Originally Posted by richarda123
Prostate out Feb 29. 1st psa at 6 weeks was .1; now six weeks later it came
back at .11. The lowest sensitivity the lab can see is .1. Is this small increase relevant? I have my first urolgy after RP next week. I imagine he'll send me to oncology? If so, any questions I should ask?
Yes, unfortunately, that .11 PSA result is relevant, as it shows that your PSA is not somewhere in the range below what that lab's test can detect with its lower limit of .1
Even if there is minor variation in the lab's PSA results due to processing issues, the .11 result indicates the value is close to that result, and that shows you have a recurrence, as you suspected from that single positive lymph node.
Officially the doctor may not declare you "recurred" yet as the commonly accepted PSA value for declaring a recurrence is .2, but in your case, especially considering that you reached a value greater than .1 within three months, he will probably conclude you are recurring. (With ultrasensitive testing, those with results of .05 and higher, provided their PSA test has a lower limit than .05, nearly always will sooner or later have a rise to .2, unless there are special circumstances, like some healthy PSA tissue left during the surgery.)
I think recurring patients are better handled with an oncologist managing their care, unless the urologist is particularly expert with recurrences. Based on a lot of contacts with fellow survivors, I don't think many urologists have that kind of expertise; after all, we go to them because they are experts in surgery, not because they are experts in drugs for prostate cancer. A urologist can certainly be on our medical team, but I believe an oncologist should have major input and should probably have the main medical input. If your urologist does not suggest that you see an oncologist, ask him about whether you should, or just ask for a second opinion referral to an oncologist. If you have a local support group, you could start checking with the group (if they meet before your appointment) or with the leaders to see if they can recommend local oncologists, or perhaps someone at the U. of Wisconsin.
You may be starting follow-up treatment soon, but if you can get in another PSA test from the same lab/same version of PSA test with at least several weeks in between, you will have some idea of the PSA doubling time, which is good to know.
There have been some very encouraging study results on using radiation that includes the pelvic area as a followup to surgery that did not get all the cancer.
The results indicate that the cancer has often not spread beyond the range of the radiation in those cases, so the followup radiation can cure.
There is a scan that can give an excellent estimate whether there is spread beyond the range of the radiation. It's known as a "fusion ProstaScint scan," and it should be covered by insurance for a case of recurrence after surgery. It's described in the book "A Primer on Prostate Cancer" on pages 54 - 57. If the scan yields negative results beyond the range of radiation, you have a decent shot at a cure. The doctor who was the pioneer with that fusion scan and arguably the world's expert, Dr. Bruce Sodee, used to practice at the Cleveland Clinic, but he passed on a couple of years ago, and I don't know of experts in your area. There's a chance the U. of Wisconsin does fusion ProstaScint scanning. The Cytogen corporation, manufacturer of ProstaScint, could probably advise about availability.
If there is spread beyond radiation's range, then the objective changes to control the cancer rather than cure - to make the cancer chronic instead of lethal. (Like I'm doing, I hope!
) You still might want to have radiation to knock down the cancer even if some of it is beyond the range of radiation, but the decision is more complicated as you have to weigh the worth of the expected benefit against the cost of the side effects and complications of added radiation in your particular circumstances.
In either case - all cancer apparently within versus some cancer clearly beyond radiation's range - there is a lot of evidence that hormonal blockade therapy improves the results of radiation substantially. Also, hormonal blockade therapy alone is a standard approach for recurrences, especially where there is metastatic spread. Some doctors are exploring the use of a short course of chemo along with the hormonal blockade, but my impression is that at this point we don't know how much value such chemo adds. My impression is that using chemo is not common in your situation, though I think it is gaining in favor.
In a case like yours, some doctors would probably want to go straight to radiation plus hormonal blockade without bothering with a fusion ProstaScint, figuring it would not alter the treatment decision. I can see sense in that, though personally I would like to get that information from the fusion ProstaScint and know where my case stood. In part that would give a better idea of what to expect, and it would enable the patient to tie in his situation to research results that are published for patients like him.
As for hormonal blockade, I'm personally convinced that triple blockade is best for the vast majority of us, but most of us on blockade are on just one drug or two drugs, not three blockade drugs. Unfortunately, there is only one study, from a single practice, in a major peer reviewed journal that indicates that intermittent triple blockade is superior to intermittent two drug blockade.
Also unfortunately, some doctors do not even believe that the second drug - the "antiandrogen" - helps,
though there is a lot of published evidence suggesting that it does.
Here's the scoop on triple blockade, which I think you've seen before. The heavy duty drug is the "LHRH agonist", and is usually either Lupron or Zoladex, both by injection - the first in the butt and the second in stomach muscle, but also sometimes Viadur or Trelstar, and I think there are some others. The LHRH agonist causes the body to shut down production of testosterone by the testes, the by far dominant source of testosterone. The second drug is the antiandrogen, usually Casodex (newer, more effective, fewer problems, more expensive but often well covered by insurance) or flutamide. This drug mainly blocks the effect of remaining testosterone, including testosterone indirectly produced by the adrenal glands, which may ramp up production when the body senses that the testes have shut down. The third drug, either Avodart or finasteride, known as 5-alpha reductase inhibitors, block the conversion of remaining testosterone into dihydrotestosterone (DHT), which is a far more potent fuel for prostate cancer. These drugs have other, less widely known but no-doubt important effects, like decreasing the blood supply to cancer cells. The third drug adds virtually no negative side effects to those that exist for the other two drugs. A bisphosphonate (like Fosamax, Boniva, Actonel, Aredia, Zometa) to protect bone density while on blockade is also needed by most of us. There are countermeasures patients on blockade should take to minimize or avoid side effects. If you start discussing blockade, ask the doctor about those and see if he is up to speed or if he is hesitant or dismissive, both signs that he isn't.
Many urologists like to administer the blockade shots, and they probably feel confident they are good managers of their patients cases, but time and again there are patient reports of urologists who do not do what they should do. They do not test to see that the drugs are working, by looking at testosterone levels (should fall to around 20 or hopefully below 20) and use other tests, such as for DHT. They are often unaware of potential problems in administering the drug or of the fact that a small percentage of patients will clear the drug too quickly, so that a drug that should work for 28 days only works for, say 23 days, lowering the protection for the remaining days. I've heard experts say that about 10% of patients will have problems with either the administration of their blockade injections or with their personal unusually rapid clearance of the drug, to the point that they do not benefit adequately. An oncologist is more likely to understand these issues and to know what to do, in my opinion as an informed layman veteran in my ninth year of intermittent triple blockade.
I hope this is not too long and is not confusing. The Primer has an excellent section on hormonal blockade, and Dr. Myers recent book is outstanding: "Beating Prostate Cancer - Hormonal Blockade & Diet." Among other things, Dr. Myers book delivers a huge dose of hope!
Take care and hang in there,