Bio chemical reoccurrence

[PeterG]

So after prostate removal over 5 years ago with undetected psa I know have a 0.2 for two tests in a row. I was given a ct with tracer and a pet with radiation marker. Both tests are negative. Oncologist sent me to consult with radiology and the recommended 20 sessions of “ salvage radiation “ treatments to my pelvic area.

It seems odd to not have a target to hit.

My oncologist says I can do the radiation or not and wait . She also said that I have gone from “ cured “ to “ Cancer Management “

Of course the radiologist wants me to have the treatment.

I’m tending to lean torwards my oncologist recommend.

There has been no movement in my psa since the .2 for 4 months .

Thoughts ?

[Consult1]

Sorry that you are in this position, especially considering the low risk pathology report.

I have no first hand experience, but if it were me I would be concerned that after 6 years there is a good chance that any leftover cancer cells may have migrated away from the prostate bed. I wouldn't want radiation in any area unless cancer was verified to exist there.

I would explore getting a PSMA Pet scan. The sensitivity is much better than what you had. I dont think its been FDA approved yet, but there are trials and opportunities to have the test done at some locations.

Good luck!

[Duck2]

You state .2 in the narrative and .02 in the signature. If you are .2 get treated now.

https://consultqd.clevelandclinic.or...oved-survival/

[PeterG]

Updated my signature

Thank you for the reply and link

[DjinTonic]

I would suggest that when typing decimal numbers less than one, we always use a leading zero. For example, 0.2 rather than .2, 0.34 rather than .34, and <0.1 rather than <.1 -- this is the way these numbers are always written and communicated in journals, scientific publications, math, etc.. The leasing zero serves as a check that the decimal point is in the correct position. Otherwise the reader may think a typo has been made, especially those accustomed to seeing a leading zero

Djin

[OldTiredSailor]

So after prostate removal over 5 years ago with undetected psa I know have a 0.2 for two tests in a row.

When you say "undetected" do you mean <0.1?

What was the date and PSA value immediately prior to the July 2019 value at 0.2?

OR - How long did it take to go from <0.1 to 0.2?

With only a single significant digit your 0.2 could be anywhere between 0.151 and 0.249.

What you really want to know now is - what is the trend in your current PSA? Is it continuing to increase?

[mikesimm]

I was in a similar situation, no target. That really confused me. In my situation, my PSA was 0.02, but I am high-risk due to seminal invasion. I finally decided to go ahead with the radiation (Proton) because I wanted to be able to look back someday if it comes back and be content that I did everything I could to kill it off.

The prostate bed is the target. Which means they are zapping "healthy tissue" and/or organs with the idea that any stray cancer cells will get caught in the crossfire. There's nothing else to shoot at!

I chose Proton because of the precision of the beam and there is no exit radiation. Protons release their energy at the target, and don't exit, unlike IMRT or similar. Maybe not a huge advantage, but any edge I can get, I'll take. Medicare pays for Proton (as of now... it is under discussion to cut Proton reimbursement to be equivalent to IMRT which will doom Proton treatments).

So I did 35 Proton treatments at MD Anderson. No problems at all... until about 3 months later when I started moderate leaking, even when just standing. Prior to radiation I was about 98% dry. So the beams set me back in the leaking department. I'm hoping it will resolve with time, but who knows. (I'm considering sling surgery next Spring if things don't get better.)

Your case IS a bit different since you are a lower risk, BUT you have the 0.2 PSA. I think most folks here would say... go do it. Yes, it's a pain in the butt. But I think you'll have better peace of mind.

The scans don't generally pick anything up at such low levels, to my knowledge. I had the fancy expensive one (Auxmin?) prior to Proton treatment and nothing was found.

I know it's a tough choice. I resisted. I saw 3-4 docs. Everyone I talked to said I should do it. So I did. I parked my RV south of Houston for two months and made an adventure out of it!

Happy to answer any questions your may have about Proton... if interested in that treatment.

