Biological recurrence definition

User

Posted 06 May 2020 at 13:49

Does anyone know the NHS/NICE definition of biological recurrence when the sensitive PSA assay is used please.

I think Lyn has quoted several times but I can't find it. Something like -0.2 or three consecutive rises or doubling time < 1 year. Not sure if it's the same for sensitive or non sensitive assays.

Cheers

Bill

User

Posted 06 May 2020 at 14:18

I think the commonly used values for prostatectomy are 3 consecutive rises above 0.1 or reaching 0.2

However, if there's some concern by the surgeon or from histology that cancer might have been left, then earlier rises can trigger actions at much lower levels.

User

Posted 06 May 2020 at 16:39

Bill

Have you had a recent test or are you reading too much into your last test. At my last test the nurse took two vials of blood from the same syringe. They went into two envelopes and were sent to the same hospital lab. The difference in the results was 0.01 (0.33 & 0.34).

Thanks Chris

User

Posted 06 May 2020 at 17:10

Thanks Andy and Chris

No recent test but I had the last one double checked two weeks later and it was the same .02. So that's a definite very slight increase. After three years of consecutive non detectables I trust the accuracy of the lab which is definitely the same one. Not panicking but next test and meeting is in three weeks and I just wanted to be able to quote and confirm the definition/guidance for the UK during the conversation.

Thanks again

Cheers

Bill

User

Posted 06 May 2020 at 22:18

The NICE guidelines are here, under 'managing relapse (paras 1.3.48 - 1.3.56) - https://www.nice.org.uk/guidance/ng131/chapter/Recommendations

The most recent version (2019) identifies all the things urology / oncology mustn't offer in the case of suspected biochemical relapse. It also states that the previous (2008) definition of BCR remains in force but if there is a rising PSA there should be at least 3 PSA tests over a period of 6 months to confirm. It also suggests that the PSA doubling time should be at 6 months or less before starting the man on HT. Unfortunately, the 2008 guidelines that it refers to are no longer available online but it was 2008 when they dropped the threshold from >0.4 to >0.2 which caused a fuss in Europe where many countries still use 0.4.

Beyond that, each Trust or CCG seems to publish their own criteria for BCR and thresholds for action:

Kent & Medway - >02
Birmingham - >0.2 or >0.1 and rising
West Midlands - >0.1 or 3 consecutive rises at usPSA

Worth checking your own Trust website to see what their stance is?

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User

Posted 06 May 2020 at 22:21

PS I see you are concerned at a rise from 0.01 to 0.02 - you are aware that hesistancy / inability to empty your bladder properly can raise your PSA slightly and that you are still 5x below the lowest threshold?

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User

Posted 06 May 2020 at 22:23

Doubling time is measured by at least 3 tests over a 6 month period and is faster than 6 months. 0.01 to 0.02 is not enough to register a doubling time.

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User

Posted 07 May 2020 at 02:27

My billion pound (PFI financed) super-hospital only tests to 0.1, so <0.1 is classed as undetectable, which has been my reading over the last two years.

I might be seeing slight changes if my tests were super-sensitive, but as they are not I am quite happy.

Ignorance is bliss!

Cheers, John.

User

Posted 07 May 2020 at 04:45

The question about PSA accuracy was asked at The FOPS support group last night. One of the consultants/surgeons said that after prostatectomy, it should be measured to at least 2 decimal places, or you can't follow the criteria to check for recurrance. His hospital can't do that in their lab, so samples from those patients are sent to one of the national cancer centres for analysis.

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User

Posted 06 May 2020 at 14:18

I think the commonly used values for prostatectomy are 3 consecutive rises above 0.1 or reaching 0.2

However, if there's some concern by the surgeon or from histology that cancer might have been left, then earlier rises can trigger actions at much lower levels.

User

Posted 06 May 2020 at 16:39

Bill

Thanks Chris

User

Posted 06 May 2020 at 17:10

Thanks Andy and Chris

Thanks again

Cheers

Bill

User

Posted 06 May 2020 at 22:18

The NICE guidelines are here, under 'managing relapse (paras 1.3.48 - 1.3.56) - https://www.nice.org.uk/guidance/ng131/chapter/Recommendations

Beyond that, each Trust or CCG seems to publish their own criteria for BCR and thresholds for action:

Kent & Medway - >02
Birmingham - >0.2 or >0.1 and rising
West Midlands - >0.1 or 3 consecutive rises at usPSA

Worth checking your own Trust website to see what their stance is?

