Possible Causes of rising PSA 18 years post prostate removal

Posted by stu6060 @stu6060, 1 day ago

Hello All,
I had my prostate taken out 18 years ago. I was 46.
About a year ago my PSA came back as 0.1 for the first time. Previously everything was reported to me as "undetectable less than 0.1."

In the last 15 months I have been somewhat obsessed with getting tests and trying to make sure I am in position to get treatment if/when I hit, what seems to be the generally agreed upon trigger number of 0.2

Depending on where I go (doctor's office or $24 private lab test) my PSA is hanging around 0.9 to .110.

It seems most likely at some point in time ( months?? a couple years??) I will find my PSA is 0.2 or more.

I am however curious, has anyone had an experience like mine and found the PSA numbers just kind of stayed at the "low numbers" for an extended period of time? Is it possible I have a small amount of normal prostate cells left that have grown and now kicking off some measurable PSA, or is the most likely case happening in that I have something small brewing and if I don't step in front of a bus sometime soon I will have a treatable condition again? thanks

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

All of what you suggest could happen. Your PSA could stay stable or it could rise. Going to the same lab each time will give you more accurate results, It can vary if you go a different Labs.

I know people with a Gleason nine that have come to ancan.org Advanced prostate cancer meetings talking about how after 20 or 30 years following a prostatectomy their PSA started rising. There is one today at 6 PM Eastern time.

If your PSA does hit .2 you should meet with an oncologist about getting salvage radiation. The following article discusses when you should do that.

From Ascopubs about what PSA to do salvage radiation.
≤0.2 ng/mL:
Starting at this level maximizes disease control and long-term survival. Patients treated at PSA < 0.2 ng/mL achieve higher rates of undetectable post-SRT PSA (56-70%) and improved 5-year progression-free survival (62.7-75%).
Delaying SRT beyond PSA ≥0.25 ng/mL increases mortality risk by ~50%.

0.2–0.5 ng/mL:
Still effective, particularly for patients with low-risk features (e.g., Gleason ≤7, slow PSA doubling time). The Journal of Clinical Oncology recommends SRT before PSA exceeds 0.25 ng/mL to preserve curative potential.

0.5–1.0 ng/mL:
Salvage radiation remains beneficial but may require combining with androgen deprivation therapy (ADT) for higher-risk cases.

This article discusses the above;
https://ascopost.com/news/march-2023/psa-level-at-time-of-salvage-radiation-therapy-after-radical-prostatectomy-and-risk-of-all-cause-mortality/
Your Gleason score is a major factor in reoccurrence. If it was a seven year, PSA may never rise high again. If it is an eight or higher than reoccurrence is more frequent.

You got prostate cancer quite young. That is frequently because there is a genetic issue.

Getting an hereditary, genetic test is a good idea. If you have certain genetic issues, there are new drugs to treat them. You can get one free here

Prostatecancerpromise.org

They will send you a kit and in about three weeks a genetic counselor will call you to discuss the results. Don’t check the box to have your doctor involved. In that case they won’t send anything until they speak to your doctor.

REPLY

Yes, these days they can just zap individual metastases with radiation, as long as there aren't too many of them. If a lot of metastases appear at once, they can give you either chemo or Pluvicto. And the second-generation ARSIs (the -lumamides) are highly effective at slowing or stopping prigression, especially in combination with ADT

If or when your PSA hits 0.2, since that's your oncologist's trigger threshold, a PSMA PET scan can show you if any of the isolated cancer cells floating around has started to multiply and produce a micrometastasis large enough to detect (there may well not be any).

REPLY
Profile picture for jeff Marchi @jeffmarc

All of what you suggest could happen. Your PSA could stay stable or it could rise. Going to the same lab each time will give you more accurate results, It can vary if you go a different Labs.

I know people with a Gleason nine that have come to ancan.org Advanced prostate cancer meetings talking about how after 20 or 30 years following a prostatectomy their PSA started rising. There is one today at 6 PM Eastern time.

If your PSA does hit .2 you should meet with an oncologist about getting salvage radiation. The following article discusses when you should do that.