Mike in Kerrville

[KarlEmagne]

Is a BCR after 5 years as likely as shortly after surgery to be caused by malignant growth in the pelvic area? They are shooting at a thing of which they don't know if it's there with guarantees only for the side effects.

If some tumor kept growing for another 5 years post RP, what's the rush to radiocute it? It already had ample time to spread, and if it didn't yet, why do we assume it would do so in the next year? Because the alternative is to wait and repeat a PET CT at a later time with higher PSA.

[DjinTonic]

Is a BCR after 5 years as likely as shortly after surgery to be caused by malignant growth in the pelvic area? They are shooting at a thing of which they don't know if it's there with guarantees only for the side effects.

If some tumor kept growing for another 5 years post RP, what's the rush to radiocute it? It already had ample time to spread, and if it didn't yet, why do we assume it would do so in the next year? Because the alternative is to wait and repeat a PET CT at a later time with higher PSA.

There is an argument to be made to wait until one's PSA is higher than 0.2 for the very reason that higher PSAs are more likely to result in positive scans. SRT done in the 0.2-0.5 range is still referred to as early SRT.

Djin

[Michael F]

So after prostate removal over 5 years ago with undetected psa I know have a 0.2 for two tests in a row. I was given a ct with tracer and a pet with radiation marker. Both tests are negative. Oncologist sent me to consult with radiology and the recommended 20 sessions of “ salvage radiation “ treatments to my pelvic area.

It seems odd to not have a target to hit.

My oncologist says I can do the radiation or not and wait . She also said that I have gone from “ cured “ to “ Cancer Management “

Of course the radiologist wants me to have the treatment.

I’m tending to lean torwards my oncologist recommend.

There has been no movement in my psa since the .2 for 4 months .

Thoughts ?

Hi PeterG! Sorry to see you return with BCR. Let's try to get this into proper perspective.

Several questions:

- What is your age?

- How frequently were you testing your PSA since surgery?

- Where do you get your PSA tested: MD's Office, Hospital Lab, Outside Lab?

- Do you get copies of the Lab Report?

- What is listed on the report? (As DjinTonic points out: ".2" is NEVER the way a PSA result is listed. It should be listed as "0.20"

- What was the date and value of your PSA prior to your 1st value of ".2" (the result before July 2019)?

Re "I was given a ct with tracer and a pet with radiation marker..:"

- Do you know which "tracer & marker" that were used? As Consult1 suggests, the newest type of scan = PSMA PET is the best at detecting recurrent PCa at very low PSA levels.
"Standard" CT scans and Bone Scans can not identify PCa at such low PSA levels.

The "good news" is it has taken > 5 years to reach BCR. Your last 3 consecutive PSAs appear to be stable at ".2" So you are not likely experiencing an aggressive recurrent PCa. If your latest scans were not state of the art, I would look into clinical trials that evaluate recurrent PCa following RP at very low PSA levels using the "PSMA PET" technology. My opinion is: it is important to pinpoint locate the site(s) of recurrence and treat them. Here is a link to the clinical trial website with the PSMA trials.

https://clinicaltrials.gov/ct2/resul...e=&city=&dist=

I'm NOT suggesting delaying treatment for any extended period of time. I'm suggesting looking into the option of identifying the exact location(s) of recurrence and determining if it can be treated focally with RT or other treatment modality.

Re "She (oncologist) also said that I have gone from “ cured “ to “ Cancer Management :“ I find this statement misleading, baffling and somewhat shocking. Because:

- You have experienced BCR, implies that you were never quite "cured." So, IMO, the Onc MD is incorrect.

- You are 6 years post primary treatment (RP) without ART/SRT and/or ADT. The RO should be focused on offering a high % possibility of Complete Cure and not solely management of disease. I would seek another opinion asap.

If you have any doubts, get a 2nd opinion consultation at a top Tier Urology Program from a URO Oncologist who specializes in treating PCa.

Keep asking questions and demand correct answers.

Keep us updated on this "2nd PCa Journey."