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User

Posted 06 May 2020 at 22:21

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User

Posted 06 May 2020 at 22:23

Doubling time is measured by at least 3 tests over a 6 month period and is faster than 6 months. 0.01 to 0.02 is not enough to register a doubling time.

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User

Posted 07 May 2020 at 02:27

My billion pound (PFI financed) super-hospital only tests to 0.1, so <0.1 is classed as undetectable, which has been my reading over the last two years.

I might be seeing slight changes if my tests were super-sensitive, but as they are not I am quite happy.

Ignorance is bliss!

Cheers, John.

User

Posted 07 May 2020 at 04:45

User

Posted 07 May 2020 at 06:21

Thanks all for your replies

I'm not panicking about the rise yet. I just wanted to have the correct info so that Im properly informed during my next consultation or whenever if it crops up.

I started the new thread because I thought it would be useful to have the info to hand for all and not mixed up deep in other threads and hard to find

Thanks

Cheers

Bill

User

Posted 07 May 2020 at 14:04

Originally Posted by: Online Community Member

Clearly a local or personal stance as in other areas, the usPSA has been discredited and withdrawn, as Bollinge says.

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User

Posted 07 May 2020 at 15:32

Can we please have a definition of the PSA tests please. There are many of us on here who are tested to two decimal points and I didn't think that was Ultra sensitive.

Thanks Chris

Think I have just found my own answer.

By the late 1990s a third generation of PSA tests had arrived, the truly ultrasensitive PSA tests, capable of measuring PSA levels down to 0.01 ng/mL and lower. The clinical value of these tests outside research laboratories is open to some question, but they are much more sensitive than the original PSA tests.

Edited by member 07 May 2020 at 15:38 | Reason: Not specified

User

Posted 07 May 2020 at 16:05

As I have stated several times before, I asked my surgeon (a world-renowned figure), the senior prostate cancer oncologist at the Royal Marsden Hospital, and my local oncologist what they thought of super-sensitive PSA assay to umpteen decimal points.

They all concurred that it is more trouble than it’s worth, because of inaccuracies due to ‘noise’ and lab error factors, although the Royal Marsden guy conceded it might be of help in very limited cases.

When I see the anxiety and anguish it causes to men here when faced with infinitesimal increases in their super-sensitive results, I am very glad I’m not on that regimen.

When they tell me <0.1 is cancer free, I believe it, when and until I’m not!

Cheers, John.

User

Posted 07 May 2020 at 16:20

John

I have always had tests to two decimal points and it has always been a good guide to where I was heading and I sincerely hope you never get there. Had I been at your hospital at around eighteen months post op and " cancer free " I would had been told sorry you cancer is back.

From the definition quoted a reading below 0.01 is obtained from an ultra sensitive test a reading of 0.02 is not obtained from an ultra sensitive test. Or have I got it wrong.

Thanks Chris

User

Posted 07 May 2020 at 16:45

Anything that measures an amount less than 0.1 is considered ultra-sensitive. The ultra-ultra sensitive test is the one that measures lower than 0.01.Once you hit the threshold of 0.1, the second digit is considered to be relevant although as in the example you gave elsewhere, the difference between 0.32 and 0.33 from the same sample on the same day shows it still isn't completely reliable. Generally speaking, once you reach 1.0 they go back to just measuring to 1 dp (i.e. 3.5, 10.4) and round up or down.

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User

Posted 07 May 2020 at 17:19

Lyn

Sorry too be a pain, is it the ultra ultra sensitive test that has be discredited or the ultra sensitive test that has also been discredited. The test that Bollinge has could be exactly the same as I have ,but not reported in the same way. The two decimal point test is still widley used. It would be nice to see some papers on the merits of the different sensitivities.

Thanks Chris

User

Posted 07 May 2020 at 18:04

It is reporting to lower than 0.1 that has been discredited - not in all areas though

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User

Posted 07 May 2020 at 18:23

One nanogramme is one thousand millionths of a gram. 10 to the minus 9.

That's 0.00000001 of a gram

So .01ng is 100 times smaller than that.

Still, if someone has many undetectable results and then a couple that register anything at all it could be significant I think.

Cheers

Bill

User

Posted 07 May 2020 at 18:48

There are a few things I've picked up on this site which run opposite to my natural inclination. One is that RT can be as good as an operation in some cases. The other is that very sensitive psa testing might not be the best thing.

