Time for me to knock on the R.O.'s door

I did my blood draw from my 3-month uPSA test last week so as to have the result ready for my next uro check-up, which was earlier today. Here's my post-RP PSA history:

5-week post-RP PSA: <0.1

11/28/17 0.010
2/26/18 0.009
5/30/18 0.007 (nadir)
8/27/18 0.018
9/26/18 0.013
11/26/18 0.012
2/25/19 0.015
5/22/19 0.015
8/28/19 0.016 (2 years post-op)
12/18/19 0.015
6/30/20 0.013
12/30/20 0.037
3/31/21 0.020
7/13/21 0.018
1/25/22 0.023
7/25/22 0.038 (5 years post-op)
10/24/22 0.036
2/2/23 0.049
5/4/23 0.054
8/3/23 0.065
11/14/23 0.068
2/20/24 0.079
5/21/24 0.094
8/14/24 0.111 (7 years post-op)

8/21/24 0.125 (repeat test)

In a nutshell: I have one post-RP high-risk factor for recurrence: my G9 (4+5) score. I was pT2 with negative margins, I had no positive nodes, and my finasteride-corrected, pre-RP PSA was <10, Decipher score was low-risk for mets, tumor burden was only 5%, and post-op PSA nadir was 0.007. Nothing of note stood out in my genomic (DNA) test panel.

D'Amico recommends that men with only 1 risk factor post-RP get SRT before reaching a PSA of 0.25 (it's lower for those with 2 or more risk factors):

PSA Cut-Point Indicates When to Start Salvage Radiotherapy in Prostate Cancer (2023)

My uro and I decided that he will go ahead and send my history to, and schedule a consult with, a Duke R.O. specialized in prostate treatment. I'd like to know my chances of my PSA plateauing (after starting to rise--slowly-- this many years after RP). If they are slim, then there isn't much benefit in waiting to irradiate the fossa. (If my chances of a plateau aren't negligible and my trend continues to be linear and slow, I might go > 1 yr before reaching 0.20.) Unfortunately, I have seen few studies on ultrasensitive PSA trends & patterns post-surgery vis-à-vis BCR and the timing of SRT. Keep in mind that the official definition of BCR is still 0.2 and rising--there is a reason it hasn't been changed to ">0.1 and rising".

Despite the low sensitivity of PSMA-PET scans at low PSA levels, my uro knows of a patient who, surprisingly, had a PSMA at Duke with a PSA of 0.1 and it did reveal a positive lesion in the prostate fossa. I don't know if insurance covered the scan, but I do believe the fellow was also a G9 with a delay of several years before his post-RP PSA began to rise.

At today's visit, my uro wanted another blood draw for a repeat uPSA to confirm my current value (although the data trend looks pretty solid). I'll report back after my consultation with the R.O. My uro also mentioned a well-established M.O. he knows who has done research in the field of PCa recurrence and SRT, in case more input is needed for me to come to a decision.

Djin (I turned 76 last April)

Djin - sorry to hear you finally crossed that threshold. Looking forward to hearing your details of how this goes for you.

I was glad in an odd way to read that D’Amico is still bullish on ART for many of us less fortunate G9’ers. It was a big decision when I made it and nice to see it is still supported by someone noteworthy.

ART was pretty straight forward and I did not have any lasting side effects. Hopefully, they have found a way to shorten the 7-8 week treatment. There is some merit in keeping the dosage down with no prostate to aim at but it is massive time waster.

Post Edited (Mumbo) : 8/22/2024 8:34:12 AM (GMT-5)

You're okay. 🙂

Thanks, mattam & Ken! BTW, my uro/surgeon made a statement that echoed something I believe we in the Forum tout as good advice for those to whom it applies: it's never too early to consult with a R.O. to get a SRT plan in place.

Post Edited (DjinTonic) : 8/22/2024 11:29:52 AM (GMT-5)

DjinTonic
Best of luck with the RO - looks like you have the option of using Duke Medical which is a plus.
My uPSA has been creeping up too...I due for the uPSA blood test next week and will of course, be following your journey.

Djin, you are so very well prepared on this topic. In fact, I predict that you will be the professor and the RO the student.😊

In all seriousness, I hope that the two of you can find a good solution.

My repeat uPSA came back: 0.125. It was 0.111 one week ago.

Mumbo--I hope researchers at the Duke Prostate Clinic are interested in exploring what PSMA-PET can contribute to managing post-treatment men with PSA in the 0.1-0.2 range.

I don't know what an MRI could show at this point, but I'm certainly open to having one if so advised. It's not as though I had PCa that produced low levels of PSA: my pre-RP PSA was 8.6 correcting for the finasteride I was on. Then again, if whatever recurrence is now there happens to be concentrated in a single lesion, something may show up on an MRI for all I know.

You said "There is no explaining cancer no matter how hard the doctors try to sound smart about it so it is what it is." This is very true. It took only a few of the seven years I've been perusing certain topics in the medical literature to realize that we don't have answers to many basic questions about PCa.

I'm sure we'll continue to improve our collective knowledge in the Forum from our individual experiences.

