Ultrasensitive PSA Test Post RP

There is still much discussion about USPSA tests and what changes mean compared to conventional PSA tests that only measure to single decimal.

There can be variation in lab results. Some factors may be if different labs are used, type of assay, calibration of equipment as well as the conditions, were you dehydrated, ore lab routine, did you intensely exercise prior, is the lab the same time of the day...

So, a change from .005 to .01 may mean different things. One thing is may not mean is a call to action, treatment! What you may want is multiple readings over time, say three, stretched three months apart that indicate a continuous upward trend. web265 is correct when he cites his radiologist - One of the statements my radiation oncologist made to me was that rate of doubling in those very low numbers such as you're in is not nearly as troubling as in the higher numbers, i.e. 2 going to 4 etc. As you can see from my attached clinical history, my PSA has bounced around since triplet therapy starting in Jan 17 through Nov 18 after surgery and SRT failed but my medical team has not felt there is a reason to act given its variability and low levels.

We do know there may come a day where that variability ends and there is a need to act. What might that day be? Well, PSA would have to hit .5 a continue to climb, why, well that's the earliest we would image endeavoring to locate where the recurrence might be. No treatment decision unless we know where it is! Belo .5 the newer imaging has <30% chance of locating the recurrence.

Another thing to think about is does acting now or waiting until you have more clinical data supporting a decision change the outcome, you and your medical team's treatment decision. Before USPA tests or if your medical team was not using USPSA then the decision criteria for recurrence was a detectable PSA defined as .2 followed by a 2nd rise that showed .3 or higher. So, by that standard, you are undetectable!

Consider to continue actively monitoring your PCa, decide if it continues to increase, what constitutes a decision to treat - I would consider not treating until I had imaging to inform the decision and for me and my medical team, that comes somewhere between .5 and 1. If there is clinical data to support a treatment decision, hit it hard with double or triple therapy.

Kevin

Hi Kevin,
You always provide excellent well informed answers. I was wondering where salvage radiation for possible local reoccurance would fall into this. We were told that at .2, time for prostate bed and local lymph nodes to be zapped. TYIA

BCR normally occurs when PSA after surgery hits .2 on a standard PSA test with a subsequent reading of .3, usually 90 days later.

The lower the PSA, the greater the chance of the elusive cure...but, that's based on the old notion that recurrence started in the prostate bed then progressed linearly to the PLNs.

That may be the case and SRT to the prostate bed is where the recurrence is and one is cured. Emphasis on may.

The more likely scenario is there are micro metastatic sites outside the prostate bed and SRT to the prostate bed only is destined to fail.

My mantra, be aggressive and match the treatment to the most dangerous situation.

If one decides to do combination treatment and radiation to the prostate bed and PLNs along with short term ADT then waiting for the PSA to rise between .5-1 (or higher) to increase your probability of a scan locating sites of recurrence and inform the treatment plan may not pose any risk to the outcome.

If one is only treating the prostate bed then waiting for the PSA to rise to increase the chances of locating with imaging doesn't pass my common sense test.

See if I can sum this up, if one believes that the more likely scenario is an increase in one's PSA after surgery indicates recurrence and you plan to treat with a combined regimen of short term ADT and radiation that includes the PLNs then it may make sense to treat once you have two or three PSA tests showing a continuous upward trend. The only thing in that case you may gain by waiting for PSA to increase to >.5 and improve your chances of the imaging locating the sites of recurrence is the radiologist can build a treatment plan that includes boosts and wider margins around the identified sites.

Generally, with confirmed recurrence, treating earlier, image only if it may change the treatment decision.

We were told .2 (with confirming timely retesting) means reoccurance and it is not wise to wait for .5 as that indicates spread rather than local. However; also informed scans are unlikely to 'catch' anything until .5. We had multiple opinions from support groups as well as 3 different 'centers of excellence' including Mayo and they indicated jumping on it with SR may be the best chance to catch it before it has spread. The consensus was not to allow it to get that far (i.e when it shows up on a PSMA scan) before starting localized treatment. The goal was cure rather than allowing for it to metas.....
Thank you for your opinion.

What you say is definitely a good way to look at it and decide.

It does make sense to hit it early...as I said, only makes sense to wait if imaging will change the treatment plan.

If the decision is SRT to the prostate bed only, that I would hesitate doing based on Mayo's own data.

It was a decision I let my medical team make when I had BCR, ignoring the data emerging from clinical trials

When that failed and I had to do ADT, chemotherapy and radiation, well, mono therapy was a word that I deleted from my decision making. That and I added shared decision making.

PSA 5 , special pet scan, no cancer found??
My husband had this special pet scan after a total prostate removal, his PSA was a 5, they could find no cancer, but keep him on those shots in which he gets severe hot flashes. What to do?

PSA 5 , special pet scan, no cancer found??
My husband had this special pet scan after a total prostate removal, his PSA was a 5, they could find no cancer, but keep him on those shots in which he gets severe hot flashes. What to do?