Post radiation increases in PSA

ASAdvocate

The American Society of Clinical Oncology set the threshold for recurrence after radiation as nadir +2.

Your nadir was .04, so you’re not there yet. But, recently, there are new studies indicating that criteria is too conservative, and any upward trend should be a concern.

In that case, it definitely should be discussed.

Prostatefree

I have no experience with radiation. But, I often read of a possible (30% of patients?) PSA bounce after radiation treatment, but I don't know what limits define it. The good news is if it settles down it is a positive indicator of a lower risk of BCR. It can follow the treatment between 12 and 24 months. The bad news is if it doesn't.

Good move to use an ultra-sensitive PSA test.

Others here can share the statistics of it. You can Google PSA bounce after prostate cancer radiation.

IADT3since2000

Hi Hiker.

I too think the increases could reflect a bounce in the works.

It could also reflect the fact that you still have a prostate that will produce a small amount of PSA after radiation, perhaps coupled with a slow recovery of testosterone after that last Lupron shot. When did that shot "run out"?

My hunch is that the radiation oncologist will simply want to monitor the pattern of PSA results. Many post-radiation patients have a PSA that finally settles down around 0.4. (Mine is extraordinarily low - not at all typical. However, it was less than 0.01 after treatment and increased to a high of 0.02 before falling back to less than 0.01. My more recent results are with a less sensitive test with a lower limit of less than 0.05.)

Radiation without ADT often results in a PSA that continues to fall after treatment. With ADT, PSA is often very low after radiation but tends to increase slightly as testosterone returns to normal. The pattern of PSA results after successful radiation treatment is not like the pattern after successful radical prostatectomy, where you want the PSA to be, ideally, less than 0.01 and stay there, though some successful patients have slightly higher levels.


Good luck!


….Jim

- - - - - - - - - - - - - - - - - - - - - - - --
22 years as a survivor. Doing well. 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, for some reason based on a less sensitive test on 7/20/2021 was <0.05, still apparently cured in my ninth year since radiation (PSA as of 12/2/2020 was <0.01). (T 93 as of 12/2/2020.) Supportive diet/nutrition, exercise, supportive medications during this journey, as well as switches in antiandrogen, 5-ARI, and bone drugs. Barely noticeable side effects from radiation; continuing low T, likely do to long use of ADT, but good energy and adequate strength. I have a lot of School of Hard Knocks knowledge, and have followed research, which has made me an empowered and savvy patient, but I have had no enrolled medical education. I have also had 225 undergraduate classroom hours just in statistics and experimental design, plus more in graduate school, which dwarfs what most doctors have, and that has made my “hard knocks” experience more meaningful. What I experienced is not a guarantee for all but shows what is possible.

Insanus

You have a unique history. Gleason 6 with a PSA north of 20 with RT and ADT as a treatment. The possibility of a higher grade cancer being present and undetected during your biopsies is a possibility. Only to,e will tell and you have not recurred yet.

Prostatefree

One definition by the National Cancer Institute.

"PSA bounce
A brief rise and then fall in the blood level of PSA (prostate-specific antigen) that occurs in some patients 1-3 years after receiving radiation treatment for prostate cancer. PSA bounce does not mean that the cancer has come back. It may be caused by the release of PSA from destroyed cancer cells or from normal prostate tissue exposed to the radiation treatment."

The operative word is "some." The question for the doctor is what defines the subset "some" and are you a candidate for a bounce?

Terry G

Welcome Hiker. I too am puzzled by the high initial PSA with only Gleason 6 found on the biopsy. Could be undetected higher grade cancer and therefore the decision to add ADT to the radiation. Or, the high initial PSA could be related to a large prostate or infection. In any event the addition of ADT will drive your PSA to very low levels temporarily and your true nadir may actually be higher.

