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PSA "undetectible" for amost a year
The fourth consecutive PSA result came back at <0.02 ng/mL, nearly one year after surgery.
Four consecutive undetectable PSAs over nearly a year are certainly reassuring and indicate that there is currently no detectable biochemical recurrence. However, they do not mean it is “all clear.” They also do not erase my longer-term recurrence risk given my adverse pathology and biology: Gleason 3+4, pT3b with seminal-vesicle involvement, extracapsular extension, lymphovascular and perineural invasion, and a high Decipher score.
For now, I plan to continue with my current strategy of regular PSA monitoring and reserving salvage radiation for a confirmed rising PSA rather than automatically pursuing adjuvant radiation. Why subject myself to treatment and its potential side effects before I need it? If there is roughly a 50% chance that I will not experience a recurrence, why undergo treatment now that may ultimately never be necessary?
I’m encouraged by the continued undetectable PSA and, as always, I welcome any and all input from the group.
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@notpetecrowarmstrong
The article does discuss the higher risk based on the PSA in this section.
Elevated risk of all-cause mortality was significant for all PSA cutpoints above 0.25 ng/mL through 0.50 ng/mL. At the 0.50 ng/mL cutpoint, the adjusted hazard ratio was 1.61 (95% CI = 1.21–2.14, P = .001).
Recommendation for ADT in higher risk cases is discussed in a lot of other places. I captured this information from an article that referenced the link I included. The only thing missing seems to be the recommendation for ADT above .5 which other articles like the one mentioned below recommend ADT when PSA level before SRT was ≥0.7. I know there are articles that discuss the .5 recommendation for ADT but it’s been a long time since I captured that information.
ADT combined with SRT appears to improve OS in patients with a PSA level before SRT of ≥0.7 ng/mL. In patients without persistent PSA after prostatectomy and PSA levels of <0.7 ng/mL, ADT should not routinely be used, but may be considered in patients with additional risk factors such as Gleason Score ≥8 and negative surgical margins.
Discussed here
https://pmc.ncbi.nlm.nih.gov/articles/PMC12170276/
@carbcounter
The answer to this question Is based on the treatment the person received.
If someone gets a prostatectomy then the PSA should stay undetectable. If It reaches .2 It is considered a case of reoccurrence and should be treated with radiation. There are a few cases where people have reached .2 and it just stayed there.
When it comes to radiation treatment for prostate cancer, the standard is that they don’t treat until the PSA reaches two points above the lowest it ever reached following radiation. If after radiation, it hit .1 then they would not treat until it hits 2.1. It would make sense to do a PSMA PET scan after it hits 1 since it is more likely to show if a Metastasis is causing the rise.
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1 Reaction@jeffmarc
Thanks for responding. At .041 my current PSA number is significantly less than .2. If it gets as high as .2 I hope my urologist recommends radiation.
@johnfinch
Sorry that I misread your .041 as .41. It is definitely low at this point. You have a while before it even reaches .2 if it does. At least now you know what the options are for getting treated.
When my PSA hit .2 after a prostatectomy, I was given a Lupon shot and two months later had salvage radiation. That’s sort of the ideal treatment, They didn’t have PSMA PET scans back then. Today you can have a scan and see if something shows up that can be zapped before SRT.
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Hug
1 Reaction@jeffmarc So they don't do radiation until two points higher, but they maintain or restart the hormone blockers much more strictly, I gather, that's really what I have questions about. I see questions here about this all the time.
As @soli says, after complete removal I can see the point.
@jeffmarc Thanks, Jeff. I appreciate you sharing your experience and your .
insights.
I am two years post surgery, and still showing non-detects. PSA testing is every 6 months. My doctor said that if it does return, the PSA level has to be high enough (that is, a tumor large enough) for them to be able to identify a target for focusing radiation treatment, rather than treating a general area.
But it seems to me that there is a third party in all these treatment decisions - the insurance companies. I dont see mine agreeing to pay for treatment at my insistence.
Congratulations on your undetectable PSA numbers for two years!
I believe most insurance companies will cover treatments that are supported by established guidelines, such as those from the NCCN.
As for when to pull the trigger, however, I have heard different opinions from prominent oncologists. Some advocate acting at a relatively low PSA threshold, particularly for high-risk patients, because salvage radiation tends to be more effective when the amount of recurrent cancer is still very small.
Others take a more cautious approach. They argue that if PSA returns but remains relatively low—for example, around 0.2 to 0.5 ng/mL—there may be only a microscopic amount of cancer that cannot yet be seen on imaging. Their concern is that radiation to a broad area, such as the prostate bed and/or pelvic lymph nodes, can cause significant side effects, including worsening urinary incontinence and bowel problems. From this perspective, treating too early, without knowing exactly where the cancer is, could cause permanent harm without necessarily guaranteeing a cure.
As you can imagine, both approaches have advantages and disadvantages. One emphasizes treating early, when the cancer burden is smallest and potentially most curable; the other emphasizes avoiding potentially unnecessary treatment and its side effects until there is stronger evidence of where the cancer is located. The appropriate choice can therefore depend on the individual’s pathology, genomic risk, PSA trend, and personal priorities.
I was also a Gleason 3+4, pT3b with seminal-vesicle involvement, but they cut them out.
1) Also had Non-focal extraprostatic extension is present.
2) Then further down said Margin Involvement by Invasive Carcinoma in Area of Extraprostatic Extension (EPE): Not identified.
That seems to be a contradiction? First one means Non-focal extraprostatic extension (EPE) means prostate cancer cells have grown through the outer edge of the prostate gland into the surrounding fatty tissue in a more extensive or widespread manner rather than just a tiny, isolated spot.
The second one means the cancer does not touch the outer edge of the removed tissue sample in the area where it grows outside the prostate.
the first I heard about PET scans was when my urologist ordered one for me earlier this year. Since my scan showed "no uptake in the prostate", an area which had a biopsy proven Gleason 4 lesion in it, I became interested in looking into better types of scans.
I was researching different tracers today, but ran into discussions of PET scanners with dramatically improved sensitivity. I'm not convinced one of these would be more useful for me, but it sounds very interesting for patients who have cancer detectable with PSMA PET.
One of these "extended axial field-of-view" scanners, the Biograph Vision Quadra PET/CT, has been at Mayo Rochester since 2022. Apparently this was the first installation in North America. https://newsnetwork.mayoclinic.org/discussion/mayo-clinic-installs-1st-quadra-pet-ct-scanner-in-north-america/
An article "High Detection Rates for Prostate-specific Membrane Antigen–avid Prostate Cancer Recurrence at Low Prostate-specific Antigen levels on Extended Axial Field-of-view Positron Emission Tomography/ Computed Tomography" located at https://www.eu-openscience.europeanurology.com/action/showPdf
concluded: "In comparison to literature data, the Quadra
scanner has substantially higher positivity rates at very low PSA levels. At these levels, disease was largely confined to the pelvis and potentially amenable to salvage radiotherapy"