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Thread: Question on BCR - Using PSA to predict time until serious symptoms

  1. #1
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    Question on BCR - Using PSA to predict time until serious symptoms

    I am collecting information on post-prostatectomy treatment options. My first PSA after surgery was 0.10 and I had a follow up PSA test three weeks later to verify. The second was 0.133. The second one I specifically asked for the actual lab report so there were no transcription errors.

    So I may have to make some decisions soon. There is one option that I have not read anything about at all. That option is to allow the disease process to follow its natural course. In other words, do nothing at all, seek no further treatment.

    I'm trying to find out if there are any general guidelines as to how long it would take before someone (post prostatectomy) started to present with symptoms of metastatic prostate cancer. I'm assuming the symptoms would be pain. There are so many variables that I don't think this question can be answered. It would depend on the grade/genetics of the cancer and where it metastasized among other things. In general, do people with BCR start having symptoms while the PSA is still low? I've heard of people being diagnosed with PSA scores in the hundreds because they had no symptoms. I'm trying to figure out if I can use PSA velocity and PSA doubling time to predict when symptoms will start showing up.

    My goal is to figure out if there is a way to predict how long I will have a good quality of life if I decline further treatment. If people say "You won't notice anything until your PSA gets above 10" then I can track my PSA results and predict how long it will take to get to 10. But then, I know there are too many variables in each individual case to make blanket statements like that. I'm just thinking out loud trying to figure out how to process the information. It's 1:45 AM so I don't know how coherent this post will be.
    DOB 1961
    2010-05 2.42
    2015-07 7.0
    2015-08 5.4
    2016-02 6.2
    2016-09 7.86
    2017-02 7.2
    2017-05 5.65
    2017-06 biopsy 7 of 13 cores G6
    2017-10 7.11
    2018-04 7.47
    2018-11 11.80

    2019-01 Da Vinci RALP
    Pathology report:
    Final stage pT2C
    Histologic type: Acinar adenocarcinoma with focal mucinous features
    Grade: 3+4=7 35% pattern 4
    23% of prostate involved
    EPE-
    BNI-
    SVI-
    PNI+
    LVI+
    Margins focally positive [1-3 mm] 4 locations
    Cribriform pattern noted

    2019-02 PSA 0.1 Abbott Architect Total PSA
    2019-03 uPSA 0.133 Roche ECLIA
    2019-04 uPSA 0.116 Roche ECLIA
    2019-05 uPSA 0.143 Roche ECLIA
    2019-05 PSA 0.1 Abbott Architect Total PSA

  2. #2
    Hi Busby. Was your first post-op PSA 0.10 or 0.100, or perhaps you don't know? If it was a 2-decimal test, then you really can't compare it to your 0.133 and should look at the next uPSA to see what's going on. Some folks have persistent but stable, low PSA after surgery. Many men wait for higher PSA around 0.2 to 0.4 for SRT. Make sure you stay with the same test drawn at the same lab. You will need a few points to plot the velocity of an upward trend.

    In your case, if your PSA goes up, we wouldn't be talking about BCR (biochemical recurrence) because your PSA has persisted after surgery rather than recurring after being undetectable.

    I would have Decipher test done on your RP tissue to learn the propensity of your PCa to metastasize. IF your PSA continues to rise, in addition to the velocity of increase, your genomics can be a valuable aid to deciding on a reasonable PSA point to start treatment.

    You certainly don't want to wait until you have symptoms! You are young! The idea is to treat remaining local cancer before it metastasizes. You should discuss all your concerns with your uro, and, if your PSA is increasing, an RO. They can give you an accurate picture of the possible outcomes and treatment timing.

    Which aspect of possible treatment worries you, HT or RT?

    I'm not sure you can use PSA to predict symptoms. My uro has men being treated for many years with HT, who have prostate-confined disease with high PSA.

    Djin
    Last edited by DjinTonic; 03-17-2019 at 10:53 AM.
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. biopsies, PCA3 -
    2013 TURP (90→30 g) path: neg. for cancer; then 6-mo. checkups
    6-06-17 DRE: nodule R and PSA rise, on finasteride: 3.6→4.3
    6-28-17 Biopsy #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 5% RLM
    Bone scan, CTs, X-rays: negative
    8-7-17 Open RP, neg. frozen sections, Duke Regional
    SM EPE BNI LVI SVI LNI(16): negative, PNI+, nerves spared
    pT2c pN0 bilat. acinar adenocarcinoma G9 (4+5) 5% of prostate (4.5 x 5 x 4 cm, 64 g)
    11-10-17 Decipher 0.37 Low Risk: 5-yr met risk 2.4%; 10-yr PCa-specific mortality 3.3%
    Dry; ED OK with sildenafil
    9-16-17 (5 weeks) PSA <0.1;
    LabCorp uPSA (Roche ECLIA):
    11-28-17 (3 mo. ) 0.010
    02-26-18 (6 mo. ) 0.009
    05-30-18 (9 mo. ) 0.007
    08-27-18 (1 year) 0.018
    09-26-18 (13 mo) 0.013 (checking rise)
    11-26-18 (15 mo) 0.012
    02-25-19 (18 mo) 0.015
    05-22-19 (21 mo) 0.015

