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Thread: Significance of trace PSA reading after a Prostatectomy

  1. #1

    Significance of trace PSA reading after a Prostatectomy

    I am familiar with the Johns Hopkins study but I can find no info on trace PSA and its significance. I have questions:

    1. Since we are told that only PCa can cause a PSA reading after a RP, why is a re-occurrance considered to have occurred only at a PSA reading of .2 or greater?

    2. Has anyone here had a Gleason 8 cancer that had a steady PSA reading in the .02 - .09 level?

    Why I ask:
    On 4/12/04 I had a RP at 54 yrs old. at Memorial-Slone Kettering Cancer Center
    Gleason 8 - Negative margins - negative nodes as well as all other structures

    Over the last 46 months I always had a 6 month PSA result of <.1
    My last test was .1 which caused considerable concern. As a result I found a lab that tests to two decimal places. Their test shows me a .06. This leaves me to assume I have been less than .05 for 46 months and it just got high enough for the 1 decimal place lab to read it and round me up to .1

    If that is true, it still means I must have raised from something like at least .04 to .06 in the past 6 months. I can find nothing that discusses the significance of PSA increases at these levels.

    I intend to now monitor the doubling rate (assuming it is steadily climbing) with this more sensitive test.

    Any enlightenment on this issues and these questions is appreciated..
    History: PSA's every 6 months 6.7 neg biopsy - PSA 16.6 neg biopsy - PSA's 8.2, 8.1, 8.7 - Biopsy showing 4+4 Gleason 8. Lap RP Apr 2004, age 52 All neg margins, nodes, and structures. (T2a). Post RP PSA: every 6 mo. <.1 until Feb, 08 (46 mos) PSA .1 - I then got sensitive tests beginning 2008: Feb .06, May .09, Jun .10, Aug .10, Nov .15 - SRT Dec 2008
    Post SRT PSA 2009 Feb .10, May .09, Aug .06, Dec .04, 2010 Mar .04

  2. #2

    first part of question

    I think I can answer the first part of the question--why 0.2?

    The answer is, it's still a debatable point. However, there seems to be a group of men, around 33% who will progress into the 0.1 to 0.2 range *and not progress further*, at least within 3 years. Since radiation, although much kinder now than in the past, has potential side effects, doctors want to avoid unnecessarily treating these patients ("first do no harm").

    For patients who go over 0.2, the situation is MUCH different. 86% will progress within one year, and 100% will progress within 3 years, so the alarm bell should be rung. But most doctors (like mine) will want to see two sequential rises over a certain amount. When I hit 0.2, we waited. It was not fun. When it went up again we acted.

    The crunch will come in with regard to salvage radiation. Once you know you're in biochemical failure, and want to try radiation, you need to get it started while your PSA is as low as possible. If you're not going to have radiation, there's no reason to rush.

    See "Defining the ideal cutpoint for determining PSA recurrence after radical prostatectomy." http://www.ncbi.nlm.nih.gov/pubmed/12597949

    When ultrasensitive tests are used, the "background noise" (think about what a tiny, tiny thing 1/100th of a billionth of a gram is) can cause the patient considerable--often unnecessary--anxiety. See "The relationship of ultrasensitive measurements of prostate-specific antigen levels to prostate cancer recurrence after radical prostatectomy" at http://www.ncbi.nlm.nih.gov/pubmed/1...t=AbstractPlus where the researchers say the meaning of "trace" (as you say) levels of PSA is unclear and "The amount of 'background noise' produced within this [ultrasensitive] range precludes the ability to use this test as a clinical indicator of disease recurrence."

    You might also be interested in "The Downside of Ultra-sensitive Tests" at http://www.phoenix5.org/Basics/psaPostSurgery.html . In that article, Daniel Chan of Johns Hopkins says "You cannot reliably detect such a small amount as 0.01. 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 nondetectable, or zero.''
    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
    Administrator Top User brainman's Avatar
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    I do not have much to add to this discussion. I do know that most doctors think of test results of 0.1 or less as being the same thing as zero and a lot of doctors do not even start the think about cancer unless the result is between 2 and 10. Although I have never read or hear of this, I still think there has to be other normal prostate cells that produce a small amount of PSA.
    Jim
    Long-term cancer survivor
    1992 Astrocytoma grade 2, left motor strip
    2005 Recurrence this time said to be an Oligodendroglioma grade 3, same location.
    http://cancerforums.net/viewtopic.php?t=2405
    My Story Part 1: http://cancerforums.net/viewtopic.php?t=2528
    My Story Part 2: http://cancerforums.net/viewtopic.php?p=7350
    My Story Part 3: http://cancerforums.net/viewtopic.php?t=8029

  4. #4

    Jim

    A small clarification-

    You wrote "a lot of doctors do not even start [to] think about cancer unless the result is between 2 and 10"

    This is only the case before surgery. After surgery, PSA is a much more useful tool, and at a much lower level. Doctors will say "your cancer's back" way before you get to 2.0 ng/mL. Also, after you pass the 2.0 mark, the probability of a response to salvage therapy diminishes rapidly.
    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

  5. #5

    Re: Replicant & Brainman

    Replicant,

    I so appreciate your detailed response (I am an information hound). My wife and i had a pretty uneasy week after the .1 test. The .06 helped us relax a bit and put it in perspective, at least until the next test. Just touching base here was a help.

