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  • 13 years after prostatectomy and salvage radiation

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    Old 07-18-2020, 11:00 AM   #1
    replicant2049
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    Question 13 years after prostatectomy and salvage radiation

    Hi there!
    I used to be a regular poster here, under the name "replicant". I wanted to come back, but couldn't recover my login, and my previous email account is no more, so now I'm replicant2049.

    I had a prostatectomy in 2006 at age 43. Initially my PSA was undetectable (less than 0.1 on the standard assay). However, on my second post-surgery check, it was detectable and subsequent tests showed it was rising quickly. So I had SRT in the form of IMRT in 2007. By my second post-radiation PSA test, it was less than 0.1 and stayed there.

    I never had any other treatments. Just surgery and radiation.

    I have never had an ultrasensitive PSA until a couple of weeks ago. I didn't ask for it, but that's what the lab did as part of my annual physical.

    It came back at 0.02. Now, I know that's a very low number but it's not nothing. It wasn't "less than 0.02".

    Back in the day, I know the standard wisdom was not to freak out about ultrasensitive PSA results, at least not single results that were still very low, like less than 0.05. I'm guessing that these tests have gotten better over the past decade and a half. Am I right? I really haven't been keeping up with the research these past few years. And obviously, I haven't been on this board.

    At this point, I'm not going to take any action, other than make sure I check it again next year. (I'll have a sneak preview before then at a health check at work, but that one so far has not been ultrasensitive).

    What do you guys think? Likely just a blip? Or are blips not that common? Now that I'm living here in the future (2020) does 0.02 indicate there's something there?

    Thanks!

     
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    Old 07-20-2020, 05:56 AM   #2
    Steve135
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    Re: 13 years after prostatectomy and salvage radiation

    Re check your post I see it was at 0.1 and stayed there. Then today its 0.02 which is lower than 0.1 Then I see a 0.05 ?
    steve

     
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    Old 07-20-2020, 06:04 AM   #3
    replicant2049
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    Re: 13 years after prostatectomy and salvage radiation

    It has been <0.1 for 13 years; just had my first ultra sensitive test which showed 0.02.

     
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    Old 07-20-2020, 12:46 PM   #4
    Steve135
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    Re: 13 years after prostatectomy and salvage radiation

    That's great nothing to do now looks like they got a good stop!

     
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    Old 07-21-2020, 12:18 PM   #5
    IADT3since2000
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    Re: 13 years after prostatectomy and salvage radiation

    Hi repliccant2049 and welcome (back?) to the Board!

    Ultrasensitive PSA testing has been key for management of my case, and I know this technology territory pretty well, but your situation Is beyond what I know. Here’s what I’m thinking.

    An ultrasensitive of 0.02 would be very good after surgery, or excellent after radiation, but I’m not sure if that is so after salvage radiation; I suspect it is, especially since you have done so well for 13 years since your radiation in 2007. One way of looking at this is that 0.05 was the lower limit of detection for ultrasensitive tests for some years, and you are STILL below that after all these years!

    Here is a link to an abstract of a paper that provides some insight, as well as additional references: https://pubmed.ncbi.nlm.nih.gov/21514736/ Here’s a key line from the abstract: “Significantly more distant metastases developed in patients with a PSA nadir greater than 0.05 ng/mL after SRT, and they had significantly inferior prostate cancer-specific and overall survival rates.” Keep in mind that this study looked at statistics for results at the five year point, and you are FAR beyond that.


    I too am thinking you are doing great, but it seems wise to me for you to get another ultrasensitive PSA test in a year from now just to be on the safe side. Even in the unexpected event that you did have a recurrence, it would probably be a very mild one, perhaps not needing any treatment.

    Good luck!

