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Rising PSA years after radical prostatectomy

Posted by olanordman @olanordman, Feb 22, 2021

I am 60 years and I had radical prostatectomy on 23rd Nov 2018. I was told out of the 15 lymph nodes taken only one was affected less than a millimetre. It was Gleason score 7B with PSA around 13 at time of surgery but 11 at time of diagnosis in June 2018.

The PSA been fluctuating between 0.09 and 0.18 since surgery on 23rd November 2018
I have no incontinence as well as Erectile dysfunction. I take hypertension medication – Norvask Amlodipine 5mg daily and Cetirizine 5mg for allergy. Below are some of the test results. I have many of these test results – a few below
Jan 2019: 0.11
April 2019: 0.11
June 2019: 0.09
August 2019: 0.12
December 2019: 0.12
April 2020: 0.12
August 2020: 0.11
October 2020: 0.17
December 2020: 0.15
February 2021: 0.18

I am worried the cancer may be returning or might have spread. I met my doctor today and expressed my concerns. He has agreed to refer me to the hospital where I had the surgery. Any suggestions based on this brief history?

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gently | @gently | Dec 9, 2023

Ask for PSMA pylarify. It has specific attachment in the lymph nodes.
wishing you well

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edmond1971 | @edmond1971 | Dec 10, 2023

Those are very low PSA values and while post-surgery ideally you would want to see zero, the time series provided shows that the PSA isn't increasing much. The data listed stops in 2021, but I'll presume for input-sake that it is still in the 0.1 to 0.2 range.

Some of the webinars on BCR and imaging indicate that on occasion that specific tests will be delayed until you hit a minimum values, such as waiting until the PSA is 2.0 for performing a PSMA scan. As for me, my PSA skyrocketed from 9 to 19 in 3 months and so we did imaging, but the basis for the imaging was the more elevated PSA.

Time is on your side, it is rare for PCA to wake-up and kill on the same day, keep doing your homework and feel good about being prepared.

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gkm | @gkm | Dec 10, 2023

It would be useful if you provided an update as it would appear that your PSA, post RP is approaching .200 which is the generally agreed definition of BCR (biochemical recurrence) which indicates that further treatment needs to be undertaken.

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bettwils16 | @bettwils16 | Dec 11, 2023
In reply to @q95oldies "Dr. was concerned with a .22??" + (show)
@q95oldies

Dr. was concerned with a .22??

Jump to this post

Yes, .22 is concerning. My PSA was .24 and repeated 3 wks later, again, .24. I had a prostatectomy in 2014 and met criteria for BCR. PSMA PET Scan was neg. I had 37 radiation treatments to prostate bed. PSA 3 months after, 0.02, 6 months after 0.02. Another one next week.

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dontpanic67 | @dontpanic67 | Feb 5 1:59pm

Same thing happened to me once it reached 0.2 they should give you a PSMA Pet to rule out spread and set you up for salvage radiation, your PSA is still low like mine was and get another chance to kill this disease good luck

REPLY
jackiepie | @jackiepie | Mar 3 6:48pm
In reply to @jackiepie "I am 75 and in good health. I had a robotic-assisted radical prostatectomy in 09/2020. I..." + (show)
@jackiepie

I am 75 and in good health. I had a robotic-assisted radical prostatectomy in 09/2020. I had right and left apex and left inferior positive inferior margins however no adjuvant radiation treatment. Gleason score was 3+4; pT2, pNO. The PSA results were: 12/28/2020 < 0.1, 04/06/21< 0.1, 10/08/2021< 0.1, 04/05/22 .05, 10/.07/22 .05, 03/30/2023 .06, 10/02/2023 .08. The PSA is slowly rising. My Dr. is getting Decipher test done so as to help guide what treatment might be needed in the future. My next PSA test will be 1/02/24.
Is there anything I should be doing between now and then? If the PSA continues to increase, when should I consider salvage radiation? If we get to that point, what kind of external beam radiation therapy (EBRT) should I choose? I understand that the various forms of EBRT are: 3D conformal radiotherapy, intensity-modulated radiation therapy (IMRT), image-guided radiation therapy (IGRT) and stereotactic body radiation therapy (SBRT). I put these questions to this forum because over the last two years I have been reading the posts here and I have learned so much from them. Any advice would be welcome.

