PSA Persistence after RP and Salvage Radiation

Posted by aldenrobert @aldenrobert, Dec 27, 2022

I have not seen much information on PSA Persistence post RRP and Salvage EBRT. I think most biochemical recurrences occur over an extended period of time. I am kind of alarmed at how quickly my Prostate Cancer has progressed. Are there others out there that have been down a similar path? If so would you mind sharing some of your experience? Thanks.

03/25/21 I had my Prostate removed. PSA prior to surgery was 11.6.
05/31/21 my 1st PSA test post surgery was 0.37
09/09/21 PSA continues to climb to 0.69, salvage EBRT suggested. Because of low decipher score no ADT recommended.
09/27/21 thru 11/12/21 7 weeks, 34 rounds of radiation to the prostate bed.
12/10/21 PSA continued to climb during radiation up to 1.29
01/12/22 PET/CT scan comes back as negative. All looks good.
11/11/22 PSA doubling time is 4 months PSA up to 6.56
12/16/22 PET/CT scan shows " moderately PET Avid site near the right lung hilum that may be Prostate Cancer" No other areas of suspicious tracer uptakes.
12/30/22 Telemed visit with my oncologist "Consideration for biopsy should be made."

Interested in more discussions like this? Go to the Prostate Cancer Support Group.

@melcanada

What is Ebearla?

I have metastatic in L2 T10 an dT12 Radiated once May do again On Zolodex injections and now want me on Enzalutamide PSA was 1.2 now 6.6 I'm 78

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Ebearla is a pill that kills testosterone. You take 4 per day, cost 15,000. Per month. Yes, very expensive. Similar to Zytiga or abireterone
After 11 years of this, I feel most of the medicines work to restrain the PSA. They are not designed to cure cancer but to contain it. As you can see $15,000 per month is a great incentive to keep you on the medication. My urologist sells me mine, it does not come from the pharmacy. I suggest you see a naturopath and add that to your treatment regime. It will include boost and vitamins and minerals and some diet changes. All easily doable.

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Obviously, your cancer had spread already. Now you’re in need of finding where it has landed and in what form and treating that. If you haven’t had a pet scan or bone scan, I would suggest one of those and if you want, see a naturopath to change up your diet and add more vitamins and minerals. Do you want to eat as healthy as you can.

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@dirtdancer

Ebearla is a pill that kills testosterone. You take 4 per day, cost 15,000. Per month. Yes, very expensive. Similar to Zytiga or abireterone
After 11 years of this, I feel most of the medicines work to restrain the PSA. They are not designed to cure cancer but to contain it. As you can see $15,000 per month is a great incentive to keep you on the medication. My urologist sells me mine, it does not come from the pharmacy. I suggest you see a naturopath and add that to your treatment regime. It will include boost and vitamins and minerals and some diet changes. All easily doable.

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Ebearla must then be like the Zolodex injections I am on 3 months each

Enzalutamide is planned in Jan 4 pills a day 13K CDN for 90 pills yet our health care covers it if over 65 I am 78

Comments appreciated

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@tom86

Hi Kevin,
Having read the article from NCCN, do you think a DRE is required if US
PSA is negative? I found it to be unclear.
Thank you,
Dee
Glad to hear you are stable. Great news!

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Perform routine DRE's? PSA? You decide.

A few years ago the medical establishment decreed that routine PSA testing be discouraged or declined (mine only continued as a professional courtesy).

Likewise, a few years ago, I switched from an excellent primary care physician (female) who always did a DRE, to an excellent new doc (male) who has never done a DRE on me in the 12 years with him. I was surprised. He said is was no longer recommended.

Someone somewhere in the medical establishment must have decided that the DRE "yield" in PCA was too low to justify, or perhaps there were too many false positives.. I always thought this odd since I seem to recall that in the early days of PSA testing, the literature indicated the DRE picked up some cancers that PSA missed. In the case of my physicians, they belong to the same major medical center.

So, DRE? Here's the experience of a friend, same age as me whose PCA diagnosis proceeded mine by six months. He was not receiving a routine DRE. His PSA's routinely ran in the high one's. One day, he was temporarily moved to a different primary care doc. This one did perform a DRE and found a suspicious nodule. It was biopsied. His PSA was 2.1; the biopsy was significant Gleason 7/8. He proceeded to Brachytherapy then EBR and now on Lupron (and hates it).

So, I concede that this is anecdotal, but should we continue to do DRE's? How are these medical decisions being made? On what data?

So, what about PSA? Should we have discontinued routine PSA testing? I have a 30 year record of PSA tracking over time, and it caught my PCA, but not before my doc was convinced that an annual PSA value of 1, 2, 4, and finally 7 justified evaluation. We should have done an MRI at 4 for sure or more frequent testing after 2. How are PSA values being employed today to make evaluation decisions? What are the guidelines, Based on what data?

