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Thread: Psa after Rp

  1. #1

    Psa after Rp

    I've seen you guys mention some Uros due different types of psa testing.. Ie. Some that use. 0.00 or 0.0 When its time for our 3mth check , which particular psa testing should I request for most accurate? Want to make sure we are getting exactly what we need for testing
    DOB 5/76
    Age 42
    PSA 2017 n/a, 1/2018 2.66 1/2019 3.39 Reset 2/019 3.04
    MRI 3/2019 3 Lesions 2 Pirads 3 and 1 Pirad 4
    Biopsy 4/11/2019
    PCA positive- all grade group 1 and Gleason score 6(3+3)
    RMB: involving 10% of 1 core
    RMM: involving10% of the tissue (fragmented specimen).
    RMA: High-grade prostatic intraepithelial neoplasia.
    RLB: involving 25% of 1 core.
    RLM: involving 70% of the tissue
    RLA: involving 50% of 1 core.
    LMB: involving 80% of 1 core.
    Lesion #2, in 3 of 3 cores, involving 80%
    of total tissue
    RALP 6/5/19 USMD Arlington Dr Robert Parham
    Cath 6 days, bladder spasms, cath back in for 5 days
    Grade group 1, Gleason 6(3+3)
    SV, bladder neck invasion, adipose tissue, ECE, Margins, 0 of 8 lym- all negative, prostate confined~ PT2N0
    10% of prostate involved by tumor

    Quest Diagnostics: uPSA
    9/7/19 (3m) <0.02

  2. #2
    Quote Originally Posted by Honeybun078 View Post
    I've seen you guys mention some Uros due different types of psa testing.. Ie. Some that use. 0.00 or 0.0 When its time for our 3mth check , which particular psa testing should I request for most accurate? Want to make sure we are getting exactly what we need for testing
    I would suggest you get the 3 decimal test, but even that can get a little confusing. Some labs will go as low as <0.01, others <0.02, <0.03 or <0.05.

    Surprisingly the big cancer centers don’t test to very low values.
    YOB 1957

    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.

    3/6/19. Pathology - Grade Group 4 with Intraductal Carcinoma
    T3aNO, GS8, 21 mm unifocal tumor 10%. -7 Nodes, - SV, - Margins, - PNI,
    - bladder neck neg., +LVI, + EPE non focal apex/mid lateral 1mm max extension, Cribriform pattern present. Decipher .86 High Risk.

    PSA 3/27/19 03 (29 days)
    4/25/19 <.03. (58 days)
    5/25/19 <.02. (88 days)
    9/10/2019. <.02. (198 days)

    3 Part Modality Treatment

    2/25/19 Robotic Laparoendoscopic Single Site Surgery outpatient Cleveland Clinic,

    ADT - started 6/19, end date 6/21.

    ART - Completed 9/26/19. (78 Gy, yes, I glow in the dark)

  3. #3
    Hi Honeybun078! Discuss his post RP PSA monitoring program with Dr Parham. It is highly unlikely that monitoring via uPSA will be recommended.

    "Final path Grade group 1, no gleason upgrade Gleason 6(3+3)
    SV, bladder neck invasion, ECE, Margins, 0 of 8 lym- all negative, prostate confined~ PT2N0M0
    " = a very favorable post RP Path Report that does not support monitoring via uPSA methodology. uPSA can generate a lot of unnecessary "PSA Anxiety" as a result of slight bounces that have no clinical significance.

    Now is the time to relax and focus only on achieving complete recovery. Soon this prostate experience will slowly fade into the rear view mirror!

    PSA: Oct '09 = 1.91, Oct '11 = 2.79, Dec '11 = 2.98 (PSA, Free = 0.39ng/ml, % PSA Free = 13%)
    Referred to URO MD
    Jan '12: DRE = Positive: "Left induration"
    Jan '12: Biopsy = 6 of 12 Cores were Positive: 1 = G7 (3+4) and 5 = Gleason 6
    Referred to URO Surgeon
    March '12: Robotic RP: Left: PM + EPE. MD waited in surgery for preliminary Path Report then excised substantial left adjacent tissue(s) down to negative margins and placed 2 Ti clips for SR guidance, if needed in future.
    Pathology: Gleason (3+4) pT3a pNO pMX pRO c tertiary pattern 5 / Prostate Size = 32 grams / Tumor = Bilateral: 20% / PNI: present
    3 month Post Op standard PSA = <0.1 ng/ml
    1st uPSA at 7 months Post Op = 0.018 ng/ml
    uPSA remains "stable" at 91 Months Post Op: Mean = 0.022 (22x uPSAs: Range 0.017 - 0.032) LabCorp: Ultrasensitive PSA: Roche ECLIA
    Continence = Very Good (≥ 99%)
    ED = present

  4. #4
    Top User
    Join Date
    Aug 2016
    Quest post RP ultrasensitive is <0.02. It helps relieve the uncertainty of a 3 decimal test by not exposing the back ground noise evident at 3 decimal levels. If your PSA exceeds 0.02 it is highly likely to be considered detectable, indicative of recurrence, and allows for accepting new information that in some profiles treatment as early as 0.03 is beneficial.

