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Thread: <.1 PSA Compared to .1 PSA

  1. #1
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    <.1 PSA Compared to .1 PSA

    I got my first post robotic surgery PSA on December 4th, 6 weeks after robotic surgery. The results showed <.1. Wednseday, I had my second test & got the results today in the mail. Today's result was .1. I am going to see my surgeon Friday for my 6 month checkup & want ask him if there is a difference between the 2 numbers. Do any of you all have any info as to whether there is any significance in the 2 numbers? I guess I am falling prey to the fabled PSA anxiety. Thanks in advance!
    PSA 18, Gleason 3+3+6, Age 58, Rising PSA since 1999, Biopsy 5% of one core
    Robotic surgery 10/26/09 T2B Tumor 30% of prostate involving left & right lobes NOMX Gleason 3+4=7 Urethral Resection margins & resection surface clean Seminal vessicles clean

  2. #2

    well..

    I know that a lot of the time, what should be <0.1 gets reported as 0.1, either through typing error or, in the case of my radiation oncology nurses, part of their software doesn't like the less than symbol. So on a couple of occasions they have told me "0.1" and when I say "REALLY?" they say, "Oh, wait a sec, you're right. Less than 0.1"
    I've heard of this same sort of thing happening to others.

    Hopefully, that's the case with you. As far as I know, after prostatectomy, you really want <0.1.

    Also, with standard PSA testing, you could be looking at lab errors that large. My test is the standard (not ultrasensitive). When my PSA hit 0.2 after surgery, I called a chemist at the lab, and she told me that normal variation on their equipment could be as high as 0.1. So my reading of 0.2 could have possibly been in the range of 0.1 to 0.3.

    So I would hope that you're either seeing measurement error or reporting error, and it will be okay on a subsequent test.

    Just my layperson's 2 cents as usual.

    Wishing the best for you.
    Replicant

    Dx Feb 2006, PSA 9 @age 43
    RRP Apr 2006 - Gleason 3+4, T2c, NXMX, pos margins
    PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
    Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
    PSA 6/07 0.1, 9/07 (and thereafter) <0.1
    http://pcabefore50.blogspot.com

  3. #3
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    The first thing you should do is retest your PSA. It should be <.1 Unless the lab admits it's a reporting error.

  4. #4
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    Hi Traveling man, - In simple terms, <0.1 ng/ml Is essentially saying that there was NO detectable reading OR that any reading detected was LESS THAN that assay's acknowledged reliable sensitivity threshold of 0.1 ng/ml. In both instances such results are considered Clinically "undetectable". In the case of 0.1 ng/ml (without the < preceding it) an actual detectable reading has been recorded.

    Once you are monitoring Prostate Cancer (PCa) treatment results, the use of the term term "undetectable" is no longer sufficiently explicit in reporting PSA results, in my opinion. In fact, I don't believe it is sufficient even, in pre-treatment circumstances without it being accompanied with the actual numerical reading itself.

    The term "undetectable" means different readings to different "Doctors and Patients alike and there is always the increased chance of misinterpretation when communicated verbally. Everyone that has PCa, I believe, should always be told his SPECIFIC PSA result, accompanied by the clarifying interpretation of "undetectable" when appropriate. The wise patient will also request a copy of the actual Lab report for his records.

    The long standing CLINICAL definition of the term "undetectable" is a reading of LESS THAN 0.1, Nanogram per milliliter of blood, reported as <0.1 ng/ml, which coincides with the reliability threshold of all but one of the Standard PSA Tests, which are used in nearly all institutions as the primary diagnostic PSA assay. This represents 1/10th of a Nanogram of PSA per milliliter of blood. A nanogram is one BILLIONTH of a Gram. So a Nanogram is 1/10th of a Billion, an infitesimal amount.

    The Standard assay is also still used in MOST Institutions and Laboratories, for the ROUTINE monitoring of low and medium risk PCa patients for post-treatment results and even, similarly, with many high-risk patients.

