PSA at 6 months after salvage RT—not so good

I did not have surgery but had IMRT as prostate treatment with ADT/ARSI. That said my numbers are on the same trajectory as yours although somewhat higher. My PSA went from 0.19 in August, to 0.23 in December, to 8.80 and then 10.295 two weeks later in April. ALP was 165 at last check in April. PSMA PET lit up right side of prostate and L5. Called RO and we're going to zap L5 next week, but the prostate issue is going to have to be a medical solution since it was just radiated last October. If I could re-live the last 6 months, I would have insisted on monthly PSA checks after the first rise in PSA, with PSMA scan scheduled as soon as it would have been detectible. Probably could have gotten L5 zapped sooner before it started keeping me up at night. I think the docs tend to shrug at a 1st time PSA rise. I would argue that if PSA is going in the wrong direction after treatment, it needs immediate attention, not wait for the next 3- or 6-month test. Test sooner and often to shorten the gap between discovery and treatment. In my case, after 6 months on ADT it should have been undetectable, not rising. In your case, you have no prostate so it should not be rising. In both our cases, high ALP + rising PSA = bone met possibility and, in my case, confirmed.

Sorry, bit of a rant. Best wishes!! 👍

As you have found, a high ALP can mean that the cancer has come back in the bones. You need to get a PSMA pet scan to see if anything can be found. They may want to wait until your PSA hits .2 but that may not be necessary. You’ve had prostate cancer and it is at best in remission. This indicator that it could be in the bone Is a lot more significant because of your history.

Watching the PSA test to see if it is rising at a significant rate is really the only thing you can do, Unless your doctor thinks a PSMA pet test would be useful.

At this point, I would want monthly PSA tests. My doctor actually started me on monthly PSA tests when my PSA started rising 2 1/2 years after salvage radiation.

@mjp0512 First, sorry to hear that your numbers are trending the wrong way. Sure hope that continuing therapy brings things under control.

I concur with you about the frequent (monthly) testing. I’ve noticed that there is a hesitance with many docs to go beyond quarterly testing. I will push hard on that if necessary.

Many thanks for sharing your situation, and best wishes back at you!

Mel

@jeffmarc Thanks Jeff. Yes, I am going to insist on monthly PSA testing. Need to see for certain which way it is trending, especially in light of the ALP result.

I had elevated ALP about 8 years ago. My PCP at the time was a bit alarmed because it was a potential marker for bone mets. I was referred to an endocrinologist who, with further testing, determined a Vitamin D deficiency. That was corrected, and my ALP has been normal, until this last week. After a routine metabolic panel showed elevated ALP (149), my PCP ordered a Vitamin test and a hepatic panel. ALP came back at 150, all other liver values were normal and Vitamin D was normal. I got the PSA test on the same day. The combined ALP and PSA are concerning to say the least.

I going to message my urologist as well with all the data. He’s a specialist in advanced PCa and seems to have a proactive approach.

Currently, I thinking that I should test PSA in a month, and then if there is an upward trend, a PSMA PET scan would be the next step. But, I am open to sound advice from any quarter. Maybe there is reason to act sooner on the PSMA PET scan.

@melvinw
You may want to take the PSE test from Oxford Biodynamics. It is a biomarker blood test. It looks at 3D chromatin‑conformation signatures in immune cells — essentially, epigenetic patterns that change when the immune system is interacting with prostate cancer cells. It works after prostate removal or radiation with 94% accuracy. Your PCP can order it. Here is the link to their product web page:
https://www.94percent.com/

@bens1 Thanks for that suggestion. I’ll look into it.

Today, I’ve been pondering if the PSA rise from 0.086 to 0.113 could be a PSA bounce. I know this phenomenon is well documented in men who had radiation as their primary therapy and still had an intact prostate. But I had not heard of this occurring in men who had a prostatectomy followed by salvage radiation. Well, this was first documented in 2020 in the paper, "Prostate-specific antigen (PSA) bounce following salvage radiotherapy to the prostate bed in a patient with prostate cancer post-prostatectomy”.
https://pmc.ncbi.nlm.nih.gov/articles/PMC7450009/
So, although the rise in my PSA and elevated APL are still concerning, the data are far from conclusive about what is going on. I will be having discussions with my RO, urologist, and PCP this week so that we all get on the same page. Monthly PSA testing still seems warranted until the data tell a clear story. Bottom line: need to know if the simultaneous rise in PSA and elevated APL are just a strange coincidence involving random fluctuations, or if this is an early indicator of bone mets.

