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    Old 12-30-2011, 07:38 AM   #1
    toyourhealth
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    Question Low PSA and bone mets

    I am posting about my husband, whose cancer has recurred after 12 years and appears to be anomolous because of his very low PSA, slow doubling rate, asymptomatic, yet with imagery evidence of bone mets. The key question is how would this impact his course of treatment?

    Here's his story.
    - He is now 75 and in active good health; plays tennis and is a busy jazz musician
    - Diagnosed in 1999 with PSA 6.7 and Gleason 5. Had brachytherapy in June 1999 with no complications
    - In 2006, he had an x-ray (unrelated to PCa) which showed a 1 cm spot on the pelvis. Nothing on follow-up bone scan. That same year he reached nadir at 0.18.
    - Starting in 2008, he noticed that his PSA levels were slowly rising to a score of 1.65 in May 2011 (doubling every 14 to 17 months). Since then, he had a bone scan followed up by x-ray, MRI and CT scans. These have confirmed 3 blastic lesions (a 2.9 cm one at the same spot as the 1cm lesion found in 2006 (tripled in 5 years), a 1 cm spot, and a third smaller one (unmeasured). PSA taken in Nov 2011 showed a rise to 1.92, a slightly slower rate of increase.
    - His is a familial cancer. His father died at age 87 of prostate metastatized to bone. We don't know when it was diagnosed and what, if any, treatments he had. We do know that he didn't experience pain until the last year. His paternal uncle also died of/with?? prostrate cancer at age 80, and his older brother has been diagnosed and treated for the same thing.

    We met with the oncologist in December and he wants to start my husband immediately on hormone treatment. We've read the medical advisory that recommends ADT as the standard of treatment for advanced prostate cancer. We've also read about IADT protocol and my husband wants to pursue that course, primarily because of better quality of life. We're pursuing a second opinion. I've also been doing research on low PSA with bone mets, and that seems to be associated with highly aggressive variants of PCa.

    Anyone run across this particular mix of circumstances? Given that the cancer appears to be non-aggressive (so far!) is there any urgency to start hormone therapy immediately or can there be a period of monitoring? How to tailor the classic IADT protocol to someone with such low PSA score and doubling rates? Our oncologist recognized the latter but wants to start treatment immediately given the imagery evidence of mets.

    Is this really prostate cancer? We have imagery evidence but no tissue evidence. Our oncologist recommended against a biopsy because of the location on the pelvis. Is there any non-invasive test that would confirm prostate cancer before we progress to hormone therapy?

    We're now on this second leg of our journey and I fully expect lots more questions. My husband is very optimistic and I swing between panic and something more positive (won't call it optimism though). I manage it by learning all I can.

    Thanks in advance for all your advice and support.

     
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    Old 12-31-2011, 10:27 AM   #2
    Baptista
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    Re: Low PSA and bone mets

    I read with interest your post because mine and your husband’s cancers have similar characteristics. Both are G5s, the PSADT has been at 14 months and we are asymptomatic.
    Surely one should think that in prostate cancer no two cases are equal but your descriptions stroked me because of the slow increasing pattern of PSA in which both cancers have grown. Mine however comes from an higher initial PSA level of 24.2 (at surgery).

    I gave particular attention to the fact that your husband had a decreasing PSA while metastases were forming, found in 2006 (PSA=0.18). Since then, the spread in bone has continued but the PSA did not display a sharp increase as one could expect. Instead it continued its doubling typical of low aggressive cancers.

    It is in fact a case to doubt if those spots relate to cancer. A biopsy could be done with needles to extract a sample of the tissue and get a definite conclusion. The procedure is not so invasive as thought.
    In any case, the rise of PSA is indicative of cancer growth and the metastases need to be cared. Your husband should start hormonal treatment, adding a drug similar to Xgeva to treat the metastases in bone.

    Some aggressive cancers with high Gleason scores produce low amounts of PSA, but in view of your husband’s Gleason score of 5, the only explanation could be that he has also a type of aggressive prostate cancer that do not produce PSA. This is the case of the so called Small Cell Carcinomas. They can coexist with the more traditional Adenocarcinoma and grow unchecked.

    I was diagnosed with adenocarcinoma of the prostate in 2000 (50 years old) with a PSA of 22.4, Gleason score of 5 (2+3). All image studies and DRE were negative but all 6 needles of biopsy were positive for cancer. I had open surgery in which the path report indicated positive margins and extra-capsular extensions (pT3a pN0). Recurrence occurred just 6 months after RP with a PSA of 0.26. Doctors (3 second opinions) and a series of testing diagnosed my case with micrometastases.
    After a failed SRT, when the PSA reached my doctor’s threshold of 1.0, I started ADT with an Eligard 6-month shot. That was in Nov. 2010 and it has been enough to arrest the PSA down to 0.2 in one year. I am hopeful for the intermittent modality which is scheduled to start once the last shot loses its effectiveness. The side effects have been numerous but mild

    Your husband is in an advanced status that needs care the soonest. In his age of 75 most medical guidelines recommend palliative treatments. I would recommend him to do a series of tests now and to investigate on possible protocols with the newer drugs. Wishing you find a satisfying answer for your husband’s case.

    Baptista

    Last edited by Administrator; 01-02-2012 at 09:19 PM.

