Ultrasensitive PSA Test Post RP

Honest question @round5 , is an absolute zero possible? I've never hear of it. Or are you referring to a non ultra sensitive PSA?

I am referring to non ultra sensitive PSA. I think the ultra sensitive is useless and leads to fear and over treatment.

Post RP, biochemical recurrence can occur as far out as 15 years and PSA can fluctuate at very low levels during that entire time and yet you may never experience a recurrence.

The old definition of biochemical recurrence/failure was PSA of 0.2 (I believe two successive readings at or above that level.)

Since the advent of ultrasensitive tests, many now consider biochemical recurrence being an ultrasenstive result of 0.03 or greater.

Being a new user I can't post a link but google PMC4527538 for more info.

My post RP ultrasensitive tests at two large centers of excellence consider undetectable as anything less then 0.02 so the lab results will say "undetectable < 0.02". They don't bother displaying the actual number if it's less than 0.02 because studies have shown that readings below that are effectively unreliable indicators for any sort of actionalable decision making. I've read at least 6 studies following patients for years after treatment and how their uPSA results corresponded to whether they had biochemical recurrence or not. One study summed it up well in my opinion. It said a reading of 0.01 or less as far as its predictive ability is essentially the same as flipping a coin. So results in the .001 - 0.005 range are essentially meaningless except for the fact they are below 0.02 and therefore considered to be in the 'undetectable' range. PSA can be produced in tiny amounts by other things than Prostate Cancer cells is why. I'm almost wondering if you have your decimal point in the wrong place? As I've very surprised any lab would report any numbers below 0.01 since even below 0.02 is considered undetectable and inactionable and recurrence isn't considered until you hit 0.03 or about 75-300 times the levels you are referencing.

So in my opinion you are wasting your time being concerned about any PSA changes when results are < 0.02. No Urologist or Oncologist worth their salt should be recommending any sort of action based on PSA readings < 0.03. Keeping in mind they used to not take any action as long as PSA was < 0.2 (some medical professionals still may go by the higher 0.2 number but one study showed if you go by 0.03 it gives you on average 18 months lead time before you hit 0.2 so the salvage therapy has a much higher chance of being curative if performed after you hit 0.03 instead of the much higher 0.2)

A more interesting question to me is what PSA level is required to get insurance approval for salvage radiation treatment? I wonder if it's the older 0.2 level or if they now will approve at 0.03 due to recent studies regarding uPSA results being a strong predictor of recurrence. I suppose you could appeal a denial by referencing the latest studies. But I would bet it is virtually impossible to get approval of treatment at PSA < 0.03 or < 0.02. As these levels are not proof of recurrence so salvage treatment may not be necessary.

In addition PET PSMA scans are virtually useless at PSA < 0.5 in my opinion. They will miss areas containing cancer cells because the sensitivity rates of PSMA PET/CT according to PSA levels are 55-60% (0.2-0.5 ng/mL), 72-75% (0.5-1.0 ng/mL), 93% (1.0-2.0 ng/mL) and 97% (≥2.0 ng/mL)

Finally I should note there is such a thing (as mentioned by one user here) as "persistent PSA" after RP. I don't think it's that common but you could have a PSA in the 0.03 to ~0.15 range that remains in that range indefinitely, also termed by another user here as "stable PSA". This throws a monkey wrench into making early salvage treatment decisions. I had bilateral nerve sparing and am at 7 months post RP and my erections are slowly coming back (were a 10/10 pre-RP and at 7 months I'm at about a 5-6/10 erection and Urologist says I will eventually recover to a 9/10 (I'm only 54 years old.) BUT, if I do salvage radiation, that will be the nail in the coffin as far as achieving erections due to the blood vessel damage from the radiation, so no erections without a pump, injections or high-dose Viagra/Cialis (which may not be enough.) I think personally I would error on the side of caution and assume BCR at 0.03 and go for early salvage therapy for a higher chance of cure at the expense of significant permanent loss of EF. Versus waiting several months to see if my PSA will stabilize while the micro-metastatic cancer cells could be spreading farther out beyond the field of radiation during that time. Your EF is a moot point when you're on ADT, Chemo or are dead.