From Ascopubs about what PSA to do salvage radiation.
≤0.2 ng/mL:
Starting at this level maximizes disease control and long-term survival. Patients treated at PSA < 0.2 ng/mL achieve higher rates of undetectable post-SRT PSA (56-70%) and improved 5-year progression-free survival (62.7-75%).
Delaying SRT beyond PSA ≥0.25 ng/mL increases mortality risk by ~50%.

0.2–0.5 ng/mL:
Still effective, particularly for patients with low-risk features (e.g., Gleason ≤7, slow PSA doubling time). The Journal of Clinical Oncology recommends SRT before PSA exceeds 0.25 ng/mL to preserve curative potential.

0.5–1.0 ng/mL:
Salvage radiation remains beneficial but may require combining with androgen deprivation therapy (ADT) for higher-risk cases.

This article discusses the above;
https://ascopost.com/news/march-2023/psa-level-at-time-of-salvage-radiation-therapy-after-radical-prostatectomy-and-risk-of-all-cause-mortality/
Your Gleason score is a major factor in reoccurrence. If it was a seven year, PSA may never rise high again. If it is an eight or higher than reoccurrence is more frequent.

You got prostate cancer quite young. That is frequently because there is a genetic issue.

Getting an hereditary, genetic test is a good idea. If you have certain genetic issues, there are new drugs to treat them. You can get one free here

Prostatecancerpromise.org

They will send you a kit and in about three weeks a genetic counselor will call you to discuss the results. Don’t check the box to have your doctor involved. In that case they won’t send anything until they speak to your doctor.

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@jeffmarc Jeff thanks for all the good information. This might be a big question but, if I have
an especially troublesome genetic situation does that mean my son certainly has the same situation? thank you

REPLY
Profile picture for northoftheborder @northoftheborder

Yes, these days they can just zap individual metastases with radiation, as long as there aren't too many of them. If a lot of metastases appear at once, they can give you either chemo or Pluvicto. And the second-generation ARSIs (the -lumamides) are highly effective at slowing or stopping prigression, especially in combination with ADT

If or when your PSA hits 0.2, since that's your oncologist's trigger threshold, a PSMA PET scan can show you if any of the isolated cancer cells floating around has started to multiply and produce a micrometastasis large enough to detect (there may well not be any).

Jump to this post

@northoftheborder thank you for the information. I appreciate your time.

REPLY
Profile picture for stu6060 @stu6060

@jeffmarc Jeff thanks for all the good information. This might be a big question but, if I have
an especially troublesome genetic situation does that mean my son certainly has the same situation? thank you

Jump to this post

@stu6060
If you have a genetic issue, like BRCA2, ATM etc ALL direct relatives should be tested. Aunts, uncles, cousin’s grandparents and children. They have a 50% chance of having the same problem.

All of my relatives were tested. I am the only one left from my grandfather passing it down.

Two aunts had beast cancer and one died of it as did her daughter.

REPLY
Profile picture for jeff Marchi @jeffmarc

@stu6060
If you have a genetic issue, like BRCA2, ATM etc ALL direct relatives should be tested. Aunts, uncles, cousin’s grandparents and children. They have a 50% chance of having the same problem.

All of my relatives were tested. I am the only one left from my grandfather passing it down.

Two aunts had beast cancer and one died of it as did her daughter.

Jump to this post

@jeffmarc Jeff, thank you for the input, I knew you would have the information.

REPLY
Profile picture for stu6060 @stu6060

@jeffmarc Jeff thanks for all the good information. This might be a big question but, if I have
an especially troublesome genetic situation does that mean my son certainly has the same situation? thank you

Jump to this post

@stu6060 I have the BRCA2 mutation and have 3 children. My oldest daugh was tested and does not carry the mutation. My son is about to be tested and my youngest daugh (25) does not want to be tested yet. I have 2 sisters and my mother carried the BRCA2 mutation and pass it on to all 3 of us. We were tested many years ago and at the time the genetic counseling mostly focused on my sisters risk of breast cancer and just kind of off-handedly mentioned to me that you do have a slightly higher risk of prostate cancer. I was kind of dismissive of it at the time (much younger) and wish I had followed up on it. The problem with these types of genetic mutations is that they are rare and most doc's do not have knowledge around them. When I was diagnosed with PC, out of the 6 docs i saw only 2 understood the BRAC 2 impact - the others had NO knowledge of it. Knowledge is power - as I told my son, its just information but it's good to know if you are positive and at your age (30) you'll be fine but get the test. He's going for the test and to get a PSA at 30 so he has a baseline for later in life. Honestly, most men should have a PSA test in the 40s but it seems like most docs wont suggest or do it unless you ask.