    I will argue a distinction between the uncertainty of a very low 3 decimal test and testing anxiety in general. Test anxiety is unavoidable and normal, managable and an outcome of accepting responsibility for your healthcare. You can dismiss it once it has done its job if you are clear in its source. It exists with any test. The view that there is no anxiety as a result of ignorance of what is occuring is one of intentional deception and not true peace, imo.

    I do not accept some professional's view we need to be protected from the truth that affects us. My view is it is an unwillness to educate their patients or accepting a low opinion of our ability to understand. Neither are in our best interest as patients, imo. What we do know is the industry in general is doing a substandard job in public education, awareness, and screening. More importantly, we are allowing it.

    The protocol of <0.1 is too broad of a one size fits all approach given what we know of this disease. While it may fit most older men who have acted responsibly in early detection and early treatment, each of us may make our own choice based on a full understanding of its purpose and our individual circumstances. Be informed and have a plan and open and ready to change it.
    Last edited by Another; 06-18-2019 at 01:08 PM.

  5. #5
    Further to Another's comment above that anxiety will exist with any PSA test: You can make a case that the fewer the number of decimal places, any decreased anxiety over minor fluctuations and "noise" will be offset by the greater surprise you might get if your right-most digit does go up. Simply put, you may have less warning/lead time that your PSA is, in fact, trending up.

    It's curious that there is neither a consensus nor a best practice when it comes to the type of PSA test for following men after primary treatment. On the contrary, there is controversy about the use of uPSA tests. As Duck2 mentioned, most of the big cancer institutes either don't use it or use, e.g., a 2-decimal test with a LLD of, say, 0.05.

    For all but high-risk men, a 2-decimal test like Quest's is probably fine. However, to take Another's example, if you and your docs are thinking about possible salvage treatment at 0.03, IMO, you would be better served by a 3-decimal uPSA because of rounding uncertainties. A change from 0.02 to 0.03 could represent am actual change from 0.024 to 0.025; or it could be a jump from 0.020 to 0.034. So a PSA record like 0.02, 0.02, 0.02, 0.03, 0.03, 0.03 can mean different things. Is my PSA really going up significantly? If so, is it now steady at 0.03 or is it continuing to rise? Or has been steady around 0.024/0.025 all along?

    Keep in mind that a PSA test can measure a concentration equal to its LLD (lower limit of detection); anything smaller is reported as <LLD. So Quest's more sensitive test can report 0.02 (or greater) or <0.02, depending on your actual value. Likewise, the "pre-surgery" test often used for the first post-op PSA can return a value of 0.1 (and up) or <0.1.

    My suggestion is to use a PSA test that provides (at least) one digit to the right of the decimal place you're watching.

    Lastly, there was a study done that found that a post-RP nadir above or below 0.010 was a good statistical prognosticator that catagorized BCR risk. Clearly you need a sensitive uPSA test if that is of interest to you.

    Anyway, that's my take on it.
    Last edited by DjinTonic; 06-18-2019 at 02:06 PM.

  6. #6
    Wow. That was alot to try and understand. Lol.... You guys know your stuff. @Another @Djin to make sure I understand, you guys recommend the 3 decimal to watch trend. For ex 0.002 vs <0.2 or 0.02.. The first way(0.002) would show be more of a steady or if starts to trend up. I'm learning this lingo so simply a little for me lol😅

  7. #7
    Quote Originally Posted by Honeybun078 View Post
    Wow. That was alot to try and understand. Lol.... You guys know your stuff. @Another @Djin to make sure I understand, you guys recommend the 3 decimal to watch trend. For ex 0.002 vs <0.2 or 0.02.. The first way(0.002) would show be more of a steady or if starts to trend up. I'm learning this lingo so simply a little for me lol��
    Honeybun, Sorry if that was TMI . For you and your husband, I think you'll be fine with whatever PSA test your doc orders. You do not need a 3-decimal test! The official definition/mark of biochemical recurrence (BCR), the return of a concerning PSA after RP, is 0.2. Some men don't start their salvage RT until even higher values, like 0.4 or 0.5. So if your husband's first test is <0.1, for example, all is good--even with the one decimal place! The less-than sign (<) is the important thing with a one-decimal test.

