7 years post RP - PSA slowly rising - currently .08

TheWife · New User Joined: 08 Apr 2008 Posts: 8

My husband had RP in 2001. The first several PSA tests after surgery measured his PSA at <.1 Beginning in 2004, ultrasensitive assay was used and PSA was measured at .04. It was .04 again in 2005 but has risen annually and now is .08, so PSADT is 3+ years. His PSA before surgery was 5.0, GS was 6 before surgery, 7 at path. report. He had positive margins on one side, no seminal vesicle invasion.

With this low of a PSA value, is it too soon to consider salvage radiation? I know that results are better the sooner radiation is started, but he hesitates to risk the possible side effects if radiation is unnecessary.

Should he shop for a radiation oncologist the same way he shopped for a surgeon for the RP? Is the treatment pretty standard for IMRT at all hospitals or would he be served by going to a distant cancer center? His urologist has recommended someone but we don't really know how to check him out.

Thanks for any advice.

Replicant · Moderator Joined: 01 Nov 2006 Posts: 271

You've asked some thoughtful questions. I can tell you've done some homework on this.

As a layperson who's done a lot of reading on this (and been through RP and salvage IMRT), I think it's way too early to pull the trigger.

The studies by Andrew Stephenson (see my blog) show that indeed, the earlier the better with salvage radiotherapy, but you don't want to start before you know a recurrence is underway. The textbook definition for this has been a rising PSA that has hit at least 0.2. Stephenson says it's optimal to start at 0.5 or lower with the salvage radiation, and definitely before hitting 1.0.

Shopping for the radiation oncologist is a more difficult question. I would get a recommendation from the urologist. Then check to see if the rad oncologist has done a lot of prostate work, look into the person's curriculum vitae, check with the board of medical examination for complaints, etc.

I don't think there's a need for most patients to look outside their immediate city for IMRT. However, if you're interested in protons as salvage, you would need to start thinking and pre-planning for that, since temporary relocation might be required, as well as dealing with the wait list for treatment and getting insurance approval.
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T3a, N0M0, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 <0.1, 12/07 <0.1, 4/08 <0.1, 11/08 <0.1
http://pcabefore50.blogspot.com

TheWife · New User Joined: 08 Apr 2008 Posts: 8

Thanks, Replicant, you've kind of confirmed what I was already thinking. I appreciate the good advice.

interval · Regular Joined: 11 Apr 2008 Posts: 39

I think that having .08 PSA after 7 year of RP is a good condition. I understand that it rise every year, but if I could be in the patient's shoes I choose a watch and wait strategy. We do not know how old he is to consider a right advice.

vigo

Oh, you're right, sorry - I forgot to post his age. He's 62 now. He was 55 at diagnosis.

I do agree that .08 isn't a bad number. It's the fact that it has doubled, when we had expected it never to rise, that is troubling. He will wait and watch it carefully.

brainman

Uhhh who are we talking about? vigo, are you the same person as TheWife? Very Happy

. No problem if that is the case... just confused about how you know the gentleman's age Wink

.

Anyhow, I too am only concerned because the PSA doubled and seems to be on the rise. It still is low but close monitoring is good advice.

Age really should not be a factor on treatment decisions; what is really a factor is overall the overall health of the patient. If the guy is 90 but still active and vigorous he is a better candidate for treatment than a 50 years old guy with multiple health issues.
_________________
Jim
Site Administrator and long-term cancer survivor
1992 Astrocytoma grade 2, left motor strip
2005 Recurrence this time said to be an Oligodendroglioma grade 3, same location.
My Story Part 1: http://cancerforums.net/viewtopic.php?p=7350
My Story Part 2: http://cancerforums.net/viewtopic.php?t=8029
Blog http://jimhawkinsport.blogspot.com/

TheWife · New User Joined: 08 Apr 2008 Posts: 8

brainman -

Yes, I'm the same person as Vigo. I must have had an old cookie stored on the old computer that I posted from back then. No wonder you were confused! I only just got back to this forum after a couple of months and found your post.

To update you a bit, my husband had decided to wait a bit and have his PSA retested monthly to more closely monitor its rise. In May he saw his internist for a physical and the PSA test was done as part of an entire series of other blood tests (lipids, etc.). His PSA tested at 2.0, which scared him half to death Shocked

, but I felt that it might be because it was done at a different lab from all of his other PSA tests done at the urologist's office. He went back to the uro 2 weeks ago and PSA was 0.07. While we were relieved at that, we're still concerned that it has risen from 0.04 almost 4 years ago. He has an appointment with a radiation oncologist next week to get an opinion and he will make a decision with her help.

