Post prostatectomy: What do rising PSA levels mean?

Posted by hoard @hoard, Sep 10, 2019

New to group! Wish I had checked this out 2 years ago while supporting my husband! Now over e years post prostatectomy, wondering what might make psa go from all 0 to 2.6…

@aakrogstad

Hello, I am new here. My husband had Prostatectomy 2 years ago. PSA was 0.01 until last week we found out it is 0.3. I am scared. His doctor said it is still consider undetectable, but he'd rather see it 0.1. He said we have to wait for another 6 months to do another PSA test. Please let me know if you have any update on your case.

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Hi @aakrogstad and welcome. A rise in PSA, however slight so easily creates concern. I can imagine you're scared. I'm tagging @dandl48 @hoard @horace1818 and @ken82 to offer their thoughts.

A single elevated PSA measurement in a patient who has a history of prostate cancer does not always mean that the cancer has come back. Your doctor may look for a trend of rising PSA level over time rather than a single elevated PSA level.

The waiting part is the hardest. Do you have ways to distract your thoughts or calm them?

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@colleenyoung

Hi @aakrogstad and welcome. A rise in PSA, however slight so easily creates concern. I can imagine you're scared. I'm tagging @dandl48 @hoard @horace1818 and @ken82 to offer their thoughts.

A single elevated PSA measurement in a patient who has a history of prostate cancer does not always mean that the cancer has come back. Your doctor may look for a trend of rising PSA level over time rather than a single elevated PSA level.

The waiting part is the hardest. Do you have ways to distract your thoughts or calm them?

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@aakrogstad @colleenyoung Colleen, you might want to edit your post to read .3 instead of .03 that you have posted. With regard to the rise in PSA to .3, I personally would wait the 6 months although it would be stressful for me also. I'm not a doctor just what I would do. I had SBRT for my Prostate cancer back in September 2020 and I did stress out waiting for my 6 month PSA test in March that came back at <0, now I'm waiting for my next PSA scheduled for September with a little less stress. Best of luck,
Dave

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@aakrogstad

Hello, I am new here. My husband had Prostatectomy 2 years ago. PSA was 0.01 until last week we found out it is 0.3. I am scared. His doctor said it is still consider undetectable, but he'd rather see it 0.1. He said we have to wait for another 6 months to do another PSA test. Please let me know if you have any update on your case.

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Assuming your placement of the decimal point is correct and his PSA is ..3, up from .01, then it's time to throw the BS penalty flag on his doctor. After surgery, BCR is commonly defined as two consecutive increases in PSA, generally 90 days apart. Of course, with the introduction of the USPSA, there is uncertainty since the conventional PSA used for so long had undetectable at <.1 so then anything .1 to .019 was reported at .2 and thus "detectable."

So, a .3 is considered "detectable," especially if his previous reading was .01. You don't say the timeline for his PSA testing but I'm assuming in the first year after his surgery it was every three months then in the 2nd year every six months.

As to the doctor saying " we'd have to wait six months…" again, BS, it's your call, he can recommend and explain why he wants to wait six months but it is your decision, he simply has to write the lab order.

So, a rise from .01 to .3 may indicate BCR. You are within your rights to ask for a PSA sooner, (it's called shared decision making between you and your medical team) could be 30 days, could be 90 days. If the next test shows a rise to .4 or higher, you've confirmed BCR. If it goes back down or stays the same, ok. I have had mine go from .07 to .16 to .29 (I test every 90 days) then back down and stay there.

If the next PSA shows a continued rise, consider imaging. There are three approved by the FDA, C11 Choline, Aximun and PMSA Gallium (the latter at only two location in California, though FDA approval is expected soon for other locations currently in clinical trial status). The challenge will be at PSA <.5 even the most sensitive imagining will locate the site of the recurrence 30% of the time. It jumps to 60% when PSA climbs to .5 to .99 and 80% at 1.0 to 3.9. A 2mm tumor has 8 million cells, a 3 mm tumor 27 million cells, PMSA can detect those, a one millimeter tumor has one million cells, PMSA generally cannot detect that.