  3. #3
    Busby, you are a young man and your pathology was not that bad. It appears from your sig that the cause of your PSA is your positive margin and lymphoascular invasion. So there is likely some cancerous tissue remaining local to your prostate bed. My non-professional recommendation would be to treat it NOW before it leaves the pelvic area and moves on to other parts of your body. At that point it would become incurable, and you would be destined for lifelong HT, or a slow painful death. You are much too young for that. Hit this thing with everything available NOW to knock it out before it takes over. Good luck!
    Late 2012: PSA 4, age 62 all DRE's 'normal' ... Early 2014: PSA 9.5, TRUS biopsy negative
    2015: PSA's 12 & 20, LOTS of Cipro ... Mar'16: PSA 25, changed Urologist
    Jun'16: MRI fusion biopsy, tumor right base, 6/16 cores: 2-40%+2-100% G8(4+4)
    Aug'16: DaVinci RP, -SM, 11 LN-, 53g, 25% involved, PNI, 6mm EPE, BL SVI, pT3B
    Jan'17: started 18 months Lupron ADT, uPSA's ~.03
    May'17: AMS800 implanted, revised 6/17
    Aug'17: 39 tx (70 Gy) RapidArc IGIMRT
    Jan'18-Jan 2019: PSA's <0.008, T=9 (still on Lupron)
    Apr'18: Dx radiation colitis, Oct'18: Tx sclerosing mesenteritis
    "Everyone you meet is fighting a battle you cannot see"
    Mrs: Dec 2016
    Dx stage 4 NHL/DLBCL, Primary Bone Lymphoma
    spinal RT boost+6X R-CHOP21+IT MTX via LP. Now in remission
    Read our story at CancerCoupleBlog

  4. #4
    Top User
    Join Date
    Aug 2016
    Posts
    1,436
    What is your life expectancy? I put mine at between 85 and 90 on thelie side. Of course, you can die anytime, but some things are obvious; family history, fitness habits, and your personal commitment to your health.

    There are life expectancy calculators on line. Most insurance companies provide them. They seem remarkably accurate. They are the masters of actuarials. They put mine at 86. It seems accurate, if conservative. You can play with the differences of weight, exercise, drinking and smoking. They do not go into family history or mental health. I've had several parents and grandparent live into their 90s so there is that.

    Assess your mental health. Depression, even if not chronic, can be a factor in your thinking and can impact your view of your healthcare. Your PSA history indicates a reluctance to deal with healthcare issues effectively. Early detection early treatment is the mantra for prostate cancer, or any cancer. PC seems to have gotten a dangerous reputation as being non life threatening. You now know differently, or do you? If you do nothing, it is unlikely you will die of something else as most men are eager to quote (if not believe).

    Research death from prostate cancer. It can happen as quickly as 3 to 5 years. Research PC lymphatic invasion as the adverse condition you are confronting.

    PC can be successfully managed for a long time in many cases. You don't know if you don't try. We have plenty of history and diagnostic tools to help, but it is clear we can't predict how it is going to go for any one person.

    In fairness to you it's also a question for your doctors; what will happen if I do nothing? And, it is a very good question we all ask ourselves. If more men asked it and got it answered for themselves in a timely manner (sooner) we'd have less of them here.

    There may come a time for all of us when we are confronted with a treatment option worse than death. Imo, this isn't it for you unless you are dying of something else in the next 5 years you haven't shared with us.

    I may be wrong, but it seems you hesitated once before with this disease and here you are. Do it again and you may not have this second chance a third time.
    Last edited by Another; 03-17-2019 at 01:35 PM.

  5. #5
    Senior User
    Join Date
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    Posts
    310
    Quote Originally Posted by RobLee View Post
    Busby, you are a young man and your pathology was not that bad. It appears from your sig that the cause of your PSA is your positive margin and lymphoascular invasion. So there is likely some cancerous tissue remaining local to your prostate bed. My non-professional recommendation would be to treat it NOW before it leaves the pelvic area and moves on to other parts of your body. At that point it would become incurable, and you would be destined for lifelong HT, or a slow painful death. You are much too young for that. Hit this thing with everything available NOW to knock it out before it takes over. Good luck!
    You make some valid points and I do not advocate no treatment, but with the LVI is there is a reasonable possibility that things are not still regional. Going through RT with possible zero benefit will likely be the recommended treatment.
    DOB 5/1957

    PSA - 11/2010=1.9, 6/12=2.3, 12/13=2.19, 12/14=2.64, 3/17=5.29, 3/17=3.91, 6/17=3.47, 12/17=4.50, 12/17=3.80, free PSA low risk (local (Uro, “My opinion you don’t have cancer), 8/18=5.13, 10/18=5.1, 10/19 ISO PSA 56% risk cancer. All DREs negative.

