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First Follow-Up Post-RALP

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Posted 9/1/2022 2:48 PM (GMT -5)
Today I had my first follow-up after my May RALP. My PSA came back at 0.012, and the surgeon said he was waiting for the Decipher test results to help guide his thinking. He was "cautiously optimistic" that I'm out of the woods, but pointed out that my PSA wasn't actually zero, and he wanted to be thorough and cautious.

So I'm a little bummed that he didn't say "you're out of the woods!", but I guess it's good to have a very thorough prostate cancer specialist.

The plan now is to wait for the Decipher results, and wait another three months to see what the PSA looks like. If the Decipher results show a low risk, I believe he intends to leave me parked where I am and just monitor. If the Decipher test shows a high risk, he's probably going to recommend radiation as a precaution. At least, that was my takeaway from the meeting.

Thoughts??
Posted 9/1/2022 3:07 PM (GMT -5)
Hi AZ. Of course any PSA test, including a 3-decimal PSA test like Labcorp's ultrasensitive (which you probably had) can never come back "zero," but rather only "undetectable" with regard to its lower limit of detection is (for Labcorp's uPSA test it happens to be <0.006). You probably have yet to reach your PSA nadir (in fact, I've read that the slower you reach it, the better, statistically speaking). It's very possible your nadir will be below 0.010, which is the best place to be as far as BCR risk. (For example, I didn't reach my nadir until about 7 months post-op.) It's good that you are being monitored with a uPSA test, so you will eventually know what your nadir is. A PSA nadir below 0.030 is good; below 0.010 even better.

Please update your signature with your RALP results: your final Gleason score, pT grade, and all adverse findings mentioned your post-op path report. For men who choose surgery, this information replaces their biopsy info as the most important picture of what was going on with your PCa. at the time of your primary treatment. If and when you have further treatment, it is your path report and not your biopsy that is paramount along with your PSA trend and any future imaging.

I don't remember your post-op pathology, but I have my doubts whether you'd be advised to have RT based solely on a high-risk Decipher result without a rising PSA. That could be overtreating what may turn out to be successful surgery.

Keep in mind that none of us are ever probably completely out of the woods. Rather, the trees just keep getting more sparse as time goes by smile

All the best,

Djin
Posted 9/1/2022 4:08 PM (GMT -5)
A thoughtful urologist shouldn't use that kind of language ('you are out of the woods') right after surgery. Although I certainly hope that the surgery did remove all cancer, there are too many examples of late recurrences. Some years later, as described in recent posts.
Let's just hope that your PSA will drop a bit lower and stay there for decades.
If not, radiation is the usual follow-up.
Posted 9/1/2022 4:24 PM (GMT -5)

Sr Sailor said...
A thoughtful urologist shouldn't use that kind of language ('you are out of the woods') right after surgery. Although I certainly hope that the surgery did remove all cancer, there are too many examples of late recurrences. Some years later, as described in recent posts.
Let's just hope that your PSA will drop a bit lower and stay there for decades.
If not, radiation is the usual follow-up.

To be fair, the surgeon refused to offer anything more than cautious optimism. The "out of the woods" was a euphemism used by me.
Posted 9/1/2022 4:37 PM (GMT -5)

DjinTonic said...

Keep in mind that none of us are ever probably completely out of the woods. Rather, the trees just keep getting more sparse as time goes by smile

All the best,

Djin

Thanks for the reminder to update my signature -- done. The post-RALP pathology showed no change to the Gleason score (Group 2, 3+4=7). Percentage of pattern 4 was 25%, and the percentage of pattern 5 was 0%. Histologic type was "acinar". Other findings: No IDC, No cribriform glands, no EPE, no SVI, and nothing into the lymph nodes. The estimated percentage of the prostate involved by the tumor was 35%. Stage classification was pT3a, pN0, pMn/a. Nothing on the margin, except what my surgeon classified as a false positive -- the bladder neck -- of which there was none (it was all prostate tissue due to a TURP a few months ago). The reason for the pT3a was, as I understand it, because of the bladder neck issue.
Posted 9/1/2022 6:16 PM (GMT -5)
Yes, if you have (only) EPE and/or BNI (with or without positive margins), the grade is pT3a.

A seminal study of Decipher scores found that for G7 (3+4) men with pT3a pathology, the distribution of Low, Intermediate, and High scores is 45%, 23%, and 31%, respectively.

Djin

Post Edited (DjinTonic) : 9/1/2022 4:27:59 PM (GMT-7)

Posted 9/1/2022 6:27 PM (GMT -5)

DjinTonic said...
Yes, the grade is pT3a if you have EPE and/or BNI.