I chose radiation as a monotherapy and if you check my signature you can see my PSA has been bouncing following treatment. I’m five years post treatment and I believe past the bounce phase. During the bounce phase my treatment team was unconcerned. It’s always good to be vigilant and asking questions. No one has more skin in the game than the patient. Keep us posted as we all learn from one another. Terry

__________________
Rising PSA:
11/13 1.95; 9/15 3.28; 10/16 5.94
TRUS 1/17
Bx: Three of twelve cores adenocarcinoma Gleason 6 (3+3) all on left side, no pni.
DOB 7/21/47; good health; age 69 @ Dx
Treated 6/17 SBRT @ Cleveland Clinic by Dr. Tendulkar
Reduced ejaculate only side effect; everything works
To view links or images in signatures your post count must be 10 or greater. You currently have 0 posts.

PSA’s post.SBRT 1.1, 1.1, .9, 1.8, 2.7, 1.0, 0.3, 0.6, 0.8, 0.4

Prostatefree

A PSA of 20 does put you in a range for a statistically significant chance of metastisized prostate cancer.

Hiker2020

Thanks everyone for their comments. i saw my radiation oncologist this morning and she was not really concerned but wanted to continue documenting PSA levels every 6 months. One thing I learned from her is that the drop in PSA at the end of radiation treatment is almost all due to Lupron as opposed to the radiation. The effects of radiation on PSA levels takes at least 2 years to start showing. Therefore, the 'bounce' is largely due to the elimination of Lupron from your system. If the radiation treatment is successful, then the PSA should stabilize at a low level after the 2 year mark and stay there.

__________________
PSA results: 9/16-12.73;11/16-13.26; 7/17-14.97; 1/18-14.08; 4/18-13.94; 7/18-17.61; 10/18-16.29; 2/19-17.09; 4/19-17.84; 6/19-17.81; 10/19-16.24; 1/20-23.14;3/20-19.41; 5/20-17.66; 7/20-20.86; 12/20-0.1, 5/21 0.04, 5/21 0.08, 11/21 0.12, 5/22 0.16

Biopsy results: 10/17-Gleason 3+3=6- Group 1; 11/18-Gleason 3+3=6- Group 1; 11/19-Gleason 3+3=6- Group 1 Increases in PSA even with no change in biopsy results indicated the need to begin treatment. Decided on IMRT.
Lupron injection #1: 7/20; Markers and spacer placed 8/20; Lupron injection #2 10/20
Radiation treatment began 9/15 and ended 11/06: 39 sessions at 200cGY per session
Side effects of radiation general fatigue and painful frequent urination treated successfully with Flomax. Stopped using Flomax after 2 months due to it causing a severe dry cough.

Prostatefree

Good info. Thxs. So, does this apply to everyone who chooses radiation and ADT?

Hiker2020

I believe it does if you are on a short course (6months) of ADT. My previous understanding was that ADT worked to shrink the prostate so the radiation target was smaller thereby reducing the long term effects of radiating a larger area. While this is still true, ADT does so by limiting the blood supply to cancerous cells and slowing their growth. I assume this is why long term ADT works to control cancer growth after it has spread. My RO put it in the context of ADT and radiation being a double edged sword that is more effective than using either treatment alone.

__________________
PSA results: 9/16-12.73;11/16-13.26; 7/17-14.97; 1/18-14.08; 4/18-13.94; 7/18-17.61; 10/18-16.29; 2/19-17.09; 4/19-17.84; 6/19-17.81; 10/19-16.24; 1/20-23.14;3/20-19.41; 5/20-17.66; 7/20-20.86; 12/20-0.1, 5/21 0.04, 5/21 0.08, 11/21 0.12, 5/22 0.16

Biopsy results: 10/17-Gleason 3+3=6- Group 1; 11/18-Gleason 3+3=6- Group 1; 11/19-Gleason 3+3=6- Group 1 Increases in PSA even with no change in biopsy results indicated the need to begin treatment. Decided on IMRT.
Lupron injection #1: 7/20; Markers and spacer placed 8/20; Lupron injection #2 10/20
Radiation treatment began 9/15 and ended 11/06: 39 sessions at 200cGY per session
Side effects of radiation general fatigue and painful frequent urination treated successfully with Flomax. Stopped using Flomax after 2 months due to it causing a severe dry cough.

guitarhillbilly

Just had a 6 month visit with my UR. Completed Radiation IMRT 2 years ago and completed Lupron Injections 7 months ago. My UR said that my next PSA test results should reflect an accurate reading because the Lupron should be gone from my system. Immediately After 42 IMRT treatments my PSA was 0.4 and then it quickly dropped to 0.0 . It has been 0.0 or 0.1 for 1.5 years.
According to MY UR - NADIR + 2.0 is my New MAX Number.