    DX 12/18, GS 8, 4+4 6/12 cores, LL Apex 100%, LM Apex 60%, LL Mid 50%, LMM 40%, LL Base 5%, LM <5%, Right side negative, (Uro opinion “This has been going on for a year”.... ah, more like 2 years ). Bone scan/CT negative

    2/25/19 R-LESS (Robotic Laparoendoscopic Single Site Surgery) outpatient Cleveland Clinic,

    3/6/19. Pathology - Grade Group 4 with Intraductal Carinoma
    T3aNO, GS8, unifocal tumor 10%. -7 Nodes, - SV, - Margins, - PNI,
    - bladder neck neg., + EPE non focal apex/mid lateral 1mm max extension, Cribriform pattern present. Decipher .86 High Risk. 38% risk 5 year metastasis.

    PSA 3/27/19 .03. (29 days)
    4/25/19 <.03. (58 days)
    5/25/19 <.02. (88 days)

    ADT started 6/3/2019

  6. #6
    There are many statistics about PCa progression after biochemical recurrence (BCR). But, let's just use the simple ones found in the Johns Hopkins research paper about the Natural History of BCR after prostatectomy and with no additional hormonal therapy.

    At 5.3 years post surgery 15% of men had BCR (PSA > 0.2ng/ml)
    The median (half the times were less and half were more) time to BCR was 2.3 years
    Eventually 1/3 of those men developed metastatic disease (About 1 in 20 of the original study group of prostatectomy patients)
    The Median time to metastatic disease symptoms was 8-years
    About half (actually 44%) of men with metastatic disease died from the disease (About 1 in 40 of the original study group of prostatectomy patients)
    The Median time to metastatic disease death was 5-years AFTER development of symptoms (About 13-years after initial PSA > 0.2)

    As others have mentioned - your life expectancy and Quality of Life is critical in the SRT / ADT / HT Yes or No? decision making process. All the the life expectancy calculators I've used give me at least another 20-years and I expect them to be good years. My father and I went for a 3-mile hike in the Everglades on his 89th birthday and he felt great doing it. SO - for me it seems I should do everything possible to fight the renewed growth of PCa IF I experience BCR.

    The recent post describing two brother's current SRT and HT therapy with few side effects has been very encouraging for me. They make it sound like SRT & HT can be experienced with a minimal degree of suffering and long term effects. Yet another reason to plan on additional treatment if BCR does occur.

    Several surviving partners of men who died from Metatstatic Prostatic Cancer disease have posted threads here describing the last two years of their partners journey to death. It sounds like a horrible way to die and is also very hard on the surviving family. I've promised my wife, 8-years younger than me and from a family where all the women live to be older than 95, I will outlive her. Thus I have a strong incentive to submit to whatever additional treatment I need to delay or deny PCa return.

    I've written several more detailed threads about BCR and prognosis, which summarize much of the research I've found. Here is one link:

    https://www.cancerforums.net/threads...t-RP-prognosis
    Last edited by OldTiredSailor; 03-17-2019 at 02:24 PM.
    DOB: July 1947
    PSA: 2.0/2004 4.0/2010 5.8/2010 4.5/2012 5.6/2013 ALL Normal DRE
    5/18 PSA: 9.2
    6/18 PSA: 10.2 & 8.4% Free
    DRE small soft prostate w/no abnormalities
    6/28 3T mpMRI PIRADS 3
    18 cc gland=PSD 0.57 ng/cc
    0.32 cc lesion in apical PZ with subtle T2 signal hypointensity
    mild restricted diffusion of contrast into lesion prostate unremarkable intact capsule
    7/18 4KScore 34% Probability Gleason =>7

    8/03/18 Bx: Adenocarcinoma 6 of 13 cores ONLY L lobe
    T1c / Grade II / unfavorable intermediate
    extent of G3-G4 tissue far greater than indicated by MRI
    G6 (3+3) 70% LL Base 50% L Lateral Mid 20% L Base
    G7 (3 +4) 100% LL Apex 20% L Mid 60% L Apex
    8/15/18 Clear CT scan and Bone Scan
    RALP 8/23/18 pT3a, G7 (3+4), 20% involvement, SM+ (Focal 2mm G6), EPE(Focal G6)+, PNI+, LNI-, SVI-, LVI-
    7g Tumor 20x size in MRI & biopsy report & in BOTH lobes not just L as biopsy reported

    PSA Post Surgery
    10/3/18 0.021
    01/4/19 0.018
    04/03/19 0.022

  7. #7
    Top User
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    Quote Originally Posted by Duck2 View Post
    Going through RT with possible zero benefit will likely be the recommended treatment.
    I can't imagine any doctor recommending RT with no benefit. You will not have to worry about that possibility. There are other treatment choices besides RT.

