PSA and Biopsy predictions

I have PSA and prostate biopsy coming up soon and find myself speculating on the results of both. If the PSA doubles from the last reading in February, the MO wants another PSMA, the results of which may have a significant impact on any salvage treatment. So how to predict what the PSA will be without pure guessing is one question. I do have some basis for a prediction: it’s generally understood that radiorecurrent cancer is often aggressive and one grade higher than the original cancer. My initial Gleason was 3+4, so following that logic I might be 4+3 or 4+4. The PIRADS 5 also lends support for a high Gleason and the usual effect on PSA. That would explain the significant increase from 2022 to 2024, and the rather large increase in one month from January 2024 to February 2024.
The MO might disagree with me. When I sat down for my first meeting with him, he pulled up the PSMA images and pointed out the apparent tumor and said I had low risk disease. What makes you say that I asked. You have PSADT of ~24 months, recurrence is most likely confined to the prostate, and you’ve had this for 9 years and it hasn’t spread yet, so I'd say it’s a GL 6 or 7, he said. I didn’t agree with him but kept my mouth shut since I had already made him angry by asking how he calculated the PSADT. I hope he’s right, but I wouldn’t bet on it.
My Urologist is always optimistic. When I asked him what he thought the next PSA would be he said it might go up a tenth. I burst out laughing. A tenth——are you serious? It went up 4 tenths in one month.

I bet the PSA doubles more or less.

Now the second question──the Gleason score. I’m having transperineal biopsy, with the tumor shown on PSMA and mpMRI targeted, along with 12 systematic and seminal biopsies. I’d be very surprised if cancer is found in any place other than the targeted area. So much for the accuracy of PSMA and mpMRI if it is.

I expect Gleason 8 pathology based on the logic I used for the PSA prediction.

I’d be interested in your predictions.

‘It is hard to make predictions……especially about the future”. Attributed to the inimitable Yogi Berra, and, perhaps Nobel physicist Niels Bohr.

I say to investigate and proceed appropriately. Predictions will rarely be accurate and of what value is the exercise? I agree with the MO that if this has been working for nine years, it must not be very aggressive. After a significant period of nearly flat readings the increase from 22 to 24 is concerning, warranting your current investigation. How are the docs explaining that? Am I correct that you missed 2023? Have you considered the possibility of infection causing the recent increase? You think the next PSA will approach 8. But what will your thoughts be if it is, say 3.78? What will your thoughts be if your biopsy shows a G3 and not any G4?

Seems to me you should avoid getting too far over your skis and wait for the biopsy results. Don’t worry, be happy.

Thanks HR. I feel for you. You presented the perfect situation for a quick and effective cure using any of the available treatment options and you chose a well proven one, which proponents were selling as the most superior method, at the time. You were very low volume and overall low risk. But, now you find the inferred most effective, fail safe treatment……. failed. Compare your dx to mine and who in the world would have thought it would be you suffering the recurrence?

What hasn’t been done, to my knowledge, is to determine why it failed. Was it the physics of the treatment, or the bio-chemical aspects of the cancer? In other words, was it a misapplied treatment or do you just have that one-in-a million weird G6 that survives radiation for some unknown reason? Is the now-suspected lesion in the same area as the one positive core from the original biopsy? Have you had the radiation plan and delivery reviewed by another RO and team? How would a small G6 tumor survive the onslaught of what, 78gy of proton decimation? I am wondering whether they actually got it properly zapped in the first place. Has Zelefsky actually studied the original radiation plan and delivery? Or, has he deferred any real study until he gets all the data including the upcoming biopsy results?

Regarding your RO and uro during the period of rising PSA, it appears they were following the reactive approach. Don’t do anything or think anything is happening until the car actually goes over the cliff. To me, when you were developing a trend with clear upward inertia why would anyone think it would stop just shy of the Phoenix definition? It is unfortunate that you were being told not to be concerned. At some point, I would have hoped that one of the professionals would have said, this doesn’t look right, let’s try to figure out what is happening before it might get out of hand. Obviously, if you had started out high risk, their approach might have been different.

So going forward with the biopsy. How, and for what, will the specimen be tested? And, who will be doing the testing? And, will a second assessment be made as we suggest with original dx? Will it just be the standard volume, location and G? Or has the chosen pathologist(s) been told to do bio-chemical genetic testing to see why the radiation failed? There are more than 24 known such variations of PCa and some have shown to be radio-resistant. Will such analysis be applied to yours? Could it be that you had the very rare G6 neo-neuroendocrine strain that would have indicated surgery would be more effective than radiotherapy or ADT?

A lot of questions, but when we don’t know, we question. Too few questions and we may never know. You are trying to apply a focal treatment in a curative attempt, instead of facing a long term systemic treatment for a disease not yet indicating it is systemic. A tough position to be in. Wish you the best.

Let's be clear about my original Gleason. The initial biopsy was GL 3+4. I had 2nd done at JH. They said GL 3+3. Florida Proton wanted one of their own. They said GL 3+4. So, I was officially a GL 3+4 at Florida.
My local urologist speculated on why I failed. He raised 2 possibilities: the sample core from my prostate biopsy might have been just a millimeter away from more serious disease such as GL4+3 or GL4+4. Or maybe some tertiary GL 5 in there. That little core sample tells us almost nothing about what's in the entire prostate. We didn’t have the scans 9 years ago that we have today. Maybe if I had taken ADT for 3 months during and 3 months after it would be a different story.
During my 8 weeks treatment in Florida we were scheduled to have 5 treatments M-F, followed by 2 days off. During the week leading up to Thanksgiving we had equipment failure and we missed 4 days of treatment. I asked my RO about it and he said studies showed it would not have any effect on treatment, but I always wondered. One of the techs told me they were one day away from using IMRT for us because the maximum time of delay was 5 days.
I’m really not interested in why I failed unless it helps me avoid failure again if I choose salvage radiation. I'm focused on how I'm going to move forward in this process of testing and possibly curative treatment,
As to looking back on the rising PSA and not reacting to it, I mentioned that to my MO. I said in retrospect I should have insisted on PSMA. His response was that I couldn’t have had one even if I had pushed for it. My incremental increases were still a long way from the cutoff of BCF. I wasn’t a candidate.
As to the biopsy and pathology, it will done at Duke by my urologist there and a staff pathologist. I haven’t decided yet if I will send it to JH for 2nd opinion. I do know that Zelefsky will do his own pathology.
I haven’t spent much time thinking if the outcome would be different if I had chosen surgery. Surgery fails too. There are side effects to surgery that I didn’t have. I made my choice. No point in looking backwards.

PSA on Wednesday 8/28. Wondering if time of day and fasting matters. Some small studies suggest it does, but most say it doesn't. One says afternoon is lower than morning and food has no impact. Another says fasting 7-9 hours before has a lower reading.
I know using the same lab and doing the same schedule as before is a consistent approach. I always fast and do first thing in the morning, but this time will eat breakfast and lunch and have afternoon test.

Looking forward to getting the update. Tired of wondering what it will be.

P.S. Biopsy was scheduled for Thursday Aug 29 but Doc called this afternoon and cancelled. Rescheduled for Oct 8. I will reschedule the PSA as well sometime before the biopsy.

Post Edited (hrpufnstuf) : 8/26/2024 3:45:01 PM (GMT-5)

The only diet item that I know of that can affect PSA is drinking a ton of water 30-60 minutes prior to blood draw. But you don't want to "fix" the result. Just do what you would normally do