PSA Rising (I think) after RP - (SRT ???)
Four years after RP my PSA went from .06 - .09 - .10 in 3 month intervals. I had a consultation with a medical oncologist at Memorial Slone -Kettering Cancer Center (MSKCC). He referred me to an MSKCC Harvard Grad Radiation Oncologist (RO) specializing in urological cancers and a couple more sophisticated procedures. In short the RO recommended SRT. He also said it is a basic bread and butter procedure that any good board certified radiation oncologist could competently do (assuming that they do 3D conformal or IHRT). My local outpatient cancer center seems to fit the bill and I get very good feedback on one of their 4 radiation oncologists.
Before ending the consultation at MSKCC I asked if I should start immediately or take another PSA test? He said, "Radiation does not come without a cost. I would get another test and if the PSA did not bump up past the current .1, I would wait. With this sensitive test, I am not completely convinced your PSA is rising."
Well it did not bump up. I find it difficult however to conclude I have a .10 without PCa being somewhere. I have a consultation with my local Rad. Onc. in a week. What to do, what to do ???
History: Biopsy showing 4+4 Gleason 8. Lap RP Apr 2004, age 52 All neg margins, nodes, and structures. (T2a). Post RP PSA: <.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, 2011 .02, 2012 .02, ---- STARTED UP Feb 2014 .06, Jul 2015 .10, Oct 2015 .10, Feb 2015 .15, Jun 2015 .17, Dec 2015 .25
I found myself in a similar situation where at one point I wasn't sure. But then my PSA went up again, and I put things in motion.
I've read in several places (journal articles) that there is a certain percentage of men who will progress to 0.1 after RP and then not progress further. I can't find the articles right now, but on Google books I did find it in a textbook co-authored by Peter Scardino:
"While it is generally assumed that any detectable PSA level after radical prostatectomy represents persistent or progressive disease, this generalization may not always be true. Some men develop detectable but stable PSA levels that do not appear to progress...."
The authors then go on to detail a couple of studies, and conclude:
"...both (studies) suggest that some men develop a low but stable serum PSA after radical prostatectomy that fails to demonstrate an upward trend."
Source: Comprehensive Textbook of Genitourinary Oncology
By Nicholas J. Vogelzang, Peter T. Scardino, William U. Shipley, Frans MJ Debruyne, W. Marston Linehan
Contributor Nicholas J. Vogelzang, Peter T. Scardino, William U. Shipley
Published by Lippincott Williams & Wilkins, 2005
And it's true that there is some morbidity (side effects) associated with radiation, so the general cutoff point these days is 0.2 for declaring recurrence. Sometimes it's 0.2 and any subsequent rise.
Andrew Stephenson and others have shown that you want to start SRT before it hits 1.0, and optimally before it gets to 0.5. According to that measure, and the fact that there is a risk of side effects (see my blog for the side effects that happened to me), the MSK oncologist was exactly right.
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