0.03 ng/ml best indicator of biochemical recurrence (Johns Hopkins)

OK I think I got it now...this isn't calculus is it? So the .02guy has essentially a 50/50 chance of BCR...a coin toss but not the 87% or whatever it was for BCR with a nPSA of .03 ? I swear , not only do you become weaker and more tired as you age...you get dumber. I used to teach physiology at Cornell...I think...maybe that never happended. LOL

Hi, guys

I just got my first post-surgical PSA and it was "<.05." After reading about "<.02 and <.01" for so many months, and now reading this thread, I am wondering if some labs don't get any more sensitive than .05? I have emailed my doctor but he has not responded yet. If he tells me that the testing procedure used is no more sensitive than .05, it seems like it would make sense to have a PSA analyzed under a more sensitive protocol, does it not? Thanks,

Rick in Oregon

I just got my last uPsa result yesterday. I was disappointed to see it come back at .014, 16 months post RP. Doc suggested another test in 6 weeks, instead of 3 months, to see if this increase is a trend or just calibration noise. If it's a trend he will refer me to an RO. He likes to pull the trigger at .03. I asked him if he would suggest any ADT in addition to RT but he said not likely based on my pathology. Other posts I've read seem to indicate there could be some added benefit with a shot of ADT. Anybody have thoughts on that? And there will be new bone and CT scans before any RO to rule out any spread. Are these scans pretty standard or should I be looking for something that provides I higher accuracy? I've been using Memorial Hermann in Houston, but I'm thinking I might take a look at MD Anderson. I sense that they might have the latest and greatest equipment but maybe they're all standard. In any case, I've got another 6 weeks to soak it all in. Allen, thanks for starting this thread.

Thanks Rob. I'm not sure how to open my e-mail address without including it in my signature. I sent you an e-mail. John

Pratoman, you are definitely getting an ultrasensitive test if you are seeing two digits to the right of the decimal. But even among "ultrasensitive" PSA test systems, different machines report different numbers of significant figures. Also a doctor or medical institution may not release three digits to the patient because they know it might not be that reliable a number and may just cause the patient to get anxious unnecessarily and then chew up staff time asking questions. So for example, the machine may spit out ".014" and the medical center may report ".01" to the patient. I ran into this at UCSF.

If you want to know whether medical center is redacting data you can ask for the vendor and model of the machine that is used, and then google to find the manual or spec sheet.

One can wonder why these 3 digit (<.001) tests even are available? Are they ever clinically indicated and requested by any uro anywhere in the world? Who could benefit from such analytic sensitivity? The discussion here is about if the optimal BCR is 0.10 or 0.03 or 0.05 (not if the limit is 0.00x or 0.00y).

BTW, here is another article about the optimal BCR definition www.europeanurology.com/article/S0302-2838(13)00850-6/fulltext/optimal-definition-of-biochemical-recurrence-after-radical-prostatectomy-depends-on-pathologic-risk-factors-identifying-candidates-for-early-salvage-therapy

JFL1957,

I think one consideration about whether to include adjuvant ADT with SRT should be what the Gleason score was specifically at the positive margin. That info isn't always included in path reports, but I think it should be. While a recent study did show a benefit, it is not at all clear from the info released so far that that benefit accrues to cases where the Gleason score at the margin is 3+4 or less. If you want to read a discussion of those issues:

Combining ADT and salvage radiation therapy improves outcomes

- Allen

0.000035 ng/mL ! Wouldn't surprise me if they soon measure PSA in female blood.

In my professional world, I remember a well received paper from some 20 years ago entitled "Zero, the unreachable goal". In it, the author argued that just because we think we can measure a parameter down to some "gnat's ass" level, doesn't mean (a) that we're really doing it and (b) that a reading at some super-low level has any particular meaning. And that is what this discussion is about.

0.000035 ng/l indeed. And what are the conditions required to get this result? A vibration free environment in a laminar flow room at 25C +/- 0.05 with the analyst in a level A suit? Further, what conditions for sampling are required and how is the sample to be collected, stored, preserved, and shipped to the laboratory?

Do any of you detect my dubious perspective of the value of this analysis?

As I read through the JH and UCLA details, the thought that occurred to me is that the RO are basically saying "you should have decided on radiation treatment as your primary method instead of RP, because now you have gone through that miserable RP procedure and now we think you should go through the RT anyway."

