PSA rise from 20 to 30

I have seen a handful of men posting in forums with PSA of over 60, and then multiple biopsies not finding cancer.

But, in those cases, the spikes quickly moved down, and the history of readings were very unstable. Prostate cancer is usually a steady rise.

Yes, it’s possible that cancer won’t be found, but his case demands intensive testing. What about his free PSA, PHI, or 4K score results? Those tests should be available and provide more data points.

Thanks DJin Tonic, ASAdvocate for your inputs.
Thanks a lot, Cyclone-ISU. Your words are always encouraging. I hope your dad and uncle are doing great.
God bless!

Just an update.
After having antibiotics for 15 more days, the PSA has come down to 45 from 50.
Continuing with the course of antibiotics for another 2 weeks before we see the urologist again.

Any insights on this would be helpful.

Post Edited (Abhinav_Malhotra) : 3/4/2021 11:09:54 AM (GMT-7)

Hello, Abhinav ----

You have been very mindful of your father. I know your father is 80 years old, and living in India.

The drop in PSA tells you that some of the heightened PSA levels may have been due to infection or prostatitis.

The PSA level could also be attributed in part to an enlarged prostate.

I think you are wise to remain vigilant and proactive.

I know your dad has an upcoming appointment with his urologist. Are you able to be present at the appointment? Your dad may need an advocate, who can ask insightful questions.

What side effects is your dad experiencing? Does he have urinary retention or symptoms such as that?

Does the urologist seem concerned and cautionary?

I think my main question would be whether further diagnostics should follow?

If there's cancer lurking there, there can be treatments and medications that could greatly help your father.

Make sure you have an insightful and experienced doctor, guiding your father.

Your devotion to your dad and his healthcare and well-being is very evident. I am sure your dad is grateful for your devotion.

Let us know what is gleaned at your dad's upcoming appointment.

With my best,
CYCLONE ~ # Iowa State University

It seems to me that with PSA remaking at a high level like that after a protracted period of antibiotics treatment, even with the relatively small drop, there’s something more going on besides prostatitis.

As far as I know, and I don’t know a lot so could be wrong , prostatitis is very capable of raising PSA but not usually to such a high level.

Hello again. As some of us suspected, your dad does have clinically significant prostate cancer. As stated, a Gleason score of 8 (4+4) puts your dad in High Risk Grade Group 4 (just under the most serious, 5, Very High). A 2nd opinion on the exact Gleason score by an expert in prostate pathology, such as Dr. J. Epstein at Johns Hopkins, is always a good idea. You can have his slides sent to him directly (if you do, have them send all the slides, not just those they found have cancer).

The one thing I'm not clear on is whether all 15 cores were taken in the Left Base, as it would seem from the labeling in the report as you typed above; however, that doesn't sound right.

Even though I posted a link to an paper on surgery for selected men in their 80's, given his age plus what you posted about his MRI findings:

"a) Lesion involving the left posteromedial, posterolateral and anterior peripheral zone at the level of the mid gland causing bulging of the prostatic contour with part of the lesion extending into the periprostatic fat planes with involvement of the left seminal vesicles and left neurovascular bundle."

I think his docs will be looking at radiation and hormone therapy (ADT) for his primary treatment, since it appears the cancer is not confined to the prostate and has advanced locally. They will probably suggest a bone scan to check for bone metastases.

One can have biopsy tissue sent for a Decipher test. It is a genomic test that evaluates the risk (low, intermediate, high) of one's cancer metastasizing within 5 years. Note that this risk is fairly independent of one's Gleason score. The results might help in planning treatment (for example, in determining the size of the area to irradiation (narrow or wide).

It is quite possible that your dad will have very successful treatment!

Keep us posted on the advice you get. Ask us and your docs your questions, of course.

Djin

Your Dad has prostate cancer as do a high percentage of men in their 80's so no big surprise there. The higher grade is not great news but you can get that reviewed if he wants to confirm. The pathology report is a little confusing as Djin noted but that is not uncommon. The report implies that the 9 positive cores of 15 were in "C) Left Base" which is unlikely.

Treatment recommendations vary for men in their 80's. From my limited observations, they range from do nothing to simpler treatments. Most do not recommend aggressive treatment schemes for those at an older age as probability of death from other causes is higher and aggressive treatment side effects can diminish quality of life. It really depends a lot on how he is doing and his overall health condition.

I assume there may be some more scans now to check for spread from the prostate then some actions will be proposed. Hormone therapy will be probably started to see how he responds to that. Then radiation treatment may be proposed depending on what the scans show and how he responds to the hormone treatment. Hard to know for sure but that all needs to be discussed with his doctor(s) given his age and diagnosis.

Thanks Mumbo and Pratoman.

We have asked for the slides for re-evaluation. The doctor said the 2 cores in section C must have been broken as they sent it for evaluation 500 kms away(Difficult for me to believe).

Also, got the bone scan done. There is one met to spine(L5). One question : My dad had an injury in the spine a decade ago he fell and corner of a table had hit him in spine. Can this shady area on spine be due to that?

Can someone please suggest what is the way forward from here in terms of treatment and any specific questions that I should ask the Urologist whom I will be meeting tomorrow.