    ….Jim

    - - - - - - - - - - - - - - - - - - - - - - - -
    Diagnosis Dec 1999 PSA 113.6 (first ever), age 56
    Gleason 4+3=7 (J. Epstein, JHU), all cores +, most 100%; "rock hard" prostate with ECE - stage 3, PNI, PSADT determined later 3-4 months; technetium bone scan and CT scan negative; prognosis 5 years.
    Later ProstaScint scan negative except for one suspicious small area in an unlikely location. ADT Lupron as first therapy, in Dec 1999, then + Casodex in March 2000, then + Proscar and Fosamax in Sep 2000. Rejected for surgery January 2000; offered radiation but told success odds were low; switched to ADT only vice radiation in May 2000, betting on holding the fort for improved technology; PSA gradual decline to <0.01 May 2002. Commenced intermittent ADT3 (IADT3) with first vacation from Lupron & Casodex. Negative advanced scans in 2011 (NaF18 PET/CT for bone) and 2012 (Feraheme USPIO for nodes and soft tissue). With improved technology, tried TomoTherapy RT, 39 sessions, in early 2013, plus ADT 3 in support for 18 months (fourth round of IADT3), ended April 2014. Continuing with Avodart as anti-recurrence shield. Current PSA remarkably low and stable at <0.01; apparently cured. (This is extraordinarily low for PSA levels after radiation for men with successful outcomes.) (Current T 99 6/5/20.) Supportive diet/nutrition, exercise, supportive medications during this journey, as well as switches in antiandrogen, 5-ARI, and bone drugs.

     
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    Old 07-21-2020, 12:40 PM   #6
    DjinTonic
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    Re: 13 years after prostatectomy and salvage radiation

    Hi. It would help to know what was in your post-op path report: final Gleason score, path staging (pT?), and all adverse findings mentioned.

    At very low levels, the trend of your PSA is just as important as your absolute level. <0.02 is very good after all those years, but you don't know if it has been rising, and if it has, you don't know the rate of rise nor when the rise began.

    If you follow your test with a less sensitive test going forward, you will lose valuable information. For example, if your next test is <0.05, you could be missing a significant rise.

    I would suggest that Labcorp's 3-decimal ultrasensitive test is a good test for post-RP men (for whom this test is intended) and the best test for men post RP + SRT, who have good reason to know their actual PSA value to greater accuracy.


    Djin
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    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3-
    7-05-13 TURP for BPH (90→30 g) path neg. for PCa, then 6-mo. checks
    6-06-17 Nodule on R + PSA rise on finasteride: 3.6→4.3
    6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
    Nodule negative for PCa. Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, negative frozen sections, Duke Regional Hosp.
    SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
    pT2c pN0 pMX, G9 (4+5) 5% of prostate (4.5x5x4 cm, 64 g)
    Dry; ED OK with sildenafil
    11-10-17 Decipher 0.37 Low Risk: 5-yr met risk: 2.4%, 10-yr PCa-specific mortality: 3.3%
    uPSA: 0.010 (3 mo.)...0.013 (2 yr. 10 mo.)

     
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    Old 07-21-2020, 12:58 PM   #7
    Southsider170
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    Re: 13 years after prostatectomy and salvage radiation

    0.02 is indeed less than 0.1 so it is a "no change situation" here, so keep up the good work on the PSA.

    Good luck on your next test.

    A lot of good signs here, no known increase in PSA for 13 years- the longer the period the better the prognosis.

     
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    Old 07-22-2020, 08:00 AM   #8
    IADT3since2000
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    Re: 13 years after prostatectomy and salvage radiation

    I am unimpressed with conventional PSA tests with a lower limit of "<0.1" for post-treatment monitoring. That's like a ship navigating through an iceberg field in heavy fog.

     
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    Old 07-22-2020, 09:53 AM   #9
    Southsider170
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    Re: 13 years after prostatectomy and salvage radiation

    Quote:
    Originally Posted by IADT3since2000 View Post
    I am unimpressed with conventional PSA tests with a lower limit of "<0.1" for post-treatment monitoring. That's like a ship navigating through an iceberg field in heavy fog.