Thanks all for your input. I’ll post updates.

Mel

@melvinw
Thanks so much for this link - fascinating indeed and so important to know 👍 !

I am sending you best wishes for this to be the case for you too 🍀✨

Just an update on my recent PSA rise six months after finishing salvage IMRT.

Met with my RO yesterday. We agreed to retest my PSA in a week, then go from there. Is the post-RT rise from 0.086 to 0.113 just a PSA bounce, or is it persistent, or even rising more? If the later, then the next step would be to do another PSMA PET scan, with special focus on what is going on with the nodule in my prostate bed.

She was not overly concerned with my ALP being out of range, but did take note. I also showed her a plot of my ALP values since 2019. Of note, my ALP was staying fairly flat and in range from 2019-2024, then in the two years since a nodule was first detected in my prostate bed, my ALP has been rising, recently hitting 150 IU/L.

I do agree with my RO that in my case, PSA is the most robust marker for the status of my relapsed prostate cancer. ALP might be meaningful, but is secondary to PSA.

I summed up our visit with the following: "The best case scenario is that the elevated PSA and ALP are both random fluctuations, unconnected to one another, and do not indicate disease progression. The worse case scenario is that the PSA and ALP are related and indicative of disease progression. We need more data before inferring where I sit on the spectrum between these endpoints.”

My RO said that my summary was spot on. So next stop, another usPSA test on May 21.

I’ll bring my urologist up to speed in the meantime and see what he thinks of the elevated ALP.

To be continued…

Mel

Yet another update on this confounding PSA journey.

Just got yesterday’s (May 20) PSA test result back—0.100.

If you calculate the average of my two previous post-salvage RT values (0.086 and 0.113), it comes to 0.100.

From the three post-RT values to date, it seems that my PSA really isn’t budging one way other the other. Recall that going into RT my PSA was 0.094, and 3 months before that, at the first suspicion of a relapse, my PSA was 0.11 (standard Quest test, not Labcorp ultra sensitive test). My PSA seems to be stuck at 0.1 with a variance of 0.013.

Will be discussing the new result with my RO soon.

The question in my mind is, why has my PSA not dropped following RT and seems to be “stuck”? I have three hypotheses regarding that.

1 - the tumor in my prostate bed consists of indolent cancer. If the cancer is non-aggressive, then the cells are not dividing rapidly. If they are not dividing all that much, then they are not dying from the radiation induced damage to the cellular DNA. This is consistent with the fact that my relapse didn’t occur until ten years after my RARP. In this scenario, I might see a gradual decline in my PSA over a few years. A PSMA PET scan probably would look similar to my initial scan from last summer.

2 - the tumor in my prostate bed was whacked by the radiation but I have a distant met or mets that are producing some PSA. At this point, they may well be micro-mets, and with my relatively low PSA, they would not be likely to show up on a PSMA PET scan. But, if the original tumor is dying off, then there might be scan evidence for that (either smaller spot or lower maximum SUV). PSA should rise over time if this is the case. This hypothesis is also consistent with my elevated ALP (discussed in original post).

3 - radiation has damaged the cancer cells in the tumor but they are able to repair the DNA before dividing. Again, sort of a steady-state condition like hypothesis 1, but over time the cancer may overcome the radiation damage and grow and spread. In this scenario, I might expect to see a rising PSA over time after a period of stasis. A PSMA PET scan now probably would show little change since last summer's scan.

So, at this point, I am not sure another PSMA PET scan would reveal anything telling. Given that there is an insurance co-pay of some $200, I am less than eager to proceed with a scan at present, unless my RO can convince me that we might learn something useful.

However, frequent PSA testing (i.e., monthly) still seems like an intelligent, and no cost, way forward for now. More data are needed over time to see if my PSA is trending up, down, or just holding steady around 0.1.

All a bit puzzling, but the good news is that I am not really looking at rising PSA…yet. And I’ve heard of several cases where it took years for PSA to bottom out following salvage radiation. Not the norm, but then my case certainly qualifies for being outside the norm.

As always, I welcome your thoughts, experiences and insights.

Mel