     
    Old 01-01-2012, 09:06 AM   #3
    toyourhealth
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    Re: Low PSA and bone mets

    We've both been thinking about the decreasing PSA even while bone lesions were forming. That, coupled with the apparently very slow growth rate of the first visible one (1 to 3 cm over a 5 year period) and with his father's history, suggests that it may be very slow growing or something other than PCa. My husband was trying to recall when his father was diagnosed and he thinks it was when he around 80. Of course, we don't know at what stage it had reached at diagnosis. We do know that he lived to 87 and seemed reasonably vigorous for a man his age.

    We have an appointment scheduled with the radiation oncologist to see whether RT coupled with ADT is an option. We also are scheduling a consult with a doctor at Harvard Medical who has written about and has a clinical PCa practice that includes IADT.

    Happy new year to us all. May we each be healthier and happier a year from now than we are today.

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    Old 01-01-2012, 05:44 PM   #4
    IADT3since2000
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    Re: Low PSA and bone mets

    Hi and I'll add my own welcome you to the Board!

    As an active 68 year old, I'm envious of your husband's busy pace! Here's to many more years at that pace! He and I have something in common: we were all diagnosed in 1999 and have some challenging aspects in our cases.

    I'll add some added thoughts in green, taking off from excerpts from your post #5, earlier today. I'll put my words in green.


    [QUOTE=Gesundheit;4902531]We've both been thinking about the decreasing PSA even while bone lesions were forming. That, coupled with the apparently very slow growth rate of the first visible one (1 to 3 cm over a 5 year period) and with his father's history, suggests that it may be very slow growing or something other than PCa.

    There are ways to reconfirm that it is prostate cancer, but the doctors probably are convinced already based on sound evidence. Have you raised this concern with them? It's a concern they could explain away quickly.

    There are ways the cancer can grow under the radar of PSA, which is an excellent sentinel for monitoring for most cases, but definitely not all. Here's another possibility: your husband might have more than one kind of prostate cancer. One kind could be the more usual kind, with the PSA's drop to a nadir showing that that kind had been pretty much eliminated. Another kind could be the type that expresses very little or even no PSA, a type that is rare but certainly possible. Perhaps your husband had very little of that type, but enough to grow to where it is now showing up as several bone lesions.

    Dr. Stephen Strum advocates tracking several other biological indicators ("biomarkers") for prostate cancers that are not producing or that are under producing PSA. Over the years he has emphasized four: PAP (prostatic acid phosphatase), CEA (carinoembryonic antigen), NSE (neuron-specific enolase), and CGA (chromogranin alpha). CGA is (quoting from the Primer) "a substance produced by the neuroendocrine cells that are associated with androgen-independent PC." CEA is "A fetal antigen or protein that may be expressed by PC that is aggressive and often androgen-independent." PAP is "An enzyme or biomarker secreted by prostate cells associated with a higher probability of disease outside the prostate when pretreatment levels are 3.0 or higher." (It also happens to be the target used by the immune system booster Provenge, approved in April 2010 for certain advanced prostate cancer.) NSE is "a neuroendocrine marker; an enzyme produced by neuroendocrine cells found in more aggressive types of PC."

    The main idea here I want to give you is there are ways that will often succeed in tracking the cancer other than PSA. Other oncologists might have their own favored set of markers, though some or all of these four may be among them as there is research behind all of them. In view of the rapid pace of advances in prostate cancer technology, it's quite possible that new biomarkers have emerged.


    Quote:
    My husband was trying to recall when his father was diagnosed and he thinks it was when he around 80. Of course, we don't know at what stage it had reached at diagnosis. We do know that he lived to 87 and seemed reasonably vigorous for a man his age.
    I too have family history involved, and the ages are roughly similar. It's very, very important for you both to realize that there have been great advances in prostate cancer technology since your husband's father was dealing with the disease. Moreover, advances are not only continuing but accelerating. The disease is still no cake walk for many of us, but we have far superior odds of succeeding compared to our fathers who faced the disease a decade or more ago (or even more recently than that).

    Quote:
    We have an appointment scheduled with the radiation oncologist to see whether RT coupled with ADT is an option. We also are scheduling a consult with a doctor at Harvard Medical who has written about and has a clinical PCa practice that includes IADT.
    Getting a number of opinions for a case like your husband's strikes me as the best way to go. There are some highly respected doctors associated with Harvard who see many prostate cancer patients.

    Regarding IADT versus continuous ADT, first, you need to work with a doctor who understands intermittent therapy (avoiding those who believe that continuous therapy is the only sound approach for all), and second, you need to respond well enough to ADT (or other therapy, such as chemo) so that going off-therapy is a reasonable approach. The latter cannot be known up front.


    Quote:
    Happy new year to us all. May we each be healthier and happier a year from now than we are today.
    Amen to that!

    Here one last thought. Starting androgen deprivation therapy soon would be a wise move, but of course we are fellow patients, not doctors. One exception might be if your husband would be scheduled for an imaging scan that needs PSA that has not yet been knocked down so that results will show up better. ADT will knock down the PSA fast, so that needs to be considered. I'm in that boat myself at the moment, working toward one of the advanced new scans that sometimes indicate that we patients with challenging cases are still in the window where a cure looks possible.

    Take care,

    Jim

    Last edited by Administrator; 01-02-2012 at 09:37 PM.

     
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    Baptista (01-02-2012)
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