Post Edited (Abhinav_Malhotra) : 4/21/2021 11:55:39 PM (GMT-6)

Yes, "hot spots" on a bone scan can be many things other than cancer. If there is any imaging that was done when your dad injured himself, it can be matched to the lesion location in the bone scan. In addition, a new series of X-rays could be done now to help determine if this is an old fracture or bruise, or something else other than a metastasis. This happened with my bone and CT scans after my PCa diagnosis: a rib lesion was suspicious for a met. The radiologist ordered a separate X-ray series, and there was also a CT scan from 8 years before. The rib lesions was present then in the same spot and had not changed in size. My uro/surgeon and the RO both felt this was a cancer met, but rather an old fracture or bruise.

Biopsy cores do fragment in the specimen cup -- it's not umcommon.

If I remember, your dad just turned 80, so more aggressive treatments may or may not be ruled out. It also depends on his overall health other than this PCa diagnosis.

All the best,

Djin

If there were stupid questions (which there aren't), yours would still be far from stupid. I'll let others with experience address the ADT part of your question. Regarding benefits and risks of first-line abiraterone, I've found the following:

An up-to-date evaluation of abiraterone for the treatment of prostate cancer (2021)

"Expert Opinion: Abiraterone has shown efficacy in castrate-resistant metastatic prostate cancer, providing an additional degree of hormonal sensitivity for tumors resistant to ADT. Impressively, abiraterone in conjunction with ADT as a first-line treatment for castrate sensitive prostate cancer also confers a significant overall survival benefit compared to ADT alone. With minimal additional toxicity, abiraterone has established itself as a well-tolerated, convenient, and effective treatment option. Ongoing studies are expected to broaden the drug’s indications as well as its preference among other prostate cancer therapies."

[Emphasis mine]
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Next-Generation Androgen Receptor-Signaling Inhibitors for Prostate Cancer: Considerations for Older Patients (2021)

"Abstract
Prostate cancer is common, particularly in older patients, as the risk of getting prostate cancer increases with age. Cancer therapy brings unique challenges in older patients, as this population is vulnerable to many side effects and drug interactions, and they have varying degrees of frailty, which may limit the use of these therapies. The US FDA has recently approved several novel next-generation hormonal therapies for patients with various stages of prostate cancer, giving patients more treatment options. These therapies (e.g., apalutamide, enzalutamide, darolutamide, and abiraterone) have unique side effects that the practitioner must consider when evaluating therapeutic treatments in any patient, and these side effects also affect older patients differently. Here, we review the mechanism of action and metabolism of the next-generation hormonal therapies; report efficacy and safety data from trials of these agents in non-metastatic castration-resistant prostate cancer, metastatic hormone-sensitive prostate cancer, and metastatic castration-resistant prostate cancer; and discuss the intricacies of treating older men with prostate cancer. Key takeaways include the fact that enzalutamide and apalutamide may increase the risk of falls and fractures in older patients. Abiraterone requires the concurrent use of low-dose glucocorticoids, which can lead to side effects in older patients. Lastly, drug-drug interactions should be considered in older patients using multiple medications."
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Comparison of Systemic Treatments for Metastatic Castration-Sensitive Prostate Cancer: A Systematic Review and Network Meta-analysis (2021)

"Conclusions and relevance: In this network meta-analysis, as add-on treatments to ADT, abiraterone acetate and apalutamide may provide the largest overall survival benefits with relatively low SAE risks. Although enzalutamide may improve radiographic progression-free survival to the greatest extent, longer follow-up is needed to examine the overall survival benefits associated with enzalutamide."
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Abiraterone acetate in combination with androgen deprivation therapy compared to androgen deprivation therapy only for metastatic hormone-sensitive prostate cancer (2020)

"Authors' conclusions: The addition of abiraterone acetate to androgen deprivation therapy improves overall survival but probably not quality of life. It probably also extends disease-specific survival, and delays disease progression compared to androgen deprivation therapy alone. However, the risk of grades III to V adverse events is increased, and probably, so is the risk of discontinuing treatment due to adverse events."
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For details, see the Full Text of these articles. Their Reference sections can also point you to additional studies.

Djin

We aren't doctors, and I suggest you continue investigating the recent literature. PubMed and Google Scholar are fairly easy to use. Listen to the docs in your consults. Local experience and success at the institution you choose are important, too.

There are other new medications other than abiraterone that can be tried after failure. The effectiveness of any of them (whether one works and, if it does, for how long) will vary person to person, and the best order to try them is still being worked out. There are other treatments, such as chemotherapy, in the wings as well.

Unlike ADT, radiation (or surgery) can kill (or remove) PCa cells, and for some men can result in a cure, or a delay, often long, of a recurrence. Sometimes for the elderly ADT is used alone, since PCa can be halted for years in some cases. Here expected lifespan and quality of life need to be factored in. Again, your dad's docs and their experience can be weighed. And his docs know your dad's exact current state of health. I would say that most men in their 70s do choose either RT in some form or surgery, often with ADT, for PCa that requires treatment. I don't know the statistics for men in their 80s, although your dad is just 80.

Let's see what other Forum Brothers think.

Djin

Mumbo said...
Djin - I think it is her Dad...

Yes, momentary lapse. Corrected -- thanks Mumbo.

Djin