    I seem to get conflicting messages out of johns Hopkins about salvage radiation on gleason 8. Seems a couple doctors down there may disagree.

    Brainman, I am founder of the Peyronie Disease Society forum and administrator of the forum. I know the work involved. You deserve a big salute.

    Thank you for your contribution to us all.
    History: PSA's every 6 months 6.7 neg biopsy - PSA 16.6 neg biopsy - PSA's 8.2, 8.1, 8.7 - Biopsy showing 4+4 Gleason 8. Lap RP Apr 2004, age 52 All neg margins, nodes, and structures. (T2a). Post RP PSA: every 6 mo. <.1 until Feb, 08 (46 mos) PSA .1 - I then got sensitive tests beginning 2008: Feb .06, May .09, Jun .10, Aug .10, Nov .15 - SRT Dec 2008
    Post SRT PSA 2009 Feb .10, May .09, Aug .06, Dec .04, 2010 Mar .04

  6. #6

    Re: Replicant & Brainman

    Quote Originally Posted by Hawk
    I seem to get conflicting messages out of johns Hopkins about salvage radiation on gleason 8. Seems a couple doctors down there may disagree.
    To address the uncertainty, I HIGHLY recommend getting your hands on a copy of this article:

    Predicting the Outcome of Salvage Radiation Therapy for Recurrent Prostate Cancer After Radical Prostatectomy

    Andrew J. Stephenson, Peter T. Scardino, Michael W. Kattan, Thomas M. Pisansky, Kevin M. Slawin, Eric A. Klein, Mitchell S. Anscher, Jeff M. Michalski, Howard M. Sandler, Daniel W. Lin, Jeffrey D. Forman, Michael J. Zelefsky, Larry L. Kestin, Claus G. Roehrborn, Charles N. Catton, Theodore L. DeWeese, Stanley L. Liauw, Richard K. Valicenti, Deborah A. Kuban, Alan Pollack

    Journal of Clinical Oncology, Vol 25, No 15 (May 20), 2007: pp. 2035-2041
    2007 American Society of Clinical Oncology.
    DOI: 10.1200/JCO.2006.08.9607


    It's more than an article--it contains two decision making tools--a flow chart and a nomogram. Your nearest medical library should be able to get it for you, or your nearest public library via interlibrary loan. If you have any trouble, contact me via my blog and I'll help you get it. It definitely addresses the Gleason 8/salvage thing.

    But, of course, you're nowhere near needing salvage at this point. It would just be reassuring for an info junkie like yourself to have the information readily at hand, I think.
    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

  7. #7

    Re: Replicant - Predicting the Outcome of Salvage Radiation

    Is "Predicting the Outcome of Salvage Radiation Therapy for Recurrent Prostate Cancer After Radical Prostatectomy" available as a download (PDF etc) to physicians?

    I have a contact or 2 on our PD site that can access full clinical trials.

    Thanks again for your support.

    PS: Just as a point of interest. I attribute my Pre-surgery PSA drop from 16.6 to 8.2 to diet and supplements.
    History: PSA's every 6 months 6.7 neg biopsy - PSA 16.6 neg biopsy - PSA's 8.2, 8.1, 8.7 - Biopsy showing 4+4 Gleason 8. Lap RP Apr 2004, age 52 All neg margins, nodes, and structures. (T2a). Post RP PSA: every 6 mo. <.1 until Feb, 08 (46 mos) PSA .1 - I then got sensitive tests beginning 2008: Feb .06, May .09, Jun .10, Aug .10, Nov .15 - SRT Dec 2008
    Post SRT PSA 2009 Feb .10, May .09, Aug .06, Dec .04, 2010 Mar .04

  8. #8

    article

    Maybe, but not by virtue of being a physician. Just the likelihood of having access to a hospital library with an online subscription.

    The abstract is here for free:
    http://jco.ascopubs.org/cgi/content/abstract/25/15/2035
    and you'll see that you can buy the article online in PDF format for $22.00.

    But again, it should be possible to get it at no cost to you through a library database or service. My local city library has been able to obtain and mail me medical journal articles within less than a week at no charge.
    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

 
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