Quote:

"Nadir PSA is a strong predictor of treatment outcome in intermediate and high risk localized prostate cancer patients treated by definitive external beam radiotherapy and androgen deprivation"

Quote:
"Radiation therapy doesn’t kill all of the cells in the prostate gland, so it's not expected to cause the PSA to drop to an undetectable level. The remaining normal prostate cells will still make some PSA.

The pattern of the drop in PSA after radiation therapy is also different from after surgery. PSA levels after radiation tend to drop slowly, and might not reach their lowest level until 2 years or more after treatment.

Doctors tend to follow the PSA levels every few months to look for trends. A one-time, small rise in PSA might cause closer monitoring, but it might not mean that the cancer is still there (or has returned), as PSA levels can fluctuate slightly from time to time. However, a PSA that is rising on consecutive tests after treatment might indicate that cancer is still there. Some medical groups have proposed that if the PSA rises more than 2 ng/mL above the lowest level reached, further treatment should be considered, but some doctors might advise tests to look for cancer in the body even if the PSA has not yet risen this much.

There is also a phenomenon called a PSA bounce that sometimes happens after external beam radiation and brachytherapy. The PSA rises slightly for a short time within the first couple of years after treatment, but then goes back down. Doctors aren’t sure why this happens, but it doesn’t seem to affect a man’s prognosis."

__________________
T2a / Gleason Score 8 / PSA at Diagnosis 6.9 /
1-5 aggressive score : 4
12 cores= 4 positive
NBS = Negative
Pelvic CT= Negative
Pelvic MRI= Negative
Age at Diagnosis= 60-65 age group
Completed 42 IMRT Sessions
Completed 22 Months of LUPRON in OCT 2021.

guitarhillbilly

QUOTE:

"Lupron Depot is a hormone therapy that is used to treat prostate cancer.

Prostate cancer growth is increased or stimulated by the male hormone testosterone, which is an androgen.
Reducing levels of androgens can slow the growth of prostate cancer.
Lupron depot is a slow release injection that works to treat prostate cancer by reducing levels of testosterone to below the level you would expect with castration.

What is a testosterone flare or surge with Lupron?

The first time Lupron depot injection is given there is a temporary increase in luteinizing hormone (LH) and follicle stimulating hormone (FSH) that leads to an increase in testosterone (the 'testosterone flare') and dihydrotestosterone that lasts approximately 5 to 12 days. After this initial increase in LH and FSH levels, both LH and FSH decrease which results in testosterone levels to fall to below castration levels. For most patients the reduction in serum testosterone to below castration levels usually occurs within the first 30 days of treatment. In clinical studies testosterone levels usually remain low over 24 to 32 weeks, with regular administration of Lupron Depot.

Lupron Depot is given as a slow release injection and dosage schedule varies from monthly up to 6 monthly depending on the strength of injection.

Bottom line:

Lupron Depot is a hormone therapy that is used to treat prostate cancer.
Prostate cancer growth is increased or stimulated by the male hormone testosterone.
Lupron Depot causes a decrease in testosterone levels which can slow the growth of prostate cancer."

__________________
T2a / Gleason Score 8 / PSA at Diagnosis 6.9 /
1-5 aggressive score : 4
12 cores= 4 positive
NBS = Negative
Pelvic CT= Negative
Pelvic MRI= Negative
Age at Diagnosis= 60-65 age group
Completed 42 IMRT Sessions
Completed 22 Months of LUPRON in OCT 2021.

