2.5 Yrs After Proton Rad PSA reached 1.05

The rule if you start off with radiation, until your PSA rises two points above the lowest it ever reached after radiation, they normally don’t want to do anything.

Thing is they’ve apparently found a metastasis.

Doctor at the PCRI conference discussed using SBRT to zap any new metastasis and keep the PSA undetectable. They felt It was preferable to zap the metastasis as they came, and they felt that that gave long-term relief, Even without ADT. Normally, you can’t see metastasis with a PSA as low as yours is, If they have found one, just let them zap it.

While getting on ADT and Zytiga will stop it from growing and will manage it, but this way, you can get rid of it and not have it as a future problem.

Someday you want to stop ADT and Zytiga (both of them will fail eventually) and you will have that metastasis making PSA. It may have grown over all this time as well, Best to zap it.

Ask your doctors isn’t that what they’re encouraging you to do?

Hi Jeff and thanks for replying, your insight is great thanks, I know you have been through it all. The lymph node mets. were discovered before starting orgovyx and zytega that is why they prescribed them the psma/pet lit up a few subtle spots in the lymph nodes just 3-months ago, so started the ADT. But im thinking since i had such a robust response to the drugs maybe radiation could be postponed for a while PSA March 1.05 PSA July 09 >.1. My Oncologist does want to do some form of radiation not proton and im guessing the intended targets are those mets. that lit up on the PSMA/PET scan. Also im wondering if I can cut back on the zytega a bit since the PSA now is so low. Im just not sure if the radiation is needed now, and thinking possibly incorrectly that the ADT therapy has resolved the mets. Do you think just blocking the testosterone is enough to resolve mets? I am so excited about my first PSA reading on the meds being >.1. I asked my oncologist if I should have a PSU ultrasensitive test and she said: To my surprise That's up you--(kind of of a red flag). Apparently she sees no value in determining what the actual number is.

When somebody has a metastasis, it is not going to go away on its own. ADT and Zytiga will not eliminate it. Most radiation oncologist like to start you on ADT at a minimum, To get the metastasis to stop growing and to shrink it. At that point, they want to radiate it so that it will stop growing and be permanently killed. Yes, You do want to have radiation soon so you can eliminate the cancer that is visible in your body now. This is the standard Of care when somebody has prostate cancer.

I started off with just Lupron (ADT same as Orgovyx), Didn’t start taking Zytiga until I was castrate resistant 2 1/2 years later. You have not only had a PSA rise, you have also had metastasis show up. That usually calls for more than one drug. Yes, you could try dropping Zytiga, It might work just fine. This is something you need to discuss with your doctor, however.

When you go on Orgovyx and Zytiga Your PSA should drop to < .1 Within about three months. Yours is still >.1 So let’s see what happens in the next PSA test.

Dr Shultz said that 2-points over nadir is absurd and ridiculous. Some say 3- consecutive rises warrants further investigation. I’m a perfect example of the stupidity of the 2-point rise mine rose .75 after 3 tests and I have metastasis. I had to BEG for 2.5 years to get a psma scan, they kept throwing that two 2 point BS at me, we had a few heated argument and they finally relented.

Thanks Jeff I’ll keep you posted with the next test.

Sorry my PSA IS< .1 I kinda have big fingers and small keyboard.

The three rises rule is for salvage radiation after surgery not for an initial Radiation treatment.

I confused the 3 rises for a while, but was straightened out when I was at a conference where a radiation oncologist emphasized that point over and over. There is a study that shows you should wait until two points above the minimum ever reached after radiation, I finally realized where the two different radiation treatments Differ.

I would be exactly where you are, If my PSA started rising after initial Radiation I would want to get a PSMA pet scan when it hit about .7. That’s what I told my oncologist a couple of years ago when the PSMA Pet test was sort of new. .7 was the point of which they recommended to not go below. Since then, I’ve heard a lot of people getting the test when they’re .2. If you have large metastasis, they may show up even with low PSA.

I can understand you wanting to push your doctor I would not put up with sitting waiting for it to rise two points before doing a PSMA Pet test.

Note that Nubeqa (Darolutimide) has recently been FDA-approved for metastatic castrate sensitive prostate cancer: https://youtu.be/qFK23Na9RfY?si=nMaMKVJx1hcyny7L
So, that’s now a possible option for you to use with ADT.

As for the technical definition of biochemical recurrence (BCR) following initial radiation - a PSA rise of 2.0 ng/mL above nadir (called the Phoenix Criteria) - was established in 2005 (20 years ago!) when modern imaging techniques (like PSMA-PET scans) that can detect recurrence at lower PSA levels were not available. It’s now known that BCR can occur following initial radiation well before that “2 points over nadir” threshold is reached.

The Phoenix Criteria served Ira purpose well - to differentiate true cancer recurrence from PSA fluctuations in order to prevent overtreatment, but is now likely outdated, with today’s earlier and more effective diagnostic techniques.

(I had initial treatment of 28 sessions of proton radiation during April-May 2021. PSA now varies between 0.350-0.550; my most recent PSA was 0.473. My medical oncologist and I have agreed that should I have three successive PSA increases, that she’ll schedule a PSMA PET scan. So far, three successive increases has not happened.)

Note also that the lower the PSA, the less sensitive PET scans are at detecting prostate cancers. (See attached graphic.)

Question about your graph: Reading it, it's possible that it shows it detects less cancer at lower PSAs because there IS less cancer there, and not because it's "less sensitive at detecting prostate cancers," which sounds like it has missed cancers at those lower PSA levels? Could you please clarify? Thanks.

It’s probably a little bit of both. At .2 there may not be any cancer, I know someone who has had multiple metastasis they’re at .2 and their doctor gives them PSMA pet scans every three months. This is the case where the doctor is trying to catch the metastasis when they start showing up. This is the sort of thing that Scholtz believes in.

If somebody’s PSA is at .2 that means that their prostate cancer is not producing a lot of PSA. That would be more likely due to Small metastasis that aren’t producing much or nothing is there, and that’s just a lot below what a normal male PSA should be.

Unfortunately, there’s no easy way to figure out whether or not there are metastasis. A better option would be a PSE test to see if there’s actually something to scan.