    Since the introduction of Hyper- and Ultra-sensitive assays, however, some high risk patients (for biochemical failure) and even SOME medium and low risk patients are receiving these more sensitive assay readings, which can report PSA results to the 1/100th of Nanogram, or in limited instances to 1/1000th of a Nanogram per milliliter of blood. The two descriptive terms are often used interchangeably.

    The increased sensitivity of such readings, not only causes great confusion among those unprepared for the relative significance, or the LACK there of, that accompanies very low readings at such super sensitive levels. The long-standing clinical STANDARD for "undetectable" PSA readings, REMAINS at <0.1 ng/ml and so readings BELOW 0.1 ng/ml, constitute "undetectable" PSA results, in nearly all cases. This normally includes all readings between 0.001 through 0.09 ng/ml, that can be reported with the more sensitive assays described above, namely Hyper-sensitive and Ultra-sensitive PSA results.

    The major exception to "undetectable" representing anything less than the Clinical Standard of <0.1 ng/ml is found in very specific circumstances, usually involving the monitoring of SOME patients with advanced PCA who are on Hormonal or Chemical Therapy and who are being carefully monitored for minute (my-noot) changes in PSA, for very early indications of possible effectiveness after treatment change or POSSIBLE, very early treatment failure WARNING.

    SOME of these patients at critical times in their treatment MAY be subject to the 0.05 ng/ml level as "undetectable", but these cases represent a relatively small group of patients (percentage wise),and USUALLY tend to be better informed and more PCa savvy, after having had extended periods of treatment and subsequent education, following primary and/or secondary curative efforts that have, unfortunately, failed.

    I hope this has helped the understanding of relative PSA significance and reasons why in MOST cases, STANDARD PSA monitoring is deemed adequate for ROUTINE post-surgical monitoring, while relieving much unnecessary and unjustified PSA anxiety in at least 80% of the post-treatment patient population. I am happy to address any specific questions that anyone may have. - John@newPCa.org (aka) az4peaks

    NOTE: Here is an article from a Johns Hopkins publication that addresses the unnecessary PSA anxiety, often caused by the use of super-sensitive PSA assays in routine monitoring.

    "The Downside of Ultra- Sensitive Tests"

    You've had the radical prostatectomy, but deep down, you're
    terrified that it didn't work. So here you are, a grown man, living in fear of a simple blood test, scared to death that the PSA- an enzyme made only by prostate cells, but all of your prostate cells are supposed to be gone -- will come back.

    Six months ago, the number was 0.01. This time, it was 0.02.You have PSA anxiety. You are not alone.
    This is the bane of the hypersensitive PSA test: Sometimes,
    there is such a thing as too much information. Daniel W Chan, Ph.D., is professor of pathology, oncology, urology and radiology,and Director of Clinical Chemistry at Hopkins. He is also an internationally recognized authority on biochemical tumor markers such as PSA, and on immunoassay tests such as the PSA test. This is some of what he has to say on the subject of PSA anxiety:

    "The only thing that really matters", he says, is: "At what PSA levels does the concentration indicate that the patient has had a recurrence of cancer?" For Chan, and the scientists and physicians at Hopkins, the number to take seriously is 0.2 nanograms/milliliter. "That's something we call biochemical recurrence. But even this doesn't mean that a man has symptoms yet. People need to understand that it might take months or even years before there is any clinical physical evidence."

    On a technical level, in the laboratory, Chan trusts the
    sensitivity of assays down to 0. 1, or slightly less than that. "You cannot reliably detect such a small amount as 0.01," he explains. "From day to day, the results could vary -- it could be 0.03, or maybe even 0.05" -- and these "analytical" variations may not mean a thing. "It's important that we don't assume anything or take action on a very low level of PSA.

    In routine practice, because of these analytical variations from day to day, if it's less than 0. 1, we assume it's the same as non-detectable, or zero."