Djin

Interesting reading, thanks Djin. Well, at least for now, my surgeon's interpretation of the BNI is that -- in my case -- it was kind of a false positive. My bladder neck tissue was removed during a TURP procedure a few months earlier, leaving only prostate tissue behind. Therefore, there wasn't any bladder neck left to invade and is why the final pathology report included this special note: "The bladder neck sections are composed of prostate tissue. There is a 0.5 cm area of Gleason's pattern 3 at the margin". Therefore, the pT3a designation is a formality. His interpretation at the one month follow-up was that it was likely not a concern. No promises, of course. Based on today's meeting, his primary focus at this point is the Decipher test results. He seems to lean heavily on that when determining the need for additional treatments -- and, if so, when that should be.
Posted 9/1/2022 6:35 PM (GMT -5)
Assuming, then, that you were technically pT2, the distribution of Decipher scores (Low, Intermediate, High) for G7 (3+4) changes to 56%, 22%, and 22%, respectively.

If you doc thinks you didn't have BNI, why did he mentioned RT therapy at all with your undetectable (<0.1) PSA? If that is the thinking, even a high-risk Decipher score is of theoretical interest as long as your PSA remains low. No guy with a pT2 result with negative margins and undetectable PSA would be advised to have adjuvant RT, regardless of his Decipher score.

Djin

Post Edited (DjinTonic) : 9/1/2022 4:41:46 PM (GMT-7)

Posted 9/1/2022 6:41 PM (GMT -5)

DjinTonic said...
Assuming, then, that you were technically pT2, the distribution of Decipher scores (Low, Intermediate, High) for G7 (3+4) changes to 56%, 22%, and 22%, respectively.

If you doc thinks you didn't have BNI, why did he mentioned RT therapy at all with your undetectable (<0.1) PSA?

He wasn't willing to classify my PSA as undetectable, even at 0.012 -- he said I was on the edge of what he considered undetectable, but not what he would consider "zero". After the Decipher score comes back and we meet again, I'll have to ask him about the BNI reading (which he already dismissed) and how he interprets that alongside the Decipher results.
Posted 9/1/2022 6:47 PM (GMT -5)
There can be two meanings of "undetectable". Usually it refers to a PSA of <0.1 according to the standard PSA test designed for men with prostates, and still used very often after surgery. The other is "undetectable" according to a given uPSA test, be it <0.02 (Quest), <0.006 (Labcorp), or any other ultrasensitive test's lowest reading.

Keep in mind that BRC (biochemical recurrence) is officially defined as a PSA of 0.2 and rising. The most common definition of "persistent PSA" is an initial reading of 0.1 or greater following surgery. You are way below these levels of concern!

We have anatomical structures (e.g. Cowper's glands, the urethra, etc.) that remain after surgery and produce minute amounts of PSA. This is physiological and has nothing to do with prostate cancer.

Djin

Post Edited (DjinTonic) : 9/1/2022 8:19:42 PM (GMT-7)

Posted 9/1/2022 7:02 PM (GMT -5)

DjinTonic said...
There can be two meanings of "undetectable". Usually it refers to a PSA of <0.1 according to the standard PSA test designed for men with prostates, and still very often after surgery. The other is "undetectable" according to a given uPSA test, be it <0.02 (Quest), <0.006 (Labcorp), or any other ultrasensitive test's lowest reading.

Keep in mind that BRC (biochemical recurrence) is officially defined as a PSA of 0.2 and rising. The most common definition of "persistent PSA" is an initial reading of 0.1 or greater right after surgery. You are way below these levels of concern!

Djin

What you just said aligns with my own research as well. When I discussed this with the doctor this morning, he said that as a cancer doctor that focuses almost entirely on prostate cancer, he wants to be thorough and resist jumping to conclusions. To be fair, he's done over 2,000 RALP procedures and is considered the best in the state - I have to give him deference. However, I gotta say that I was bummed when he glossed over the 0.012 reading and didn't tell me what my itching ears wanted to hear -- that the number looked great and it was all monitoring from this point forward. He raised the matter of the Decipher test, and said "we'll see". He mentioned the possibility of additional treatment depending on the results of the Decipher and what my PSA looks like next time.
Posted 9/2/2022 12:49 PM (GMT -5)
Wish you the best AZ. I was .40 after surgery so no debate in my case. I was on 6-month ADT and doing SRT 4 months after surgery. The .40 PSA was difficult to absorb. I did well with radiation at Mayo in North Phoenix. So far so good since as I've been undetectable.
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