    13 years ago, the ultra sensitive PSA wasn't nearly as accurate as it is today, and experts including Patrick Walsh felt it wasn't worth the extra expense as well as the extra anxiety that it cost. Had the OP had the same treatment plan in 2020 instead of when he did, he probably would have received a dozen years of ultra sensitive tests

     
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    Old 07-22-2020, 12:46 PM   #10
    IADT3since2000
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    Re: 13 years after prostatectomy and salvage radiation

    Quote:
    Originally Posted by Southsider170 View Post
    1... ultra sensitive PSA ...
    It really depended on which ultrasensitive test you used back then and earlier. My tests were done with the Immulite 3rd Generation test by Diagnostics Products Corporation, and results, as indicated by research and my own experience (clearly reasonable and expected sequential results), were highly accurate and reliable by the time I was being tested in mid-2001 (took a while for my PSA to drop to the point that I needed such a test). Possibly the 1st and 2nd generations were not so reliable.


    For years surgeons like Dr. Walsh shied away from these tests. After all, if their surgeries failed to control the cancers, patients learned that many months or years earlier and were not happy. For those with good results, the gift was early peace of mind. For those not getting good results, the gift was an early caution that more treatment might be needed, and often earlier treatment is better than later treatment.

    Jim

     
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    Old 07-23-2020, 08:38 AM   #11
    Southsider170
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    Re: 13 years after prostatectomy and salvage radiation

    If an ultra sensitive test doesn't provide information that will change the treatment plan, there is really little sense in going to the expense. A low-to-medium risk cancer (as per the pathology report), or new comorbidities , could be a reason to go with a less sensitive, less costly test. OTOH, a high risk cancer with an otherwise healthy younger patient, being more proactive with smaller jumps in PSA would be seem to be wiser.

    In the situation of the OP, apparently the doctor had no intent to do anything further unless and until PSA reached 0.1. Fluctuations beneath that weren't going to change the treatment plan.

     
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    Old 07-23-2020, 01:49 PM   #12
    DjinTonic
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    Re: 13 years after prostatectomy and salvage radiation

    When I got back my first post-RP of <0.1, I asked my uro/surgeon if we could follow my PSA with Lacorp's 3-decimal uPSA test. He had no objection. Only later did I learn that just this initial <0.1 is sent out to Labcorp and the practices' patients are then followed with an in-office (Labcorp) <0.05 test. (I think first test is sent out because the practice does the test at 6 weeks post-op, and some men might still dropping but above 0.05 and unduly disturbed if their first test is detectable.)

    In a later discussion, my uro said he has plenty of lead time between an initial rise and action time with the in-office <0.5 test, and I am the only patient being followed with the 3-decimal test, at my request.

    In any case, if you and your doc have set 0.1 as a threshold value for further treatment, it gives you zero lead time if you are being followed with a <0.1 test. I'll stick to my advice that an appropriate PSA test us one that returns one decimal place more than the decimal place you are watching. In practical terms, this is usually means either a 2- or 3-decimal test.

    Uncertainty lies in the right-most digit of any test. With my rule you can round one place and have more confidence in your result, in addition to being able to monitor your trend with greater precision.

    Djin
    __________________
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3-
    7-05-13 TURP for BPH (90→30 g) path neg. for PCa, then 6-mo. checks
    6-06-17 Nodule on R + PSA rise on finasteride: 3.6→4.3
    6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
    Nodule negative for PCa. Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, negative frozen sections, Duke Regional Hosp.
    SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
    pT2c pN0 pMX, G9 (4+5) 5% of prostate (4.5x5x4 cm, 64 g)
    Dry; ED OK with sildenafil
    11-10-17 Decipher 0.37 Low Risk: 5-yr met risk: 2.4%, 10-yr PCa-specific mortality: 3.3%
    uPSA: 0.010 (3 mo.)...0.013 (2 yr. 10 mo.)

     
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