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Why is PSA leveling out after surgery and salvage radiation?

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Posted 6/11/2020 8:20 PM (GMT 0)
I had prostatectomy in 2013 with Gleason 4+3, followed by salvage radiation concurrent with 6 months ADT. PSA has continued to rise while doubling time is getting slower, around 12 months as of March 2020. DCFpyl PSMA scan April 2018 at PSA 0.5 found nothing, Axumin scan Nov 2019 at PSA 2.0 also negative, and Gallium PSMA scan March 2020 at PSA 2.3 was also negative. Surprisingly, Ultrasensitive PSA readings exactly 13 weeks apart, Sept 2019, Dec 2019, March 2020, June 2020 are respectively, 1.63,2.12,2.31,2.33. All use same lab and methodology. Doubling time using last 4 data points is now 18 months. I am trying to understand what is going on. My diet has not changed much, although perhaps less sugar. Exercise is the same. Is there a next step that makes sense or do I just continue quarterly PSA tests?
Posted 6/11/2020 8:27 PM (GMT 0)
I guess (!) that you have micro-metastases that are too small to be picked up by the scans.
Time to call on the expertise of a medical oncologist
Posted 6/11/2020 8:39 PM (GMT 0)
Hi Teddy. Sorry you haven't gotten the answers you deserve yet. First, what are your docs saying? Clearly your PSA has been rising, and you would think your level is high enough for the newer scans to pick up the source(s), but as you know, they are not perfect. The only thing that comes to mind other than a missed significant lesion(s) are multiple microlesions too small to detect. Most of these new scans have to be carefully callibrated regarding background takeup: most organs and tissue pick up the radioligand, but not to the extent of PCa cells. Also, the tracers eliminated via the kidney and not the liver light up the bladder, making lesions at the urethra-bladder junction difficult to diagnose.

Keep up posted, please! All the best,

Djin
Posted 6/11/2020 9:10 PM (GMT 0)
Yes, a good PCa MO should be guiding you now. I would say with your doubling times, you don't have a lot to worry about at the moment. If that rate holds, it could be years before you need to do anything.
Posted 6/11/2020 9:43 PM (GMT 0)
Thanks for all these comments. Yes my medical oncologist as well as the radiologist who read the recent Ga Scan said micrometastatic tumors is likely what I have and too small to pickup even with the latest scans. They also say that with long doubling times, they would not treat until PSA hits 4 or even as high as 10 - 20. I am not sure I would wait that long and will consult with another MO after the Sept results.
Posted 6/11/2020 10:25 PM (GMT 0)
Glad to see that have an MO. His suggestion for postponing treatment until PSA 10-20 is pretty spot on for many, but not all MOs. I think he's giving you a good lay of the land. Anxiety with the knowledge of an increasing PSA is understandable, but unfortunately, it may lead to the starting of ADT earlier than necessary.

There are knowledgeable members on the forum who favor the approach of starting earlier, rather than later.

Really, for the most part, it's all up to you.

Good luck!
Posted 6/11/2020 10:55 PM (GMT 0)
It doesn't mean you have to do nothing while waiting for that high a PSA. Oligometastatic PCa (1-5 lesions) is receiving much study and it's thought that some cases are even curable. Depending on their location, some lesions can be spot-irradiated. I'm sure this is frustrating for you, but be patient and stay vigilant.

Djin
Posted 6/11/2020 11:35 PM (GMT 0)
Yes. But I have not found any lesions.
Posted 6/11/2020 11:41 PM (GMT 0)
Yes. But I have not found any lesions.
Posted 6/11/2020 11:48 PM (GMT 0)

teddy9 said...
Yes. But I have not found any lesions.

Yes, your scans have been negative. I meant that you don't necessarily have to wait for a PSA of 10-20 to repeat a scan. Also, research continues into even more sensitive radioligands -- I'm sure your docs will be able to guide you as to what scan and after what interval

Your RP was some time ago, but you could inquire if the institute where it was done still has your RP tissue banked. A Decipher test to determine the genomic risk of metastasis could provide a clue whether the location of recurrence is more likely local/contiguous or metastatic.

If your docs hit a wall, you can try others at a prostate Center of Excellence, if you haven't already.

Djin
Posted 6/12/2020 1:16 AM (GMT 0)
Djin,
I recall that the hospital where I had the surgery keeps the tissue for 20 years, however I do not know if the tissue is viable for the genomic testing. I will investigate. However, given none of the 3 sensitive scans (PSMA and axumin) ever found anything, do you think that the cancer could be localized in the prostate bed vs micrometastases elsewhere in the body? What I am getting at is whether the genomic test would be useful at this stage? I wonder if medicare would pay for it.
Posted 6/12/2020 2:37 AM (GMT 0)
If they have the tissue, the test should be fine, but GenomeDx is good about answering questions about their Decipher test. Since labs can get hints of genetic material from fossils, there should be no problem with RNA from archived tissue smile. I'm not a doctor and am just putting out ideas. You could do your own research about the test's utility to you at this point, and also ask any docs you consult with what their views are. I believe the company now has a reasonable fixed out--of-pocket fee when insurance coverage is denied, but I wouldn't think it would be in your case.

I personally give weight to docs whose opinion I trust, but good docs usually agree consults are wise, too. Statistics are one thing, but the patient-centric view can be quite different. Getting more information doesn't mean you must move on to treatment -- it can also give you peace of mind to hold off. My own attitude has been that I wanted to learn as much as possible about my cancer.

PCa can spread locally to the bladder, rectum and elsewhere. There are reports it can spread by perineural invasion, to larger nerves, too. SRT can be limited to the prostate bed or it can be whole-pelvis. Obviously the latter encompasses more lymph nodes.

Djin
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