rising psa 18 months after robotic prostatectomy -advice needed on next step

.1 is the cut off most used. The use of ADT with SRT is common the theory is that the ADT weakens the PC and gives a better result. It can take a year or two for SRT to reach its lowest point so a short course of HT, won't mask the results for long. SRT and HT are about the only options if your PSA keeps rising. Doubling time isn't all that meaningful at this point, except to maybe predict the time when you'll be facing SRT.

Hang in there,
Andrew

1. is there any logic to starting IGRT prior to psa 0.2 ng/ml ? Will insurance cover IGRT if started too soon?

Yes, there is some logic to reacting sooner. In a recent study among men with pT2 (like yours) they found that PSAs higher than 0.03 predicted biochemical recurrence, and gave a 33 month lead-time advantage over waiting for PSA to go up to 0.2. They also found negative margins (like yours) were faster growing.

I've never heard of insurance problem with earlier SRT, but it can't hurt to get pre-authorization.

Ultrasensitive PSA Identifies Patients With Organ-Confined Prostate Cancer Requiring Postop Radiotherapy

4. Does my doubling time of 4 months really mean anything with these low psa numbers? Or does it only matter after psa hits 0.1 and higher?

In another study, they found that men with PSA≥0.03 who had a PSA rise ≥ 0.05 within a year often went onto full biochemical recurrence. But they did not break out separately men with adverse pathology.

Low detectable PSA after prostatectomy – watch or treat?

A recent study at Johns Hopkins also found 0.03 on the first 3-month PSA to be predictive.

Johns Hopkins: ultrasensitive PSA after surgery predicts biochemical relapse

2. Is hormone therapy ADT overkill at this point? Seems like I would want to know if the radiation is working before ADT, otherwise I may never know if my psa drops.

ADT with radiation is a temporary adjuvant treatment, and you will have a respite afterwards where they can track any PSA progression. Recent evidence is that ADT may improve outcomes for men with Gleason 4+3. But read the caveats at the bottom of the following:

Combining ADT and salvage radiation therapy improves outcomes

3. Any other treatment options I should consider?

Even given all the above, PC progression is usually very slow and it is unclear what PSA one can wait for before late treatment impairs survival. A UCSF study with 6 years median follow up, found that when patients waited for PSAs to rise above 1.0, their risk of metastases and PC mortality rose considerably. With longer follow up, it may be that earlier SRT saves more lives - we just don't know yet.

Another diagnostic worth considering is called Decipher. It's expensive, but approved by Medicare and most insurance (check first!). It tells one after surgery the risk of metastases in the next 5 years. It's pretty good at predicting which ones won't progress in that timeframe, but not so good at predicting those that will.

There is a clinical trial now for completing salvage RT in a shorter time. Early results have been excellent.

- Allen

thanks for everyone's comments. I will check out the referenced links.

teddy

Octorobo,

It's good to hear of your success with SRT. I've sent you an e-mail. My doc also said that ADT would not be required with SRT since my GS was 3+4. With my recent uPsa increase he is suggesting I start considering SRT should I reach .03. He wants me back again in 6 weeks to establish a trend if it exists.

John

thanks, Gemlin and all, I will be discussing whether ADT is necessary with my Urologist in a few days, and then also with Radiologist shortly afterward.

teddy

This is Teddy the original poster. An update -

My urologist advises ADT plus radiation given I had a 4+3 gleason, and concurs with the Radiation Oncologist. The probability of a 'cure' is better with ADT according to the nonograms at Sloan Kettering website - 50% vs 70%.
My psa test result has increased from 0.079 in Sept to 0.087 just 5 weeks later and still presents a doubling time of about 4 months. I am also seeing the head radiologist at SK this coming week to get one more opinion although from what I have read, he is likely to concur with the treatment plan.

Tentatively will be getting a shot of Firmagon that lasts one month, followed by 3 month Lupron shot. Firmagon will bring testosterone down quickly with out the bump in testosterone level (flash). I know casodex is an alternative however this works a bit faster and perhaps has less side effects. Radiation to start after 3 months ADT.

Teddy
You are following the usual protocol . However you should ask about the scope of the SRT as well. I had IMRT to prostate bed only and now I'm having it to lymph nodes due to scans finding two suspicious iliac nodes even though I had no nodes positive at RP. I would ask your rad oncologist about doing the pelvic nodes as well.
Bob

Good luck. I recently completed SRT and hit both prostate bed and nodes.

Teddy
Not sure how many there are but an MRI scan with and without contrast will determine if any PCa resides in the nodes. I had ten removed at RP all benign, but I suspect they were the ones easiest to reach. Some are very deep and not easily reachable. My scans were done at Sand Lake Imaging in Orlando where they have the capability. Very few places have the scanning capability to find lymphatic mets. I'm having imrt using DART at Dattoli Cancer Center in Sarasota which has unique radiation capability.
Bob

I see no reason not follow the advice. A retest in three months is reasonable. We're hearing that doubling time isn't as meaningful as once thought.

Not sure a MRI would show anything with that low a PSA.

Hang in there,
Andrew