Jump to this post

This is an update of a previous post that I submitted on Nov 12, 2023. Since then I have had two more PSA tests: 0.11 on 1/02/24 and 0.10 2/07/24; my Decipher test score came in at 0.36 (suggesting low genomic risk).
I have consulted with a medical oncologist, two radiation oncologists and my urologist. All four feel that the PSA results suggest that there is, or will be, a biochemical recurrence depending on the definition of biochemical recurrence one uses. The medical oncologist said that based on the Decipher result, no hormone treatment is necessary with salvage therapy at this time.
This coming week I will undergo a PET/CT tumor PSMA(w/Dose) to see if the cancer can be detected. At this low level of PSA it seems unlikely to me that they will find anything. If that turns out to be the case and because I had (three) positive margins after the prostatectomy, I think the radiation would be mainly confined to the prostate bed.
My concerns are two:
1) Should I go ahead and undergo salvage radiation this spring, or wait a bit, perhaps, until the fall to do it? The Decipher score suggests that my cancer is not aggressive and the PSA doubling time does not appear to be that fast (see my Nov. 12 post for more PSA results). On the other hand, the sooner I get this treated the higher the probability of curing the cancer.
2) Should I do photon therapy (EBRT)or proton therapy? Both approaches appear to be of equal effectiveness but the proton therapy supposedly has less side effects. Proton therapy is expensive and I would have to check that it would be covered by my insurance. In addition, the nearest proton therapy location is about 60 miles (about 70 minutes) away while the nearest photon therapy is about 6 miles (12 minutes) away.
I mainly worry about the side effects from salvage therapy. I have no urinary incontinence nor bowel issues from the prostatectomy and I certainly want to avoid them. I do understand however that salvage therapy can cause such issues. I could not find any data on the percentage of people who have these issues after salvage therapy.
Any thoughts or advice from the many who have faced these issues would be greatly appreciated,

REPLY
5 replies
hbp | @hbp | Mar 3 7:30pm
In reply to @jackiepie "This is an update of a previous post that I submitted on Nov 12, 2023. Since..." + (show)
@jackiepie

This is an update of a previous post that I submitted on Nov 12, 2023. Since then I have had two more PSA tests: 0.11 on 1/02/24 and 0.10 2/07/24; my Decipher test score came in at 0.36 (suggesting low genomic risk).
I have consulted with a medical oncologist, two radiation oncologists and my urologist. All four feel that the PSA results suggest that there is, or will be, a biochemical recurrence depending on the definition of biochemical recurrence one uses. The medical oncologist said that based on the Decipher result, no hormone treatment is necessary with salvage therapy at this time.
This coming week I will undergo a PET/CT tumor PSMA(w/Dose) to see if the cancer can be detected. At this low level of PSA it seems unlikely to me that they will find anything. If that turns out to be the case and because I had (three) positive margins after the prostatectomy, I think the radiation would be mainly confined to the prostate bed.
My concerns are two:
1) Should I go ahead and undergo salvage radiation this spring, or wait a bit, perhaps, until the fall to do it? The Decipher score suggests that my cancer is not aggressive and the PSA doubling time does not appear to be that fast (see my Nov. 12 post for more PSA results). On the other hand, the sooner I get this treated the higher the probability of curing the cancer.
2) Should I do photon therapy (EBRT)or proton therapy? Both approaches appear to be of equal effectiveness but the proton therapy supposedly has less side effects. Proton therapy is expensive and I would have to check that it would be covered by my insurance. In addition, the nearest proton therapy location is about 60 miles (about 70 minutes) away while the nearest photon therapy is about 6 miles (12 minutes) away.
I mainly worry about the side effects from salvage therapy. I have no urinary incontinence nor bowel issues from the prostatectomy and I certainly want to avoid them. I do understand however that salvage therapy can cause such issues. I could not find any data on the percentage of people who have these issues after salvage therapy.
Any thoughts or advice from the many who have faced these issues would be greatly appreciated,

Jump to this post

Good Luck Jackie. If this were me, I would want the best radiation treatment possible and sooner is better than later. Whatever insurance covers is good and I would pay what remains. A 60 mile drive would be doable ( I drive more than that to UCLA at least every 3 months and sometimes more often ). A longer life and a quality life is worth the inconvenience and expense for me.