Fingers crossed...

jimschlemmer · Regular Joined: 28 Apr 2008 Posts: 22 Location: troy, ny

Hi Vigo/The Wife.

I'm in a similar situation as your husband, though I'm quite a bit younger (46) and my numbers are a bit worse. Given my circumstances, radiation as soon as possible is what I'm going to be doing.

I think the fact that your husband went for quite a spell without a PSA rise is good news -- the longer the better. Also, it seems that acting before your PSA hits 0.5 is the important thing. So I think you have some time there if you're hesitant to start RT.

-Jim

TheWife · New User Joined: 08 Apr 2008 Posts: 8

My husband saw the radiation oncologist yesterday and she was very encouraging. She was a little concerned at the PSA rise but said that she wouldn't recommend taking any action unless it went higher than 0.1. She will monitor his PSA every 3 months.

She mentioned that many factors could influence the PSA reading, one of which was vitamin D. My husband has been taking 2000 IU for some time, so perhaps this was a factor. If his PSA stabilizes and holds below 0.1, which she says is very possible, no radiation will be necessary. A lot will depend on PSADT, too.

brainman

Hi Vigo. Glad to hear from you! I am also happy that your husband is doing well.

I don't remember if you told us already but has your husband had his free PSA checked yet? That is often a more accurate measurement than just the regulat PSA test.
_________________
Jim
Site Administrator and long-term cancer survivor
1992 Astrocytoma grade 2, left motor strip
2005 Recurrence this time said to be an Oligodendroglioma grade 3, same location.
My Story Part 1: http://cancerforums.net/viewtopic.php?p=7350
My Story Part 2: http://cancerforums.net/viewtopic.php?t=8029
Blog http://jimhawkinsport.blogspot.com/

TheWife · New User Joined: 08 Apr 2008 Posts: 8

I'm not sure. The uro only reported the PSA value to him each time. He never saw the actual lab report. This is something we'll ask the new doctor. Thanks for bringing it up.

brainman

You might what to ask him to ask for a free PSA test then.
_________________
Jim
Site Administrator and long-term cancer survivor
1992 Astrocytoma grade 2, left motor strip
2005 Recurrence this time said to be an Oligodendroglioma grade 3, same location.
My Story Part 1: http://cancerforums.net/viewtopic.php?p=7350
My Story Part 2: http://cancerforums.net/viewtopic.php?t=8029
Blog http://jimhawkinsport.blogspot.com/

Replicant · Moderator Joined: 01 Nov 2006 Posts: 271

Actually, free PSA (fPSA) is used before surgery. It's mainly used in an attempt to discern PSA from benign causes vs. cancer, in the patient with a prostate.

Post-prostatectomy, total PSA (the plain vanilla kind) is actually a very good indicator of recurrence. An undetectable PSA is an indication that surgery was successful. On the ultrasensitive test, undetectable is usually defined as less than .01. However, the consensus among urologists and radiologists seems to be that you need to hit 0.2 before declaring recurrence. Pioneering urologist Walsh, for example, doesn't trust the accuracy of ultrasensitive PSA tests.
See: http://www.phoenix5.org/Basics/psaPostSurgery.html

Dr. Moul, a leading urological researcher and practitioner at Duke University, says his hospital's definition of recurrence is 0.2 plus one subsequent rise, OR any score of 0.5 or higher.
http://www.cpdr.org/about/publication/rising1.html

There is a certain percentage of men who will progress to 0.1 and never progress further, but once 0.2 has been reached and surpassed, it is almost certain that the patient will continue to see his PSA rise.

Your husband has a very slow doubling time, so there's no need to panic or rush, but I do think it is prudent to make initial inquiries into salvage radiation. Then if your husband's PSA continues to rise you simply put the plan into motion.

There has been a recent technological development in IGRT (a more precise form of IMRT). The new technology is called RapidArc. More on it here: http://money.cnn.com/news/newsfeeds/articles/prnewswire/200806300800PR_NEWS_USPR_____AQM088.htm
Would seem to further minimize collateral damage from IGRT, which doesn't cause a lot to begin with.

If your husband's PSA continues at this doubling rate, he wouldn't even be at 0.2 in 3 years, and by then this technology could be available all over the country. Just something to think about.

Good luck.
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T3a, N0M0, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 <0.1, 12/07 <0.1, 4/08 <0.1, 11/08 <0.1
http://pcabefore50.blogspot.com

TheWife · New User Joined: 08 Apr 2008 Posts: 8

Replicant, thank you so much for those links! They are very reassuring and my husband will sleep much better tonight after having read them.

What a great resource this is! Smile

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