    Keep in mind that some of our Forum Brothers hang around also because we are in a high-risk category after treatment. We have a greater risk of our PSA increasing in the future. More decimal places in our PSA results simply means we can spot an upward trend earlier, can better measure its rate of climb, and can take action (e.g. RT) at a lower value than other men who are not at the same risk level.

    Anyone with G6 prostate cancer confirmed by RP and with no adverse findings enjoys the lowest possible risk for any kind of recurrence. After a few years you'll be testing PSA yearly and PCa will become just a memory of something you dealt with.
    Last edited by DjinTonic; 06-18-2019 at 04:23 PM.

  8. #8
    In Dr. Walsh's 3rd edition of his tome on prostate cancer, he recommends against ultra sensitive PSA testing as leading to excessive anxiety.

    He hedges on this somewhat in the 4th edition, however.

    Your husband got a very favorable pathology report after his surgery. I don't think that most doctors will be very anxious to pull the trigger on salvage treatment at very low levels of PSA, as they might if he had a less favorable report.

    The problem is that you want salvage treatment or adjunctive treatment only if its necessary, as this is both expensive, and has its own side effects.

    If you do have the ultra sensitive tests, try not to get too anxious about it.
    Nov 2013 PSA 4.2 Biopsy Jan 2014- 1 core positive, 20% Gleason 6, doctor highly reco'ed robotic RP - 2nd opinion at UPMC April 2014, put on active surveillance. 2nd biopsy Feb 2015, results negative. PSA test Feb 2016, 3.5. 3rd Biopsy Feb 2016. 3 positive cores less than 5%, Gleason 6. Octotype DX done April 2016, GPS Score of 24--rated "Low risk". PSA test 8/2016, 3.2. PSA test 1/2018 2.2 (after 7 months of proscar) PSA test 7/2018 2.3, PSA test 7/2019 2.0

    DOB 1956, in Pittsburgh, USA

  9. #9
    Top User
    Join Date
    Aug 2016
    I test with <0.02. I have no interest in monitoring at a 3 decimal level.

    Your doctor will probably recommend a <0.1 which is most common. Ask if there is any value, due to his young age, to test with a more sensitive test. The reason I mention his young age is it can also be an indicator of a more aggressive cancer even though all you found early was G6. Something more aggressive has a higher probability of developing if not caught early when it begins so soon. The assumption is there is a very high probability you got it all and it all was G6. A more sensitive test now will show if you didn't and allow you to retreat while it may still is localized in the prostate bed.

    If your husband used testosterone or a product containing testosterone I'd recommend a more sensitive test than the <0.1. Testosterone is a wild card in all this and has a history fo creating an early onset of PC and also more aggressive hard to find stuff. So there is that.

    I tend to be aggressive in all things PC. It is a treatable and managable disease, and it makes no sense to me to be anything other than proactive.
    Born 1953
    family w/PCa; grandfather, 3 brothers
    07-12-04 PSA 1.90
    07-10-06 PSA 2.02
    08-30-07 PSA 3.20
    12-01-11 PSA 5.69 Internist recommends urologist, I say no
    05-16-12 PSA 4.76 manipulate w/diet & supplements
    12-11-12 PSA 5.20, Health system changes to 3 years on testing
    03-07-16 PSA 7.20 Internist adamant on urologist
    DRE smooth, enlarged
    03-14-16 TRUS biopsy-prostatic adenocarcinoma 1%-60% across 8 of 12 samples, Gleason 3+3=6
    03-31-16 MRI pelvis w/o dye
    05-04-16 DaVinci prostatectomy, nerve sparing, Dr. Kent Adkins - recommend
    Final Path; weight 65g, lymph nodes, seminal vesicles, capsule, margin all negative, Gleason 3+4=7, Tumor volume 35%, +pT2c
    Catheter out - 16 days
    Incontinence at 6mos is minimal – no pad
    Cialis 3x/wk & Viagra on occasion
    Begin self-injection needle therapy for erections, stop after 6 due to onset of Peyronie’s
    Erections 100% - 14 months
    5-21-19 PSA <0.02, Zero Club 3.5 years

  10. #10
    I don't believe he's taking any testosterone. Why would he be taking that? Is that for ED?


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