IADT3since2000

ADT: Shrinking the Size of the Prostate, Enhancing Radiation, and Blood Supply

In addition to the key points made by guitarhillbilly, and hiker's point that ADT will shrink the prostate, here are some other points. There is a form of ADT that does reduce the blood supply to the entire prostate, causing a reduction in its size. The drugs are known as 5-alpha reductase inhibitors, and there are at least two of them, Proscar (finasteride) and Avodart (dutasteride). Neither has been approved for treating prostate cancer, but in different doses they are approved for restoring some scalp hair and treating BPH. One important way they work is to sharply reduce conversion of testosterone into dihydrotestosterone, a far more potent fuel for prostate cancer than testosterone, and that also enables them to have some effect against prostate cancer. Some doctors use them as part of an anti-prostate cancer program. I have been on one or the other continuously for that purpose since 2000 (since 2014 as part of my antirecurrence program), and they definitely had some impact on the cancer for me, probably in part also by making the antiandrogen drug part of my program (either Casodex/bicalutamide, or flutamide) more effective as the drugs no longer had to compete as hard with dihydrotestosterone (also testosterone) for docking sites (androgen receptors) for fuel on the prostate cancer cell surface, thus enhancing blocking more of the fuel the cancer cells needed. (I was also on Lupron intermittently as the primary part of my ADT program.)

ADT also has benefits for radiation in addition to its direct role against prostate cancer. A key role is making it harder for radiated cancer cells to repair themselves.

There are also drugs that do reduce the blood supply to cancer cells. The are called antiangiogenesis inhibitors, and the main one available during the time I was treated was thalidomide. (Once not allowed in the US, thereby avoiding participation in the international epidemic of severely deformed arms and legs on newborns (thank you FDA!), it was later approved for cancer under stringent use controls, and it has seen a lot of use for multiple myeloma cancer.) It was available "off label" (not approved for prostate cancer but available after informed patient consent, etc.), and I was on it for three courses to prolong my "vacation" from the heavy duty drugs Lupron and Casodex. These days, with the availability of improved drugs and much improved radiation (with supportive imaging and other technology), I doubt there is much of a role for thalidomide, a superior sister drug lenolidomide, or any other angiogenesis inhibitor. That said, knowledge takes twists and turns, and these drugs may once again play a role in the future.

….Jim

- - - - - - - - - - - - - - - - - - - - - - - --
22 years as a survivor. Doing well. 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, for some reason based on a less sensitive test on 7/20/2021 was <0.05, still apparently cured in my ninth year since radiation (PSA as of 12/2/2020 was <0.01). (T 93 as of 12/2/2020.) Supportive diet/nutrition, exercise, supportive medications during this journey, as well as switches in antiandrogen, 5-ARI, and bone drugs. Barely noticeable side effects from radiation; continuing low T, likely do to long use of ADT, but good energy and adequate strength. I have a lot of School of Hard Knocks knowledge, and have followed research, which has made me an empowered and savvy patient, but I have had no enrolled medical education. I have also had 225 undergraduate classroom hours just in statistics and experimental design, plus more in graduate school, which dwarfs what most doctors have, and that has made my “hard knocks” experience more meaningful. What I experienced is not a guarantee for all but shows what is possible.

Hiker2020

Lots of great information emerging from this thread. Thanks everyone.

__________________
PSA results: 9/16-12.73;11/16-13.26; 7/17-14.97; 1/18-14.08; 4/18-13.94; 7/18-17.61; 10/18-16.29; 2/19-17.09; 4/19-17.84; 6/19-17.81; 10/19-16.24; 1/20-23.14;3/20-19.41; 5/20-17.66; 7/20-20.86; 12/20-0.1, 5/21 0.04, 5/21 0.08, 11/21 0.12, 5/22 0.16

Biopsy results: 10/17-Gleason 3+3=6- Group 1; 11/18-Gleason 3+3=6- Group 1; 11/19-Gleason 3+3=6- Group 1 Increases in PSA even with no change in biopsy results indicated the need to begin treatment. Decided on IMRT.
Lupron injection #1: 7/20; Markers and spacer placed 8/20; Lupron injection #2 10/20
Radiation treatment began 9/15 and ended 11/06: 39 sessions at 200cGY per session
Side effects of radiation general fatigue and painful frequent urination treated successfully with Flomax. Stopped using Flomax after 2 months due to it causing a severe dry cough.