs to be pulled. In particular, in my case as a G6 with disease likely organ-contained, was the Lupron in addition to the radiation really needed? Since I had great confidence in my RO (who was consulting with my uro along the way), and having done as much research as I could on both her and the cancer center where the IMRT was done, both turning up very positive results, I went with her and my uro's recommendations to do both HT and IMRT. I trusted their judgment.

So far as a result of treatment I have been doing fine. But back to your question, was the HT (Lupron) really vital in my case? Would I have done just as well without it? Personally I think the answer to that question is that I'll never really know for sure. Perhaps it really was overkill to include it, but then again perhaps not.

But what I constantly come back to is that I'm really doing okay right now, and hopefully will continue to do so. I'm happy with that. And I'm therefore not concerned about second-guessing the treatment that did happen.

All this raises a very good question, how much of PCa treatment decisions involve art as much as science, as much the individual physician's "gut feeling" was well as anything else. A very good question.

But again, I'm doing fine so far, and, for me, that's enough.

(P.S. Re BCR and the PSA rise thing, I guess I read between the lines a bit too much. My bad)
Posted 5/20/2015 8:18 PM (GMT 0)
My RO did not think HT was appropriate for me. He had no statistics that showed better results for favorable intermediate that justified the potential SE's. Some men tolerate it pretty well as you seem to have. Others not so well. I was glad he did not recommend it for me even though I believe it probably wouldn't have hurt and may have helped.
Posted 5/20/2015 9:58 PM (GMT 0)
My prostate was 60cc before radiation and my psa is now .05 so I don' think prostate size matters as the radiation should reduce all but a little psa.
Posted 5/21/2015 3:41 PM (GMT 0)
Another thing I learned at UFPTI was that I'm still subject to prostatitis. My RO said since I had a confirmed case of prostatitis it could happen again and my PSA could rise as a result. If PSA should rise he would try antibiotics for a month and recheck PSA. It's bad enough to have a checkup every 6 months, but to have it go up and have to sweat it out for a month would be torture. Wish I had known these things before radiation.

You surgery guys will never worry again about BPH or prostatitis.

Post Edited (hrpufnstuf) : 5/21/2015 9:44:32 AM (GMT-6)

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