From what I've read testing below 0.03 is regarded as prone to error. Some say 0.03 should be a minimum. Hospitals tend to test to the capability of their machine it seems which is often 0.05 or so. Although some say it causes unnecessary worry as they won't do anything until it reaches the three consistent rises above 0.1 or reaches 0.2. They tend to use 0.1 even though their machine will do better it seems.

There is one member who got treatment at a very low level because his case had other factors. I don't know what would have happened if he'd been at the same hospital as me, but it seems an exceptional case.

My opinion is I'd want a warning if it was rising so anything above 0.03 would be of interest. If it went to 0.09 and they didn't know, then told you it was 0.15 you'd worry could have risen from 0.05 say, to 0.15 or 3 times perhaps in 6 months. That might also be worrying.

Mine is <0.05 and I'm happy with that. I'd be happy at a slightly higher threshold of measurement, although I think 0.1 is too close to the trigger level and I'd be uneasy.

User

Posted 07 May 2020 at 18:49

Or it could be that the machine has been calibrated between tests, a bit of infection, or whatever.

We have talked on here in the past about PSA not secreted by prostate cancer cells and the fact that breast milk contains PSA as does a woman's blood after orgasm. We also know that tiny amounts can be secreted from the adrenal glands but I was reading a paper on the Bartoli gland and Cowper's gland and noted that the Cowper's gland can also produce small amounts of PSA which may fit with the idea that OSA can be raised temporarily by orgasm, even in a post-RP man.

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User

Posted 07 May 2020 at 18:57

I don't deny that there were some sleepless nights when our area dropped usPSA and went to <0.1, particularly as J had already had a recurrence and was post salvage treatment. But we did get used to it and now it just seems normal, as if that was how it has always been. I guess that as time goes on, everyone has to learn to live with being someone who has had cancer that may come back and usPSA prolongs the agony of PSA test anxiety. Lots of cancers don't have a quick reference tool to give early warning that it may be recurring and those patients all have to learn to live with it.

The 2019 docs I was looking at yesterday said that something like 60% of men with BCR never go on to develop an actual recurrence and that salvage RT shouldn't be offered unless there are signs of problems other than just rising PSA

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User

Posted 07 May 2020 at 19:38

Peter

My post op PSA was 0.03 with a good chance of recurrence, so to me, having a two decimal point test gave me an indication of where I was going with no surprises. I have an attitude of if I can change a situation I will and if I can't I won't worry about it.

I understand not everyone will cope with that and as John often says ignorance is bliss.

Some interesting info there Lyn.

Bill

A grain of sugar weighs 625,000 nanograms.

Thanks Chris

User

Posted 07 May 2020 at 20:21

Quote:

colwickchris;239020

A grain of sugar weighs 625,000 nanograms.

Thanks Chris

I'm with you on this Chris. I think useful in certain circumstances.

If you have undetectable for several tests you begin to get confidence in the assay. I would think if other parts were secreting psa you wouldn't get undetected for many tests. So unless there is infection or something else involved a small rise is more significant

Cheers

Bill

Edited by member 07 May 2020 at 20:35 | Reason: Typo

User

Posted 07 May 2020 at 20:49

Some that I've picked up...

Luton and Dunstable hospital measures all PSA samples to 0.01

Royal Berks (Reading) measures post-prostatectomy patients to 0.004, and all others to 0.1

Mount Vernon measures to 0.1 (no prostatectomy patients).

Hillingdon Hospitals measures post-prostatectomy patients to 0.01 (externally), and all others to 0.1

The example at The FOPS, if I recall correctly (and I was distracted during this question), was someone G9 or 10 (can't recall) who's gone from 0.1 to 0.2, but without knowing the speed this happened from more precision, it wasn't possible to advise on the urgency of followup treatment, and hence if the patient should go on to hormone therapy now or not.

User

Posted 07 May 2020 at 22:31

Andy

At Nottingham my pre diagnosis tests were 6.9 ,7.7 but that's how they were reported, they may have been tested to two decimal points. All my post treatment tests have been to two decimal points.

Would it add quite a bit of additional work load to the labs if they had to sort samples into standard tests and super sensitive tests ?

On another site a member mentioned that the PSA test envelope requested an ultra sensitive test.

From my visit to the Christie a couple of years ago they only test to one decimal point although the prof there did say he preferred the two decimal point test.

Thanks Chris

User

Posted 08 May 2020 at 03:52

The premier cancer hospital in Britain, the Royal Marsden, only tests PSA to 0.04, and my reading was <0.04 when I was tested there about a year ago. All my subsequent tests here in Coventry have been <0.1 so should I be worried? 😉😂😷

Cheers, John.

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