PSA Rising Post SRT - Treatments?

I had a year of PSA <0.1 after SRT. Just had an elevated PSA of 0.34 at my 6 month check. Without any discussion my URO scheduled me for a PSA re-check in 3 months. Since my URO did elaborate on possible treatments, I would like to know what the possibilities are for future treatments.

Kerry

Thanks, Hope4all. I am new to this and for some reason my signature did not post. I meant to say that my URO did not elaborate.

Thanks,
Kerry

This is my interpretation of your PSA: you had a six months shot of Lupron on 08/15. This would last six months until about 02/16. After that your testosterone did recover slowly, usually it takes about three to four months post 02/16 in your case. This would take you until 06/16 with testosterone almost below castration level.

Therefore you still had a PSA value of <0.10 in 06/16. I would expect a rise of the PSA level after that since the testosterone level did continue to recover.

As Andrew wrote, the most common treatment to reduce the PSA value again in the future would be ADT. Take your current situation as an ADT holiday for now. This may end at a PSA of 4, 10 or even higher. Whatever your URO and you decide. If you are lucky, the PSA value will stop rising at some point instead or even go down again for some time.

George

Kerry,

Allen always mentions the TOAD study he has written a blog entry about. This study advocates early start of ADT. As I discussed with Allen in the past, I consider the TOAD study underpowered and question the results. So in my opinion your URO and you are free to decide since nobody knows for sure.

A few doctors start ADT when symptoms occur. This is the very latest and I would not wait that long.

George

rocketphd-

Unfortunately, it does seem that as soon as androgen suppression wore off, your PSA rose, indicating they didn't get it all and that your cancer is systemic. That certainly calls for a systemic remedy.

The TOAD RCT proved that early start of lifelong ADT cut 5-yr overall mortality in half. You can read the abstract or buy the full text here:

www.thelancet.com/journals/lanonc/article/PIIS1470-2045(16)00107-8/abstract

The lead investigator, Dr. Duchesne, made the following additional points not included in The Lancet report:

• Early start increased both prostate-cancer survival and survival from other causes (for some unknown reason)
• Health-related quality of life was not impacted by starting early, at least not in the first 2 years
• Intermittent ADT was used by ⅔ of all men in the study
• The highest survival rates were noted in men who started immediate intermittent ADT
• Castration resistance set in sooner among men who waited. It was delayed in men who used immediate ADT probably because it prevented the evolution of castration-resistant cancer cells. Many hypothesized that the opposite would happen because earlier ADT would exert selective evolutionary pressure for castration-resistant cancer cells to predominate.

Beyond the abstract comments

George misunderstands the statistics involved, and doesn't like the findings, so he is hunting for reasons to ignore them. I don't blame him - I don't like them either, but we have to deal with what is, rather than the way we would like them to be. Confirmation bias can be a deadly cognitive error. The TOAD study was underpowered to detect the differences they expected -- that's what the statistical concept of "power" is all about - but the differences turned out to be much larger than they expected, so it was shown nevertheless to be a statistically significant difference with 95% confidence. The author is working on a meta-analysis with a larger sample.That doesn't force a decision, but is certainly an important factor to consider and discuss with your medical oncologist as you move forward. I think you should be talking to a medical urologist at this point.

George is taking a "whack-a-mole" approach to his recurrent cancer. There is no evidence that it delays progression once the cancer is systemic and micrometastatic, but neither is there proof that it can't help. What clouds the picture is the very slow natural history of early metastatic progression in prostate cancer. It is not unusual to take years for the first mets to grow large enough to become visible, and for a long time to pass between the first and second mets to become detectable. I think patients have to weigh the lack of evidence and potential benefit for this approach against the real evidence from TOAD of the risk of delaying systemic treatment to allow PSA to rise and mets to become large enough to become detectable. But each patient must weigh this risk for himself, and clinical trials, now underway (at Mayo, Johns Hopkins, and several others), may prove there is a benefit.

As for other alternatives worth exploring. You had a PLND and you were N0 based on that, so there's likely to be no point looking for macroscopic mets there. It is an option, however. Fluciclovine was recently FDA approved, and Medicare is covering it, but it isn't the most precise PET scan. The one that is the most accurate so far is called DCFPyL - but I think you'll have to pay out of pocket for it. It just started entering nationwide clinical trials last week and is only available at Johns Hopkins and Yale so far. Here's more info, if this is something you'd like to pursue:

/pcnrv.blogspot.com/2016/12/pet-scans-for-prostate-cancer.html

As I said, I think your best options are systemic. I just blogged about open clinical trials (there are very few, unfortunately) for men in your situation . It really comes down to 3 choices - early treatment with Xtandi (a second-line hormonal currently approved only for castration resistant men with detectable metastases, apalutamide (a very promising new hormonal agent), and Prostvac (a promising immunotherapy). This is discussed here:

/pcnrv.blogspot.com/2016/12/recurrent-pc-non-metastatic-hormone.html

Following up after my PSA rise after salvage radiation.

Another PSA on 04/17/17 was 0.64. A bone scan and a CT were performed on 05/04/17. They were both clear. At the follow-up MO appointment for the scans my PSA was 0.56. The MO viewed the scans and PSA levels as indicative of the cancer being on the low end of aggressiveness. Follow up now is PSA every 3 months and scans every 6 months. My wife and I decided that we would not start ADT for now.

Rocketphd
Unfortunately you're case sounds almost identical to mine except I had SVI and positive margin at the base which is near bladder neck. Cancer there is a poor prognosis because it's easier to spread. You can see what my treatment history was below. When I had recurrence after SRT I waited until a scan would find why my PSA was rising and at PSA of 1.2 it found lymph node mets which I had radiated with 75 grays. Subsequent scans have found no cancer in prostate bed or lymph nodes but I now have a bone met.
The point is that Gleason 9 is hard to stop ; it stays one step ahead of treatments. When I stopped ADT it took off again. You're faced with more radiation to kill mets as they appear if you choose to and ADT to keep them from popping up.
I'm back on ADT and looking for an RO who specializes in SBRT to zap my bone met.
Bob
Bob