PSA Slowly Rising - DECIPHER test says low risk of metastasis - What to do?

I had robotic surgery in May 2011. The post-op pathology indicated a gleason of 3+3=6, EPE, and a focal positive margin. The only time my PSA came back as truly undetectable was 6 weeks after surgery. Three months after surgery, my PSA came back at .01, hence beginning my slow PSA rise to where I am today at .06. My entire PSA history since surgery can be seen by clicking on the link in my signature.

So this past month, I was already to get my referral to a radiation oncologist and get SRT scheduled (I am basing this on recent studies that suggest a PSA of .03 is the new cutoff when determining biochemical recurrence). When my PSA did not rise from the previous quarter, my urologist suggested we do a DECIPHER test in an effort to determine the aggressiveness of my PCa. I just got those results today and the test indicates a score of 1.1%, suggesting that I am at very low risk of metastasis within five years. So my urologist suggested we hold off for another three months to see what my PSA does.

So, if I understand my situation correctly, my particular PCa is of the less-aggressive type (Gleason 6) and has a very low chance of metastasizing elsewhere in my body. However, since I have an increasing PSA, and coupled with the positive surgical margin, I most-likely have a PCa continuing to grow in my prostate bed. This would suggest that SRT has excellent potential for eradicating the cancer.

So now I'm in a conundrum. Do I start SRT sooner in order to maximize the potential for success? Or do I hold off on SRT for a while longer to push-off the potential for any damages caused by the SRT?

Hi John, I would take the fact that your PSA is increasing (albeit extremely slowly) and the PNI and positive focal margin as the sign that your Gleason 6 may have an element of aggressivness or at least enough mutations to continue marching to its own tune. Since I have been on this forum, I have seen reports where this slow PSA rise in a lower-risk PC can continue for years and decades before it needs attention, but it will continue. Some people can live with it. I have also heard doctors like Myers say that one cannot be sure if this is tissue left behind after surgery that keeps producing PSA, but I am not sure if this would be the case here.

My advice would be, to get a second and third opinions of experienced PC oncologist who have had patients in these situations. My father also had a picture that did not quite fit (the first pathologist was wrong) and it seems that somehow Gleason 6 does not fit to the rest of your story, my only point being, you should not use it to base your decision on. Just like so many decisions in the management of PC, this one is also very difficult. I believe that knowledge can be a good weapon against PC, and you need more facts (from knowledgable doctors) to help you.

HD, with a G6 I believe you can wait another 3 months and re-test your psa. It might level off or maybe even fall. However, I also had a low risk Decipher result, a less than 1% probability of metastasis in five years. But my uro said that this low risk only indicated we could wait until my upsa started to rise. If my Decipher had come back high risk, he would've recommended SRT before a detectable psa. I have since gone from undetectable to 0.022. He now feels I have a recurrence. I have since been to see two RO's who have both indicated that my psa will continue to rise and eventually I will need SRT. I start 12-16-15 at MDA.

Unlike some here, I do not dismiss the new studies that suggest further treatment at a lower PSA than in the past. But, that said, given your Gleason 6 and very slow PSA rise, I wouldn't rush into any further treatment. In my own case, even as Pt3b and Gleason 7, I had nearly four years between hitting 0.4 and 0.2.

Hello Tall Allen - I was hoping you would respond as you seem to have a wealth of learned information at your fingertips. However, I do want to thank everyone for their responses.

According to my post-op pathology, "EPE is difficult to judge because tumor extends to the outer surface of the specimen." I guess because EPE could not actually be observed, the pT2c rating was indicated. But I do agree with you that I should have been classified a pT3a.

I agree that with my G6 cancer, the chances of metastasis to other areas of the body are quite slim. But with an increasing PSA (albeit slowly), that suggests that the cancer is continuing to grow in the prostate bed and I'm concerned the longer I wait, the greater the possibility of the cancer infiltrating surrounding tissues, including the colon, rectum, and other areas.

I guess at this point, it's best for me to adopt a sort of "active surveillance" approach. Since my surgery, I've always proceeded with the idea that once my PSA hits .1, it's time for SRT. I'll continue to watch my PSA and if it continues it's climb quarter-to-quarter, I'll move forward with SRT sometime before I hit that .1 threshold.

If it were me with your pretty good pathology and excellent Decipher score, I'd wait until PSA increased by over .05 in a year - you seem to still be just short of that benchmark. There's probably little risk to waiting for that benchmark. On the other hand, your peace of mind may be worth the risk of treatment SEs to you. Only you can make the call.

- Allen

Hey John! It's been a while. We were in the 2011 group of HW. I think TA has put it best. I thought I read several times on this forum, that there has never been a case of G6 metastasizing or a recorded PCa G6 death. I have not been monitoring the forum as closely lately, so I could have missed it. It seems that most feel that once G6 is confirmed, the focus turns to not over treating it if PSA returns. If you can confirm what I have just stated about G6 never progressing to a serious situation, it may help you feel more at ease about active surveillance. Your excellent Decipher score should reinforce your decision.

Pardon me for being a little direct, but also study up on the possible SE's of SRT and think about if you can live with the possibilities of those. As always, there is no right or wrong decisions and you are the one that gets to make it.

My non-medical vote for your situation goes for AS. My non-medical vote for my situation is to find a RO and maybe a MO also.

Best wishes.

Tall Allen said...
..And the trump card is your Decipher score. It is excellent at predicting which men will not recur. In fact, it's negative predictive value is 98.5% - nearly perfect - for genomic classifier scores under 0.4. That means there is virtually no risk of a metastasis in the next 5 years....
- Allen

If it were me, I would ride with the Decipher score until PSA was noticeably higher than currently.

That is the highest negative predictive value level of accuracy I have seen. And is the highest predictive value of any sort I have seen for anything related to PCa.

Compare that to the risk of potential side effects.