If you decide on treatment based on the clinical data – his pathology report, PSADT and PSAV, time to recurrence, then consider that more and more data sows the recurrence is not limited to the prostate bed but often includes the pelvic lymph nodes. So, imaging may inform your treatment decision. Consider systemic therapy which would combine some form of ADT for a limited duration, six, 12 or 18 months with radiation to the prostate bed and pelvic lymph node fields.

No reason to hit the panic button, if there is BCR, the options for treatment are many but it means you need to inform yourselves through research, there are many valuable website resources, https://www.pcf.org/guide/prostate-cancer-patient-guide/ is one, the NCCN is another https://www.nccn.org/patients/guidelines/content/PDF/prostate-advanced-patient.pdf.Many advances in the treatment of advanced PCA have been made in the last 5+ years since I was diagnosed in 2014 and many more are in the pipeline through clinical trials. It may be that we are entering a period where we live with this cancer rather than die from it for many.

Kevin

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@kujhawk1978,@dandl48, @colleenyoung, Thank you. Reading through your comments made feel better. I am waiting and praying for the best for everyone who is on the same situation. @dandl48, Good Luck next September! kujhawk1978 Tanks for the video. It was really informative. I learned a lot. I did call my husband's doctor, he still think that .3 is slightly increment and kept saying not to worry too much. Thanks again.

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@kujhawk1978

Assuming your placement of the decimal point is correct and his PSA is ..3, up from .01, then it's time to throw the BS penalty flag on his doctor. After surgery, BCR is commonly defined as two consecutive increases in PSA, generally 90 days apart. Of course, with the introduction of the USPSA, there is uncertainty since the conventional PSA used for so long had undetectable at <.1 so then anything .1 to .019 was reported at .2 and thus "detectable."

So, a .3 is considered "detectable," especially if his previous reading was .01. You don't say the timeline for his PSA testing but I'm assuming in the first year after his surgery it was every three months then in the 2nd year every six months.

As to the doctor saying " we'd have to wait six months…" again, BS, it's your call, he can recommend and explain why he wants to wait six months but it is your decision, he simply has to write the lab order.

So, a rise from .01 to .3 may indicate BCR. You are within your rights to ask for a PSA sooner, (it's called shared decision making between you and your medical team) could be 30 days, could be 90 days. If the next test shows a rise to .4 or higher, you've confirmed BCR. If it goes back down or stays the same, ok. I have had mine go from .07 to .16 to .29 (I test every 90 days) then back down and stay there.

If the next PSA shows a continued rise, consider imaging. There are three approved by the FDA, C11 Choline, Aximun and PMSA Gallium (the latter at only two location in California, though FDA approval is expected soon for other locations currently in clinical trial status). The challenge will be at PSA <.5 even the most sensitive imagining will locate the site of the recurrence 30% of the time. It jumps to 60% when PSA climbs to .5 to .99 and 80% at 1.0 to 3.9. A 2mm tumor has 8 million cells, a 3 mm tumor 27 million cells, PMSA can detect those, a one millimeter tumor has one million cells, PMSA generally cannot detect that.

If you decide on treatment based on the clinical data – his pathology report, PSADT and PSAV, time to recurrence, then consider that more and more data sows the recurrence is not limited to the prostate bed but often includes the pelvic lymph nodes. So, imaging may inform your treatment decision. Consider systemic therapy which would combine some form of ADT for a limited duration, six, 12 or 18 months with radiation to the prostate bed and pelvic lymph node fields.

No reason to hit the panic button, if there is BCR, the options for treatment are many but it means you need to inform yourselves through research, there are many valuable website resources, https://www.pcf.org/guide/prostate-cancer-patient-guide/ is one, the NCCN is another https://www.nccn.org/patients/guidelines/content/PDF/prostate-advanced-patient.pdf.Many advances in the treatment of advanced PCA have been made in the last 5+ years since I was diagnosed in 2014 and many more are in the pipeline through clinical trials. It may be that we are entering a period where we live with this cancer rather than die from it for many.