I know that I am going to get hammered about this, but I like to look at the PSA numbers on the one hand and the post RP and Post RP+RT longevity numbers on the other. If you are like me and suffered through multiple side effects (SE) from what was supposed to be a "textbook" RP you start reading the fine print and asking more pointed questions about the potential SE. For my RP SE:
* severe urinary tract infection from the surgery
* Then a month later, I developed a urinary stricture. My surgeon told me that "I must have a sensitive urethra" when he operated to open the urethra.
* An abscess in the incision -After repeatedly telling the surgeon that there was something sharp poking through the incision (and being told it was normal scar tissue, don't worry). The infection turned out to be an antibiotic-resistant staff and e-coli bacteria that took about 8 weeks to clear up.
* 9 months post RP, I developed a suture-failure hernia (also called an incisional hernia). Some of the sutures used to restore the abdominal muscles to their normal position after the surgery failed due to the abscess/infection. (Apparently hernias occur in 5+% of RP surgeries - who knew?)

After my RP, due to a positive margin, my wife and I talked to 2 different RO about the RT options as well as several other family doctors. It was interesting how both of the RO downplayed the impacts and side effects from the radiation. Neither one even mentioned quality of life impacts - their only focus is on killing the PCa. Having read the 2013 American Urological Association (AUA) Guidelines document (available at:
AUA Guidelines

We questioned both RO's about the impacts of the radiation on my body.
Specifically, we questioned the impact on the nerves and muscles related to ED (assuming the body had any chance to recover prior to start of RT), the urethra, bladder, rectum, etc. and also the risk of ancillary cancers caused by the treatment radiation and process. Both ROs told us they use the most up to date IMRT process. One RO told us that the RT wouldn't impact the nerves at all. The second RO mentioned that the radiation doesn't impact the nerves, but it will kill the capillary blood vessels that supply the nerves -but he didn't see this as an issue. The second RO said that if you have had a stricture or a "sensitive urethra" the RT has a much higher chance of causing long term urinary incontinence. One RO told us that they insert a special material between the prostate bed and the rectum to minimize long term damage including cancer and incontinence, including frequent diarrhea. The other RO said that the impacts on the rectum were "no worse than a severe case of sunburn" - SERIOUSLY!! I can't remember having a sunburn in that particular area of my body for reference.

Neither RO had any answer about the risk of additional cancers from the procedure. (Apparently no one actually tracks these formally.) However, one did mention that there is a potential issue, due to the frequent number of abdominal CT scans required during the IMRT procedure for targeting accuracy. (One of my other MD's told me bluntly that "they don't expect you to live long enough for the secondary cancer to be an issue".) However, he told us about several of his younger patients who developed bladder, colon or rectal cancer after the RT and have been largely incapacitated by 10+ years of incontinence and diarrhea. Another pointed out that it is always surprising to her that the same men who were very concerned about their exposures from Japanese nuclear reactors had little concern about going in for any radiation treatment or exposure.

The AUA Guidelines mention that their recommendations may be artificially positive for the RP+RT results since nearly half of the men might not have had a PCa recurrence regardless of the RT.

My observation is that the surgeons and RO have a vested interest ($$$) in propagating their procedures. For high risk men there are not many good options, but everyone should ask their medical professionals very specific and personal questions about how the process will impact their body and quality of life. Remember, doctors are like computers - if you don't ask the specific question, they don't generally volunteer it if it makes them look bad.

Remember that life can really suck if you happen to be one of the 5% who have any of the awful side effects.

Newlylimp-
You may be interested in reading a recent post of mine:

Why salvage radiation is bad.

I posted that in agreement with you that urologists too often are very cavalier about salvage radiation when they are discussing primary surgery. To be fair - all salvage is bad (and about equally effective) and carries increased risks of SEs over primary treatment. I wrote that for men who are considering having surgery because "I can always have radiation later " - as if it were a walk in the park.

However, for men who already made the decision, there is no point to looking backward. They are now facing salvage radiation or lifelong hormone therapy - neither are pleasant options. It is a difficult decision. The best we can do is understand what is known about the risks and benefits, and weigh that against what we are willing to live with.

- Allen

TA - thanks again for the great post on the impacts of Salvage RT. Your points mirror what my GP told be about a number of his long term patients and the changes to the former "prostate bed" area.

In his practice he has an older man who, based on what my GP has told me, went through a RP followed by radiation and HRT. Following the rad treatment, the guy hasn't had a normal bowel movement and has been incontinent for over 10 years. Granted, this is before the use of the "new and improved" IMRT process, so you can argue that some SE have probably been eliminated. However, the GP also mentioned that the long term impacts of the targeting CT scans used for IMRT may be as bad as the "old" techniques in terms of exposing the abdominal organs to radiation - and no one has been tracking this to his knowledge.

It really irritates me when I see main stream news blurbs by ROs that suggest men should jump into radiation treatment immediately after a RP and downplaying risks from complications. Reminds me of the old ambulance chasing lawyers.

My point is that this poor guy and his wife are stuck. My doctor said that due to the incontinence, they can't really go on cruises or travel any more because it became too embarrassing for them. Even driving can be problematic.

This could happen to any of us. It is sort a matter of the luck of the draw but we can't even see the cards until after me make our bets...