  5. #5
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    Quote Originally Posted by az4peaks
    Hi Traveling man, - In simple terms, <0.1 ng/ml Is essentially saying that there was NO detectable reading OR that any reading detected was LESS THAN that assay's acknowledged reliable sensitivity threshold of 0.1 ng/ml. In both instances such results are considered Clinically "undetectable". In the case of 0.1 ng/ml (without the < preceding it) an actual detectable reading has been recorded.

    Once you are monitoring Prostate Cancer (PCa) treatment results, the use of the term term "undetectable" is no longer sufficiently explicit in reporting PSA results, in my opinion. In fact, I don't believe it is sufficient even, in pre-treatment circumstances without it being accompanied with the actual numerical reading itself.

    The term "undetectable" means different readings to different "Doctors and Patients alike and there is always the increased chance of misinterpretation when communicated verbally. Everyone that has PCa, I believe, should always be told his SPECIFIC PSA result, accompanied by the clarifying interpretation of "undetectable" when appropriate. The wise patient will also request a copy of the actual Lab report for his records.

    The long standing CLINICAL definition of the term "undetectable" is a reading of LESS THAN 0.1, Nanogram per milliliter of blood, reported as <0.1 ng/ml, which coincides with the reliability threshold of all but one of the Standard PSA Tests, which are used in nearly all institutions as the primary diagnostic PSA assay. This represents 1/10th of a Nanogram of PSA per milliliter of blood. A nanogram is one BILLIONTH of a Gram. So a Nanogram is 1/10th of a Billion, an infitesimal amount.

    The Standard assay is also still used in MOST Institutions and Laboratories, for the ROUTINE monitoring of low and medium risk PCa patients for post-treatment results and even, similarly, with many high-risk patients.

    Since the introduction of Hyper- and Ultra-sensitive assays, however, some high risk patients (for biochemical failure) and even SOME medium and low risk patients are receiving these more sensitive assay readings, which can report PSA results to the 1/100th of Nanogram, or in limited instances to 1/1000th of a Nanogram per milliliter of blood. The two descriptive terms are often used interchangeably.

    The increased sensitivity of such readings, not only causes great confusion among those unprepared for the relative significance, or the LACK there of, that accompanies very low readings at such super sensitive levels. The long-standing clinical STANDARD for "undetectable" PSA readings, REMAINS at <0.1 ng/ml and so readings BELOW 0.1 ng/ml, constitute "undetectable" PSA results, in nearly all cases. This normally includes all readings between 0.001 through 0.09 ng/ml, that can be reported with the more sensitive assays described above, namely Hyper-sensitive and Ultra-sensitive PSA results.

    The major exception to "undetectable" representing anything less than the Clinical Standard of <0.1 ng/ml is found in very specific circumstances, usually involving the monitoring of SOME patients with advanced PCA who are on Hormonal or Chemical Therapy and who are being carefully monitored for minute (my-noot) changes in PSA, for very early indications of possible effectiveness after treatment change or POSSIBLE, very early treatment failure WARNING.

    SOME of these patients at critical times in their treatment MAY be subject to the 0.05 ng/ml level as "undetectable", but these cases represent a relatively small group of patients (percentage wise),and USUALLY tend to be better informed and more PCa savvy, after having had extended periods of treatment and subsequent education, following primary and/or secondary curative efforts that have, unfortunately, failed.

    I hope this has helped the understanding of relative PSA significance and reasons why in MOST cases, STANDARD PSA monitoring is deemed adequate for ROUTINE post-surgical monitoring, while relieving much unnecessary and unjustified PSA anxiety in at least 80% of the post-treatment patient population. I am happy to address any specific questions that anyone may have. - John@newPCa.org (aka) az4peaks

    NOTE: Here is an article from a Johns Hopkins publication that addresses the unnecessary PSA anxiety, often caused by the use of super-sensitive PSA assays in routine monitoring.