REPLY
melcanada | @melcanada | Mar 4 6:23am
In reply to @jackiepie "This is an update of a previous post that I submitted on Nov 12, 2023. Since..." + (show)
@jackiepie

This is an update of a previous post that I submitted on Nov 12, 2023. Since then I have had two more PSA tests: 0.11 on 1/02/24 and 0.10 2/07/24; my Decipher test score came in at 0.36 (suggesting low genomic risk).
I have consulted with a medical oncologist, two radiation oncologists and my urologist. All four feel that the PSA results suggest that there is, or will be, a biochemical recurrence depending on the definition of biochemical recurrence one uses. The medical oncologist said that based on the Decipher result, no hormone treatment is necessary with salvage therapy at this time.
This coming week I will undergo a PET/CT tumor PSMA(w/Dose) to see if the cancer can be detected. At this low level of PSA it seems unlikely to me that they will find anything. If that turns out to be the case and because I had (three) positive margins after the prostatectomy, I think the radiation would be mainly confined to the prostate bed.
My concerns are two:
1) Should I go ahead and undergo salvage radiation this spring, or wait a bit, perhaps, until the fall to do it? The Decipher score suggests that my cancer is not aggressive and the PSA doubling time does not appear to be that fast (see my Nov. 12 post for more PSA results). On the other hand, the sooner I get this treated the higher the probability of curing the cancer.
2) Should I do photon therapy (EBRT)or proton therapy? Both approaches appear to be of equal effectiveness but the proton therapy supposedly has less side effects. Proton therapy is expensive and I would have to check that it would be covered by my insurance. In addition, the nearest proton therapy location is about 60 miles (about 70 minutes) away while the nearest photon therapy is about 6 miles (12 minutes) away.
I mainly worry about the side effects from salvage therapy. I have no urinary incontinence nor bowel issues from the prostatectomy and I certainly want to avoid them. I do understand however that salvage therapy can cause such issues. I could not find any data on the percentage of people who have these issues after salvage therapy.
Any thoughts or advice from the many who have faced these issues would be greatly appreciated,

Jump to this post

Hope your on Zolodex ASAP
Get margins radiated Spot radiation if in Lumbar

If PSA rises look at Enzalutamide / Xtandi PSA is low from what you write

REPLY
perrychristopher | @perrychristopher | Mar 4 7:51am
In reply to @jackiepie "This is an update of a previous post that I submitted on Nov 12, 2023. Since..." + (show)
@jackiepie

This is an update of a previous post that I submitted on Nov 12, 2023. Since then I have had two more PSA tests: 0.11 on 1/02/24 and 0.10 2/07/24; my Decipher test score came in at 0.36 (suggesting low genomic risk).
I have consulted with a medical oncologist, two radiation oncologists and my urologist. All four feel that the PSA results suggest that there is, or will be, a biochemical recurrence depending on the definition of biochemical recurrence one uses. The medical oncologist said that based on the Decipher result, no hormone treatment is necessary with salvage therapy at this time.
This coming week I will undergo a PET/CT tumor PSMA(w/Dose) to see if the cancer can be detected. At this low level of PSA it seems unlikely to me that they will find anything. If that turns out to be the case and because I had (three) positive margins after the prostatectomy, I think the radiation would be mainly confined to the prostate bed.
My concerns are two:
1) Should I go ahead and undergo salvage radiation this spring, or wait a bit, perhaps, until the fall to do it? The Decipher score suggests that my cancer is not aggressive and the PSA doubling time does not appear to be that fast (see my Nov. 12 post for more PSA results). On the other hand, the sooner I get this treated the higher the probability of curing the cancer.
2) Should I do photon therapy (EBRT)or proton therapy? Both approaches appear to be of equal effectiveness but the proton therapy supposedly has less side effects. Proton therapy is expensive and I would have to check that it would be covered by my insurance. In addition, the nearest proton therapy location is about 60 miles (about 70 minutes) away while the nearest photon therapy is about 6 miles (12 minutes) away.
I mainly worry about the side effects from salvage therapy. I have no urinary incontinence nor bowel issues from the prostatectomy and I certainly want to avoid them. I do understand however that salvage therapy can cause such issues. I could not find any data on the percentage of people who have these issues after salvage therapy.
Any thoughts or advice from the many who have faced these issues would be greatly appreciated,