Welcome @jcrist1027. I noticed that you wished to post a URL to research article with your post. You will be able to add URLs to your posts in a few days. There is a brief period where new members can't post links. We do this to deter spammers and keep the community safe. Clearly the link you wanted to post is not spam. Please allow me to post it for you.

- Ultra-sensitive PSA Following Prostatectomy Reliably Identifies Patients Requiring Post-Op Radiotherapy https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4527538/

Welcome!

Post RP, biochemical recurrence can occur as far out as 15 years and PSA can fluctuate at very low levels during that entire time and yet you may never experience a recurrence.

The old definition of biochemical recurrence/failure was PSA of 0.2 (I believe two successive readings at or above that level.)

Since the advent of ultrasensitive tests, many now consider biochemical recurrence being an ultrasenstive result of 0.03 or greater.

Being a new user I can't post a link but google PMC4527538 for more info.

My post RP ultrasensitive tests at two large centers of excellence consider undetectable as anything less then 0.02 so the lab results will say "undetectable < 0.02". They don't bother displaying the actual number if it's less than 0.02 because studies have shown that readings below that are effectively unreliable indicators for any sort of actionalable decision making. I've read at least 6 studies following patients for years after treatment and how their uPSA results corresponded to whether they had biochemical recurrence or not. One study summed it up well in my opinion. It said a reading of 0.01 or less as far as its predictive ability is essentially the same as flipping a coin. So results in the .001 - 0.005 range are essentially meaningless except for the fact they are below 0.02 and therefore considered to be in the 'undetectable' range. PSA can be produced in tiny amounts by other things than Prostate Cancer cells is why. I'm almost wondering if you have your decimal point in the wrong place? As I've very surprised any lab would report any numbers below 0.01 since even below 0.02 is considered undetectable and inactionable and recurrence isn't considered until you hit 0.03 or about 75-300 times the levels you are referencing.

So in my opinion you are wasting your time being concerned about any PSA changes when results are < 0.02. No Urologist or Oncologist worth their salt should be recommending any sort of action based on PSA readings < 0.03. Keeping in mind they used to not take any action as long as PSA was < 0.2 (some medical professionals still may go by the higher 0.2 number but one study showed if you go by 0.03 it gives you on average 18 months lead time before you hit 0.2 so the salvage therapy has a much higher chance of being curative if performed after you hit 0.03 instead of the much higher 0.2)

A more interesting question to me is what PSA level is required to get insurance approval for salvage radiation treatment? I wonder if it's the older 0.2 level or if they now will approve at 0.03 due to recent studies regarding uPSA results being a strong predictor of recurrence. I suppose you could appeal a denial by referencing the latest studies. But I would bet it is virtually impossible to get approval of treatment at PSA < 0.03 or < 0.02. As these levels are not proof of recurrence so salvage treatment may not be necessary.

In addition PET PSMA scans are virtually useless at PSA < 0.5 in my opinion. They will miss areas containing cancer cells because the sensitivity rates of PSMA PET/CT according to PSA levels are 55-60% (0.2-0.5 ng/mL), 72-75% (0.5-1.0 ng/mL), 93% (1.0-2.0 ng/mL) and 97% (≥2.0 ng/mL)

You commented - I had bilateral nerve sparing and am at 7 months post RP and my erections are slowly coming back (were a 10/10 pre-RP and at 7 months I'm at about a 5-6/10 erection and Urologist says I will eventually recover to a 9/10 (I'm only 54 years old.) BUT, if I do salvage radiation, that will be the nail in the coffin as far as achieving erections due to the blood vessel damage from the radiation, so no erections without a pump, injections or high-dose Viagra/Cialis (which may not be enough.)

I had SRT in March 2016 after BCR. I too had nerve sparing surgery. My radiologist counseled me about the possibility of the radiation treatment causing ED. In my case, study of one, did not. Why not, who knows, study of one though. I do believe the improvement in the planning software and delivery of the radiation over the years may be a factor.

Kevin