    "The Downside of Ultra- Sensitive Tests"

    You've had the radical prostatectomy, but deep down, you're
    terrified that it didn't work. So here you are, a grown man, living in fear of a simple blood test, scared to death that the PSA- an enzyme made only by prostate cells, but all of your prostate cells are supposed to be gone -- will come back.

    Six months ago, the number was 0.01. This time, it was 0.02.You have PSA anxiety. You are not alone.
    This is the bane of the hypersensitive PSA test: Sometimes,
    there is such a thing as too much information. Daniel W Chan, Ph.D., is professor of pathology, oncology, urology and radiology,and Director of Clinical Chemistry at Hopkins. He is also an internationally recognized authority on biochemical tumor markers such as PSA, and on immunoassay tests such as the PSA test. This is some of what he has to say on the subject of PSA anxiety:

    "The only thing that really matters", he says, is: "At what PSA levels does the concentration indicate that the patient has had a recurrence of cancer?" For Chan, and the scientists and physicians at Hopkins, the number to take seriously is 0.2 nanograms/milliliter. "That's something we call biochemical recurrence. But even this doesn't mean that a man has symptoms yet. People need to understand that it might take months or even years before there is any clinical physical evidence."

    On a technical level, in the laboratory, Chan trusts the
    sensitivity of assays down to 0. 1, or slightly less than that. "You cannot reliably detect such a small amount as 0.01," he explains. "From day to day, the results could vary -- it could be 0.03, or maybe even 0.05" -- and these "analytical" variations may not mean a thing. "It's important that we don't assume anything or take action on a very low level of PSA.

    In routine practice, because of these analytical variations from day to day, if it's less than 0. 1, we assume it's the same as non-detectable, or zero."
    Hi John,
    Thanks for the detailed reply. I am somewhat familiar with the explanation you have provided. I guess I am paying closer attention to this discussion now that I have had my second post surgery PSA. The <.1 PSA 6 weeks post surgery & the .1 PSA reading from last week ( 6 months post surgery) both came from the same lab & I have a copy of both lab reports. I apologize for the anxiety, however my question is should I be concerned about the lack of that little < before the .1? Is there a way to ask the lab if the actual result was <.1 or should I assume that if it were <.1 it would have been reported as such by Labcorp? Is there a significant difference in the 2 readings?
    PSA 18, Gleason 3+3+6, Age 58, Rising PSA since 1999, Biopsy 5% of one core
    Robotic surgery 10/26/09 T2B Tumor 30% of prostate involving left & right lobes NOMX Gleason 3+4=7 Urethral Resection margins & resection surface clean Seminal vessicles clean

  6. #6
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    Travelingman, in answer to your question, yes there is a difference between <.1 and .1. The question here though is whether the .1 is telling us anything or whether it is an anomaly.

    Having a detectable PSA reading 6 months after surgery should be watched carefully. It is possible that there was some benign prostate tissue left behind if your surgery spared the external nerve bundles. Don't remember your stats - did your surgical path report state any adverse findings?

    Since you have a detectable PSA, it may be worth switching to the more sensitive PSA test. I have read that labs may round up or down - for instance, if you have a PSA of 0.06, they round up to 0.1.

    I'm also surprised that the doctor sent you the results in the mail, especially since it came back "detectable." I would think that a phone call from the doc would be in order - if nothing else to allay any fears you have and to answer any questions. That's what our urologist does for each PSA test.

    Good luck - I hope you hear some good news when you meet with your doctor.

  7. #7
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    Hi Travelingman, - No reason for any apology. To answer your follow-up questions,

    (1) Yes, it MAY be reason for "concern", IF it is accurate, but ONLY if it continues to rise in subsequent readings.

    (2) Yes the "<" is important, because, as I said, it indicates any result that MAY have been found was below the reliability level of the PSA assay used and so can only be reported as LESS THAN that proven sensitivity level.