Jump to this post

I'd ask about the viability of Proton Beam therapy when cancer cells are not located definitively. Since your numbers are low it's doubtful the PSMA scan will locate anything (which is great). The radiation will be most likely located on the prostate bed and pelvic lymph node area. Photon beam has a wider spread which I think would be used in a case like yours but I'm not a doctor either. Definitely worth a call to the Proton Beam center closest to you to ask.

REPLY
michaelcharles | @michaelcharles | Mar 4 8:16am
In reply to @jackiepie "This is an update of a previous post that I submitted on Nov 12, 2023. Since..." + (show)
@jackiepie

This is an update of a previous post that I submitted on Nov 12, 2023. Since then I have had two more PSA tests: 0.11 on 1/02/24 and 0.10 2/07/24; my Decipher test score came in at 0.36 (suggesting low genomic risk).
I have consulted with a medical oncologist, two radiation oncologists and my urologist. All four feel that the PSA results suggest that there is, or will be, a biochemical recurrence depending on the definition of biochemical recurrence one uses. The medical oncologist said that based on the Decipher result, no hormone treatment is necessary with salvage therapy at this time.
This coming week I will undergo a PET/CT tumor PSMA(w/Dose) to see if the cancer can be detected. At this low level of PSA it seems unlikely to me that they will find anything. If that turns out to be the case and because I had (three) positive margins after the prostatectomy, I think the radiation would be mainly confined to the prostate bed.
My concerns are two:
1) Should I go ahead and undergo salvage radiation this spring, or wait a bit, perhaps, until the fall to do it? The Decipher score suggests that my cancer is not aggressive and the PSA doubling time does not appear to be that fast (see my Nov. 12 post for more PSA results). On the other hand, the sooner I get this treated the higher the probability of curing the cancer.
2) Should I do photon therapy (EBRT)or proton therapy? Both approaches appear to be of equal effectiveness but the proton therapy supposedly has less side effects. Proton therapy is expensive and I would have to check that it would be covered by my insurance. In addition, the nearest proton therapy location is about 60 miles (about 70 minutes) away while the nearest photon therapy is about 6 miles (12 minutes) away.
I mainly worry about the side effects from salvage therapy. I have no urinary incontinence nor bowel issues from the prostatectomy and I certainly want to avoid them. I do understand however that salvage therapy can cause such issues. I could not find any data on the percentage of people who have these issues after salvage therapy.
Any thoughts or advice from the many who have faced these issues would be greatly appreciated,

Jump to this post

My recovery from salvage treatment has been very good.

RP Aug 2022
PSA 90 days postop .19
Surgical recovery excellent.

Feb - June 2023:

Salvage radiation photon IMRT 37 treatments over 8 wks at Johns Hopkins Baltimore to whole prostate (WPRT) and pelvic lymph nodes.
JH also has proton in DC.

Together with short term adt 4 mos (see SPPORT trial).

"Sweet spot " for BCR tx .2 - .4/.5.
Trend is to tx at lower PSA.

IMRT photon and Proton deemed equivalent at this time.

Sorry to hear about possible BCR.

Any side effects from salvage radiation tx developed weeks into tx and resolved 4 wks or so after completion.

ADT side effects dissipated over 4 months after completion of tx.

Good luck with your future tx and decisions.

Sounds like you are being followed well and have choices available.

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