Low PSA and sizable cancer?

Now that my husband is facing a suspected recurrence, and we're trying to figure out when to start salvage RT, I keep going back to something I read in Patrick Walsh's book: that some prostate cancers produce very little PSA. I've read similar things elsewhere and, recently, came across posts here on HW from rcroller that stopped me cold. (Rcroller wrote that he had a bone met with a PSA of only 0.1. An oncologist subsequently told him that about 5% of men have PCa that produce very little PSA.)

I can't help but wonder whether my husband is one of those men for whom the PSA number doesn't predict the extent of disease (and thus shouldn't be used to make treatment decisions):

Age 50 at diagnosis
Prostate size: 39 grams
+ DRE
PSA at diagnosis 1.7
Cancer comprised 25% of prostate, bilaterally
Adenocarcinoma, Gleason 7 (3+4).

Are there any others out there with (what I think is) a really low PSA but palpable cancer?

Generally, the higher the Gleason, the lower the PSA expression based on tumor volume. This low expression is also found in neuroendocrine and small cell cancer, but they are found in less than 5% of advanced PCa diagnosis. That he is adenocarcinoma and G7, it should follow the known standards.

Apart from Gleason, there are some 24 different PCa variants based on such variables as ploidy. Several years ago a doctor in Germany developed an effective method of matching the variant to a treatment plan. Since then both Bostwick and Epstein have offered more advanced pathologies, but they are not usually included in the standard tests. It turns out that about 95% of PCa is the rather standard adenocarcinoma and that looking for other strains isn’t very efficient.

Have your docs do more digging if you suspect something amiss.

Thanks for that info.

So in theory Epstein saw the slides when we asked for a second opinion after RP. But we're pretty sure he didn't see all the slides. (Long story that was never fully resolved with Lenox Hill Hospital.) Epstein's path report as well as the original both say adenocarcinoma. We never specifically asked about the more advanced pathologies; I didn't even know that was an option. Does Epstein automatically look for these?

FWIW my gut says that it's a regular adenocarcinoma that just produces very little PSA. And we'd feel better if we did some kind of scan before radiation therapy and hormone therapy just to make sure that nothing is getting overlooked. I'd love to hear any thoughts about the pros and cons of the various advanced imaging scans that are available. Thanks!

Steve,

Thanks for sharing that story. A PA with long, thin fingers discovered my husband’s nodule and we’re very grateful. Gotta have a Uro (or a PCP) with fingers like a concert pianist.

Post Edited (Melaine) : 12/11/2021 9:13:21 AM (GMT-7)

One more thing… you are correct that the tumors that produce little psa you will want to consider salvage treatment at a lower psa . For instance if a “ normal” guy would consider 0.1 BCR, our husbands might be considered for salvage treatment at .03 … This is what we were told by multiple doctors. That’s why ultra sensitive psa tests are important.

Thank you for sharing your husband’s story, Leah. It did make me feel a little better.

It’s very interesting that multiple doctors told you that. When I’ve asked, I’ve been told that it shouldn’t change the radiation trigger number. Only the MO who specializes in genetics said that we should probably get treatment at a lower PSA. (To me it seems like common sense: if the cancer initially did not express much PSA, it still is not expressing much PSA.)

Jack & Diane: We were told that the prostate tissue (2014 RP) was too old for the test to be accurate or reliable. So no, no Decipher test.

Hi Leah,

I'd be interested in learning who you talked with. The MO Geneticist is at Seattle Cancer Care Alliance/Fred Hutch/University of Washington. The doctors who didn't seem to see a correlation are at UW and at Memorial Sloan Kettering.

Try not to worry about the PSA test. That's easier said than done, obviously. I'll be hoping for good things for you and your husband.

Thanks for that info, Leah. Congratulations on your husband's great PSA test!

FYI we met with our local RO and he has ordered a Pylarify scan. Should take about two weeks. He told us (again) about the risks of false positives, and that the scan will probably not show anything. But he also mentioned another patient who did "light up" at only 0.12. This patient, he quickly added, had negative pathology that, fortunately, my husband doesn't have.

I think early SRT makes sense for your husband but, hopefully, he'll never need it. Good luck!