Kevin

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@kujhawk1978 Kevin, I found your response interesting, thanks for posting. One question, what does BCR stand for?
Thanks, Dave

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@aakrogstad

@kujhawk1978,@dandl48, @colleenyoung, Thank you. Reading through your comments made feel better. I am waiting and praying for the best for everyone who is on the same situation. @dandl48, Good Luck next September! kujhawk1978 Tanks for the video. It was really informative. I learned a lot. I did call my husband's doctor, he still think that .3 is slightly increment and kept saying not to worry too much. Thanks again.

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His doctor is "not wrong…" .3 is a low PSA, the challenge is if and when to treat. That requires data, multiple PSA tests over time to show a continuous upward trend, determine doubling and velocity times and enable imaging to locate recurrence…The contra to that is as PSA rises, it is more difficult to achieve a "cure" in say, SRT There is also a theory that says metastases are responsible for seeding new metastases that while initially no bone or organ involvement, the new metastases may now spread into the organs or bones, marking a new and more dangerous phase of the cancer. So, some say strike early and hard, reduce or limit the additional spread of metastases. Others say that is a false theory since some studies say it can take up to 8 years to see metastases thus just because you treated early doesn't mean you changed the course of the cancer. That's why clinical data is important, both past and present. In my case, GS 8, only 18 months to BCR and rapid doubling and velocity times were indicative of aggressive cancer and so we acted and treated aggressively. Those with less aggressive cancer as supported by clinical data may want to actively monitor and have decision points to implement treatment. If your husband's doubling and velocity time were 12 months or greater, hey, may not be any reason to treat. If they are three months or less, well, may be time to act. It's a heterogenous cancer, not homogeneous, inform yourself, obtain clinical data – PSA, Alk Phosphate, Imaging, symptoms, then make a shared decision with your medical team based on age, health, quality and quantity of life preferences.

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@dandl48

@kujhawk1978 Kevin, I found your response interesting, thanks for posting. One question, what does BCR stand for?
Thanks, Dave

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Dave – biological chemical recurrence – it's when your PSA rises after surgery or radiation but there is no clinical evidence of metastases as demonstrated by imaging.

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@kujhawk1978

Dave – biological chemical recurrence – it's when your PSA rises after surgery or radiation but there is no clinical evidence of metastases as demonstrated by imaging.

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@kujhawk1978 Thanks,

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Can i ask about my prostate issues or lack of a prostate issue?

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@colleenyoung

Welcome to the Prostate Cancer group, @hoard.
You ask a good question. What can rising PSA levels means years after having had a prostatectomy?
There are several reasons why one's PSA level may rise after being stable for a time. This article explains it well:
– PSA levels after prostatectomy https://www.medicalnewstoday.com/articles/323899.php

Here's an excerpt from the article:
"Seeing a rise in PSA level does not always mean that prostate cancer is returning or spreading. The test is very sensitive and can pick up small changes in PSA levels. Doctors will usually want to know how quickly levels of PSA in the blood are rising. To find this out, a person will need to have regular PSA tests. If levels of PSA remain stable or rise very slowly, treatment may not be necessary.

In some cases, high PSA levels in the blood are not due to cancer cells. Some factors that can affect PSA levels include:
– older age
– ethnicity
– medication
A doctor will take these factors and the person's medical history into account when looking at test results. This can help them decide if PSA levels are high enough to cause concern."

The PSA test alone is not enough to determine cause or next steps. Your doctor will likely consult with your husband and possibly order other tests. How long ago did your husband have his surgery? Did he have other treatments after surgery? Do you have a followup appointment schedule with his oncologist?

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Hello Colleen. I had my prostate removed September of 2019. Robotically! Awesome process! PSA level before surgery was 7.50. 3 months after surgery 2.50. Finished radiation treatments May 14th 2021. One month after radiation PSA is 3.28. Do we think this just to soon to check my numbers or should I be concerned?

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