    (3) You can assume that the < would have been included in the copy of the report you have, if it was appropriate.

    (4) the true significance of the between <0.1 (an "undetectable" result and 0.1, which is an "actual" reading should be clearer after your next PSA. If it stays at 0.1 it stays at 0.1 or rises it's reliability is confirmed. If it returns to <0.1, it was NOT accurate and no reason for concern. Carefully re-read my previous explanation, most answers are there. I know it is complicated and if you will privately E-mail me your Phone number and location, I will be happy to call you and provide further explanation.

    Let me address the comments of another Poster. In my opinion, It is unlikely that the present 0.1 reading is from residual benign tissue, since your first reading was <0.1. If PSA from measurable benign tissue is present, its effects should have been recorded on the initial PSA.

    Also responsible Laboratories do not round actual readings on the STANDARD PSA test, except as I described in detail, in my previous Post. If further clarification is needed, I will answer any specific question(s).

    Since PSA anxiety is obviously already a problem, I would suggest that you do NOT switch to more sensitive PSA at this time. Greater sensitivity provides substantially increased potential for clinically meaningless variations in results, that would only tend to increase such anxiety.

    You may wish to consider reducing the time frame to your next PSA, for earlier clarification, perhaps 2 months for instance rather than the 3 or 6 month schedule which you are probably on. This would help clarify the 0.1 true significance, if any. Lets talk. Good luck! - John@newPCa.org (aka) az4peaks

  8. #8
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    Az, not quite true. My husband has PSAs of <.1 for 17 months following surgery. In August, his PSA came back at 0.1; in September it came back at 0.3. We met with a rad onc and had the standard bone and CT scans in preparation for salvage radiation therapy. The surgeon and rad onc wanted to wait for the 3rd PSA reading to confirm possible recurrence. Third test was done in October - came back at undetectable! Another test two months later confirmed undetectable, and his PSA has remained at <0.1 since that time. Since both nerve bundles were spared, surgeon believes that benign prostate tissue remained behind and over 17 months generated enough PSA to register. Fortunately, the PSA appeared to die off on its own and has stayed that way.

    While many believe that this is a somewhat rare situation, our surgeon told me that he has seen this happen more often than we might think. The key in his mind is knowing when to wait to see what the PSA is going to do and when to pull the trigger for SRT. I wanted SRT to begin when my husband's PSA hit 0.3 - fortunately, my husband wanted to follow SOP and wait for the third PSA result.

  9. #9
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    Well Sephie, - I hope your Doctor is correct, but I believe it much more likely that the Laboratory results were not due to benign tissue, or why did it rise twice, which according to him would be regeneration. If it came from regenerated (normal, live) tissue, why would it suddenly stop producing PSA?

    I would think it more likely the increasing Lab results were wrong (perhaps different assays used), then that normal, regenerated, benign tissue suddenly died for no reason.

    But, regardless, I hope it REMAINS "undetectable" (<0.1 ng/ml) in the future, for whatever reason. That is the real test of success. Good luck! - John@newPCa (aka) az4peaks

  10. #10
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    John, I too was skeptical but a little research on the Net brought up articles about this phenomena. Apparently, a significant percentage of surgical specimens showed evidence of benign prostate tissue remaining as noted by the pathologist.

    When my husband's PSA came back at 0.1, the urologist said there are three likely reasons for this: (1) a faulty test, (2) benign prostatetic tissue, and (3) possible recurrence. When the second test came back at 0.3, he felt that reason 1 was the least likely (but did not rule it out). At his annual physical this past May, my husband's "regular" doctor snuck in a PSA test as part of his blood work (he had not been doing PSA tests because the urologist was doing them every 3 months at a different lab). The result from this latest test was also less than 0.1 which eased my mind considerably as we now had the same result from two different labs.

    Have a great day, and thanks for your responses.

    Travelingman, hope everything is going OK for you.

 
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