    That view and use of language reinforces my recommendation you be screened for depression. You need some help with this.
    Last edited by Another; 03-17-2019 at 02:23 PM.

  8. #8
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    OTS, the poster is around 58.

  9. #9
    Quote Originally Posted by Another View Post
    OTS, the poster is around 58.
    Thanks for the correction. I read his initial post and then scrolled down to the signature but the screen jumped too far and I ended up in DjinTonic's signature.

    His relatively young age, IMHO, makes additional treatment IF BCR were to occur an easy decision - DO IT!
    DOB: July 1947
    PSA: 2.0/2004 4.0/2010 5.8/2010 4.5/2012 5.6/2013 ALL Normal DRE
    5/18 PSA: 9.2
    6/18 PSA: 10.2 & 8.4% Free
    DRE small soft prostate w/no abnormalities
    6/28 3T mpMRI PIRADS 3
    18 cc gland=PSD 0.57 ng/cc
    0.32 cc lesion in apical PZ with subtle T2 signal hypointensity
    mild restricted diffusion of contrast into lesion prostate unremarkable intact capsule
    7/18 4KScore 34% Probability Gleason =>7

    8/03/18 Bx: Adenocarcinoma 6 of 13 cores ONLY L lobe
    T1c / Grade II / unfavorable intermediate
    extent of G3-G4 tissue far greater than indicated by MRI
    G6 (3+3) 70% LL Base 50% L Lateral Mid 20% L Base
    G7 (3 +4) 100% LL Apex 20% L Mid 60% L Apex
    8/15/18 Clear CT scan and Bone Scan
    RALP 8/23/18 pT3a, G7 (3+4), 20% involvement, SM+ (Focal 2mm G6), EPE(Focal G6)+, PNI+, LNI-, SVI-, LVI-
    7g Tumor 20x size in MRI & biopsy report & in BOTH lobes not just L as biopsy reported

    PSA Post Surgery
    10/3/18 0.021
    01/4/19 0.018
    04/03/19 0.022

  10. #10
    Here is an interesting factoid that might help with decision making:

    In patients with localized prostate cancer, the 5-year survival approximates 100%; however, in patients in whom distant metastases have occurred, the 5-year survival drops to 31%. Like most other solid malignancies, prostate cancer can metastasize to distant organs such as the liver, lungs and brain, but it has an unusually high propensity for metastasizing to the bone. In one autopsy study, approximately 80% of the men who had died from prostate cancer possessed bone metastases. Most current treatments for individuals with bone metastases have only palliative effects, with little effect on long-term survival International Journal of Cancer June 2012
    DOB: July 1947
    PSA: 2.0/2004 4.0/2010 5.8/2010 4.5/2012 5.6/2013 ALL Normal DRE
    5/18 PSA: 9.2
    6/18 PSA: 10.2 & 8.4% Free
    DRE small soft prostate w/no abnormalities
    6/28 3T mpMRI PIRADS 3
    18 cc gland=PSD 0.57 ng/cc
    0.32 cc lesion in apical PZ with subtle T2 signal hypointensity
    mild restricted diffusion of contrast into lesion prostate unremarkable intact capsule
    7/18 4KScore 34% Probability Gleason =>7

    8/03/18 Bx: Adenocarcinoma 6 of 13 cores ONLY L lobe
    T1c / Grade II / unfavorable intermediate
    extent of G3-G4 tissue far greater than indicated by MRI
    G6 (3+3) 70% LL Base 50% L Lateral Mid 20% L Base
    G7 (3 +4) 100% LL Apex 20% L Mid 60% L Apex
    8/15/18 Clear CT scan and Bone Scan
    RALP 8/23/18 pT3a, G7 (3+4), 20% involvement, SM+ (Focal 2mm G6), EPE(Focal G6)+, PNI+, LNI-, SVI-, LVI-
    7g Tumor 20x size in MRI & biopsy report & in BOTH lobes not just L as biopsy reported

    PSA Post Surgery
    10/3/18 0.021
    01/4/19 0.018
    04/03/19 0.022

 

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