REPLY
Profile picture for jmacpa @jmacpa

@stu6060 I have the BRCA2 mutation and have 3 children. My oldest daugh was tested and does not carry the mutation. My son is about to be tested and my youngest daugh (25) does not want to be tested yet. I have 2 sisters and my mother carried the BRCA2 mutation and pass it on to all 3 of us. We were tested many years ago and at the time the genetic counseling mostly focused on my sisters risk of breast cancer and just kind of off-handedly mentioned to me that you do have a slightly higher risk of prostate cancer. I was kind of dismissive of it at the time (much younger) and wish I had followed up on it. The problem with these types of genetic mutations is that they are rare and most doc's do not have knowledge around them. When I was diagnosed with PC, out of the 6 docs i saw only 2 understood the BRAC 2 impact - the others had NO knowledge of it. Knowledge is power - as I told my son, its just information but it's good to know if you are positive and at your age (30) you'll be fine but get the test. He's going for the test and to get a PSA at 30 so he has a baseline for later in life. Honestly, most men should have a PSA test in the 40s but it seems like most docs wont suggest or do it unless you ask.

Jump to this post

@jmacpa
that is a solid perspective,,, my one and only son is only 22. Just starting to live his own life and follow his dreams. He knows I had cancer diagnosis and surgery many years ago (when he was 4) . Layering on some genetic finding right now seems really heavy, First step is I need to get tested...then I'm thinking,, like you said.. sometime around 30 might make more sense.

thanks for the input!

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Yeah, just when you think...

First thing to think about may be discussing and developing "decision criteria" in coordination with your medical team - when to treat, if so, with what, for what period...

Part of that is what clinical data to you want to have in making any treatment decision?

Some you may already have from the pathology report and labs and jabs since, GS, GG...

Some you can determine from the data you have, PSADT and PSAV.

Some you may not have, Genomic testing results, testosterone levels, CV health, Lipids, CMPs, etc. that show liver, kidney function and other useful health data in making treatment decisions.

Then discuss the criteria...

How many PSA tests, spaced how far apart and that show a continuous increase? As others have said, to the extent possible, you want to control the conditions of labs and jabs, same lab, same time of the day, same pre-draw routine.

At what PSA will you act? That may depend on what treatment you and your medical team are thinking about. If SRT to the prostate bed, the decision is made for you, .2

If something else, then the sensitivity of imaging maybe a factor. At below .5, generally a 1/3 statistical chance of PSMA imaging showing recurrence, if .5-1.0 you double the statistical chance.

So, if your decision is SRT, you're not going to wait for PSA to rise above .2 and likely not use imaging. Here's the contra to SRT at .2, it's like dropping dumb bonds, hoping to hit the target. You can choose to be more aggressive and include te pelvic lymph nodes, ratchet up the aggressiveness even further and add short term systemic therapy, six months, though 12-18 is in play depending on the clinical data. Then again, if you miss that "golden" window of .2 for SRT, there is the possibility you lose an opportunity for that elusive cure. Put me in the group that says if surgery doesn't bring you that cure, SRT is not going to either. You are now into managing your PCa as a chronic disease requiring lifelong vigilance and treatment decisions at various points, though not continuous, maybe intermittent. Terms like progression free survival move go the forefront in your decision making.

There is some data from clinical rials that indicates MDT only may push back the need for systemic therapy. That argues for letting PSA rise to between .5-1.0, image and then treat with MDT.

Depending on your PSADT and PSAV, you may consider doing nothing but continuing to actively monitor as PSDAT >12 months supports that. You can always act later if the clinical data indicates.

Read through the NCCN and AUA guidelines, avail yourself of resources from organizations such as PCRI and PCF.

Kevin

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I had proton radiation and adt 1.5 years in 2009-2010. My psa went from 9.7 to .02 . Stopped adt in 2010. Psa went to around .2 occasionally jumping up to .3 ( after sexual activity) then back down to .2 . Level around .2 for 15 years now. My Dr says my chance of recurrence is about 1%

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