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"Perform routine DRE's? PSA? You decide."
Exactly. I believe all these things are certainly indicators but not necessarily proof of Prostate cancer, you need the biopsy for that.

My GP was a non believer in DRE's.

My PSA rise was discovered at 11. Off to a very experienced urologist who did a DRE, he said the result of that test was absolutely normal, and he was perplexed about the PSA. The biopsy showed Gleason 7.

So, in my case the GP was correct, the DRE would have told him nothing.

On the other hand, while on my journey I became aware a friend had this and his PSA went up a little a DRE caught irregularity and the biopsy showed Gleason <6. Radiation, no ADT, about 7 years ago, still good.

...and in my friends case....a DRE likely saved him from a lot of issues that those of us who get diagnosed a little later deal with.

Go figure. Seems everyone is different.

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Based on my recent prostate cancer experience, I believe the PSA and DRE are not being utilized to the extent they should be. With any individual test, there can be false positives - Annual mammograms, cardiovascular stress tests, etc... However, these tests are indicators for potential serious conditions and should be taken seriously. In my situation, they were not. My primary care physician started taking my PSA when I was 50, and it was 1.5. Three years later my PSA rose to 3.0, then two years later it rose to over 6. My doctor never mentioned this to me, but fortunately a friend within the same hospital organization reviewed my health records while analyzing my cholesterol history. She saw that my PSA level and slope increase were high and told me that I definitely had an issue with my prostate that needed to be addressed. Within three days I had an appointment at Mayo-Rochester. A week later, an MRI showed I had a lesion and we decided to do a biopsy. Another week, and the biopsy showed cancer - Gleason 7 (4/3). Six weeks later I had a radical prostatectomy (prostate/seminal vesicles & six lymph nodes removed). Absolutely wonderful experience at Mayo-Rochester. The Doctors, nurses, and support staff were outstanding. I was amazed with the level of care given to me at Mayo versus my local hospital in Iowa.
Based on my experience and subsequent research, I believe prostate cancer indicators (PSA, DRE, etc.) are not being utilized because of the high costs associated with MRI's, biopsies, etc... In my case, acting on the PSA increase earlier would have opened up so many more treatment options and not allowed for the cancer to advance to the stage it had.

Take care and Happy New Year!!

Jim

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@kujhawk1978

Given the PSA post surgery, your clinical data indicates there was PC outside the prostate.

Interesting that your SRT was to the prostate bed only and monotherapy. Various studies tend to say treat the prostate bed, entire PLNs with radiation and add short term ADT, six-24 months. Oh well, history as they say, can't change it, learn from it.

Generally, advanced PCa is not "curable." Question is, if we shorten our horizon to 3-5 years, can we "live" with it? Other diseases do, diabetes, AIDS...the changing landscape of treatments for PCa may very mean for most men with advanced PCa, they may be able to.

In your upcoming meeting consider discussing doublet therapy, radiation and short term ADT, six months. You may have micro-metastatic PCa which is too small to be seen by imaging, your PSADT supports that. The ADT treats that since its systemic therapy. When discussing radiation, bring a radiologist into the discussion and talk about treating the entire PLN system vice spot radiation to the one site identified in the imaging.

The PSADT you provided supports being aggressive, the general rule of thumb:
> 12 months actively monitor
6-12 months grey zone
< 6 months treat now.

As you can see from my clinical history, when surgery and SRT (to the prostate bed only, the standard of care at the time...another story) failed, my PSADT indicated as my surgeon and urologist said, "Kevin, I don't like what your PSA is doing...!" I was fortunate in that the C11 Choline scan showed only PLN but no bone organ involvement and triplet therapy has given me a durable progression free period.

Finally, take some time to read through the NCCN guidelines for patients on advanced PCa, Chapter 7 - https://www.nccn.org/patientresources/patient-resources/guidelines-for-patients/guidelines-for-patients-details?patientGuidelineId=50

Kevin

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What is PLN system? How and what could I treat it with, radiation? Thanks, Nate

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Nate

I get lazy sometimes and use abbreviations when I should be spelling them out...

I'm referring to the pelvic lymph node system which is where prostate cancer cells go to and establish new metastatic sites, initially too small to be seen by imaging when they are micro metastatic but depending on doubling tones, can rapidly become visible on imaging.

Best to discuss with your radiologist on how they would treat the entire pelvic lymph node system as it may depend on imaging. In my case, one of the four was pretty high and would not have been in a standard treatment field.

Here's a link which may help you understand- https://training.seer.cancer.gov/lymphoma/anatomy/chains/pariental-pelvis.html

Kevin

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