Djin

Post Edited (DjinTonic) : 8/22/2024 11:42:07 PM (GMT-5)

Hi island time! Good to hear from you.

You make valid points. I hope to get input from more than one specialized M.D at Duke. I'm not adverse to setting a higher PSA threshold for SRT and waiting, if so advised. I think you can look at my uPSA data and make the case that I've had a very slow increase from the start, even if the rate of climb has increased.

Post Edited (DjinTonic) : 8/23/2024 8:42:39 AM (GMT-5)

DjinTonic said...
I don't know what an MRI could show at this point, but I'm certainly open to having one if so advised.

I am thinking about having an MRI with and without contrast way before the PSMA scan. I worry that a PSMA will probably not show anything at my lower uPSA of ~.17, though it's obvious I've got something going on. Also, the PSMA costs three to five times that of MRI. Even with insurance, I do consider societal cost.

OTOH, I was corresponding with a fellow warrior recently -- told me his recurrent nodule has been showing on MRI since he hit .08, but his PSMAs have never shown anything even though he's now in the .3 to .4 range! (via his Mayo and other top providers).

It's interesting you and I are kinda tracking together. Both became uPSA visible in 2017. Both kinda similar uPSA now (your .125 vs my .17). You had one adverse (high Gleason), my one was a positive margin that Epstein rated as 3+3=6.

Here is a relevant publication for MRI:

https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8887697/

"Conclusion:

Multiparametric MRI could be a useful tool before SRT, showing local or regional relapse with sensitivity and specificity reaching 90%. Combined with PSMA PET-CT, ideally during the same session, it allows to spare some patients with distant relapse from a futile SRT. In the future, it could be proposed to patients with BCR, particularly when the PSA is higher than 0.3–0.5 ng/ml, to facilitate the delineation of target volume and allow dose escalation on a specific area."


==============================

Since our cases are kinda similar, I will share a portion of the write up my uro did at my annual visit around last Thanksgiving. Maybe it will interest you, or not. I am not sure about his plan.

"5. Rising PSA after prior treatment for prostate cancer - I discussed with the patient the recent advent of advanced prostate cancer specific imaging with a PSMA PET scan. This test may be able to help localize his cancer recurrence and may alter his treatment plan. In a large prospective study, the overall sensitivity of the test was 85% with a range of 40% to 95% when the PSA varied from 0.2 to > 2.

If his scan is negative, then he likely has multiple microscopic areas of recurrence and I would treat him with systemic ADT based on his PSA value.

If he has multiple areas that are positive on his scan, I would likely start ADT now regardless of PSA level.

If he has an area of isolated recurrence, I would recommend directed salvage therapy as indicated based on the location.

Patients with medicare should be able to receive the test for any rising PSA after prior treatment. Most commercial plans will cover the test for 2 rises in the PSA above nadir. Some plans may require a previous negative bone scan and abdominal and pelvic CT. (The following diagnoses codes should be included: C61, Z85.46 and R97.21)"


Robert

Djin,

I think we are both going to have to make some decisions based on less than perfect info.

This will be really challenging for me. I will be reluctant to start any ADT or radiation based on scan results that are known to be questionable at lower uPSA levels. But I don't want to let things get too out of hand, either.

On your nodes question, answer is eight. All negative on both first and second post-RALP path reports.

I was Gleason 3+4=7 for biopsy (2012) and also on first post-RALP path report (2012). Same on the second path done by Epstein (2013). I wanted the second path because my first path did not report the Gleason at the one positive margin. Epstein did report that (3+3=6). So Epstein's report still says 3+4=7 overall, but lower Gleason 6 at the margin. I'm glad I got that because my uPSA became a thing four years after that. So now I am wondering: (1) if my uPSA is only from the remaining tissue at the margin, and (2) Gleason 6 does not metastasize and probably will not become clinically noticeable, then (3) why not just do nothing and plan to die of something else? Turning 75 soon, so it will be a tough decision when the time comes.

Please keep the site updated on your journey. It will help me and others.

Robert

Djin, sounds like it's onto the next phase. But to echo so many others here, I can't think of anyone more qualified to navigate this than you. Wishing you the best!

Relevant to this topic:

Best Approaches and Updates for Prostate Cancer Biochemical Recurrence (Full text, 2022)

"Abstract

Biochemical recurrence develops in almost one-third of men with prostate cancer after treatment with local therapy. There are numerous options for management, including surveillance, salvage radiation, androgen deprivation therapy (ADT), and clinical trials. This article reviews the current approaches to radiation therapy, ADT, and molecular imaging in men with biochemically recurrent prostate cancer. First, radiation therapy, including selection of field, dose, and use of concurrent antiandrogen therapy, is reviewed. Next, molecular imaging is addressed, including prostate-specific membrane antigen PET imaging and its increased sensitivity in identifying sites of disease. Finally, the factors associated with starting ADT are explored, and the data supporting intermittent over continuous ADT are reviewed. Lastly, the use of prostate-specific membrane antigen PET imaging and its potential role influencing therapy are discussed."