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Scan clear after SBRT but 2 rises in PSA. What now?

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User
Posted 31 Aug 2020 at 10:39

In January my OH's PSA was 0.6 and we had a PSMA scan in Heidelberg which revealed cancer in one lymph node. He had 3 sessions of Stereotactic Body Radiotherapy in April and the day he finished we got the result of the psa test prior to the radiotherapy. It had jumped to 1.1 from 0.6 in January. This does not fit in with the doubling time he had (see profile) and was very worrying.

3 months later in July his scan was clear but his PSA was 1.3. The oncologist said to try again in a month as sometimes PSA can go up. It's now 1.5. 

I am trying not to have a panic attack here...I feel so frightened for us both. He has emailed the oncologist so now we have to wait till she gets back to us. My husband is still away doing jobs at our holiday cottage and I am back home with my 15 year old who is going back to school today. Life goes on and apart from this (and Covid) life is good. But I live with this permanent sense of dread which today is like something heavy sitting on my chest. 

My husband really hadn't wanted to do hormone therapy. He thinks mathematically for a living and is terrified he'll lose his edge....not to mention all the other side effects. Hes scared though he doesn't let on, but his increasing grumpiness gives the game away! I wear my heart on my sleeve and I can't bear to tell anybody this news. I'd love to hear that it isnt necessarily bad news yet...maybe a rise like this for a while after is normal? The scan is clear after all.

But I feel hormone therapy is the least of our worries...at all stages along the way his cancer has behaved aggressively. I have seen it though they never said it. Somebody here once told me that aggressive cancers respond better to radiotherapy...I think a maybe a John's Hopkins study showed this? Is there still room to hope? 

User
Posted 31 Aug 2020 at 14:17
It seems likely that the cancer was in more than just the one lymph node that could be seen at the time of the PSMA scan - PSA can rise a little after RT (think of it as like the cells screaming as they die) and this is known as PSA bounce but with no prostate, the PSA is high enough to conclude that systemic treatment is needed. The onco's skill will be in deciding the best time to start the HT - not too early that it stops working and not so late that the disease spreads unchecked.

Assuming the PSA has risen again at the next review, they may recommend chemo with the HT; for at least half of patients, the chemo makes the HT work better and for longer.

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

User
Posted 31 Aug 2020 at 20:32
SBRT can be done again if the target area is not in the same place as the previous shots. Whether or not it is a good idea or worthwhile depends on the oncologist's confidence that there aren't just many more tumours ready to pop up in other lymph nodes.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 31 Aug 2020 at 20:35

Originally Posted by: Online Community Member

Yes I think the urologist said it was an Adenocarcinoma. The reason I thought it was aggressive is the speed at which it developed. He went from a normal psa test to 4 in a year or maybe two at most (he had been having a psa test every year or two)and then up to 4.8 just a month later. I have no idea what PSA was when they took out prostate a further 7 months later. Then the return of cancer after 2.5 years, the fairly short doubling time which escalated even faster after this January and the fact that all the time his testosterone has been through the floor. 

 

PSA can't be used to judge how aggressive a cancer might be - you can have a PSA of 3 and mets all over the body or a PSA of 80 and no prostate cancer at all. As a G6 who may or may not have been upgraded to G7, his cancer would not be considered aggressive. It might be that the onco wants to check that it was indeed an adenocarcinoma. 

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

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User
Posted 31 Aug 2020 at 14:17
It seems likely that the cancer was in more than just the one lymph node that could be seen at the time of the PSMA scan - PSA can rise a little after RT (think of it as like the cells screaming as they die) and this is known as PSA bounce but with no prostate, the PSA is high enough to conclude that systemic treatment is needed. The onco's skill will be in deciding the best time to start the HT - not too early that it stops working and not so late that the disease spreads unchecked.

Assuming the PSA has risen again at the next review, they may recommend chemo with the HT; for at least half of patients, the chemo makes the HT work better and for longer.

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

User
Posted 31 Aug 2020 at 14:29

Originally Posted by: Online Community Member
But I feel hormone therapy is the least of our worries...at all stages along the way his cancer has behaved aggressively. I have seen it though they never said it. Somebody here once told me that aggressive cancers respond better to radiotherapy...I think a maybe a John's Hopkins study showed this? Is there still room to hope?

 

I think that is only part of a sentence ... some of the more rare & aggressive prostate cancers respond better to RT than others. One way or another, your OH's cancer would not usually fall into the aggressive group - it was G6 (3+3) with some elements of tertiary 4 seen at pathology and unless you have just never posted the details, I assume it is adenocarcinoma rather than a rare one? It is uncommon for a G6 to spread but not rare, in that sense.

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

User
Posted 31 Aug 2020 at 15:07

If it was me, I would do what you did before again, i.e. another PSMA PET scan, and SBRT if that finds something somewhere else.

User
Posted 31 Aug 2020 at 15:33

Thanks Lyn. Thats what I was afraid of. Would they no't have zapped the lymph nodes next to the one that had the visible cancer in it also as a precaution though?

I did wonder how they would know it was only in one LN for sure, when the cancer was too small for us to see the first time we had a PSMA pet scan.  (The Jan PSMA pet scan was our 2nd time getting one as nothing showed up first time)

I assumed that it could have spread beyond that one LN but had been reassured that they would have seen it as they now knew where to look. 

Is that it now? Are we just living with it until we aren't? Or is there any chance it may still improve? Why has the clear scan not resulted in any reduction in PSA...would it have jumped even higher without the SBRT? 

User
Posted 31 Aug 2020 at 16:08

Yes I think the urologist said it was an Adenocarcinoma. The reason I thought it was aggressive is the speed at which it developed. He went from a normal psa test to 4 in a year or maybe two at most (he had been having a psa test every year or two)and then up to 4.8 just a month later. I have no idea what PSA was when they took out prostate a further 7 months later. Then the return of cancer after 2.5 years, the fairly short doubling time which escalated even faster after this January and the fact that all the time his testosterone has been through the floor. 

User
Posted 31 Aug 2020 at 16:09

Will this be an option? Can you have SBRT more than once? 

User
Posted 31 Aug 2020 at 20:32
SBRT can be done again if the target area is not in the same place as the previous shots. Whether or not it is a good idea or worthwhile depends on the oncologist's confidence that there aren't just many more tumours ready to pop up in other lymph nodes.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 31 Aug 2020 at 20:35

Originally Posted by: Online Community Member

Yes I think the urologist said it was an Adenocarcinoma. The reason I thought it was aggressive is the speed at which it developed. He went from a normal psa test to 4 in a year or maybe two at most (he had been having a psa test every year or two)and then up to 4.8 just a month later. I have no idea what PSA was when they took out prostate a further 7 months later. Then the return of cancer after 2.5 years, the fairly short doubling time which escalated even faster after this January and the fact that all the time his testosterone has been through the floor. 

 

PSA can't be used to judge how aggressive a cancer might be - you can have a PSA of 3 and mets all over the body or a PSA of 80 and no prostate cancer at all. As a G6 who may or may not have been upgraded to G7, his cancer would not be considered aggressive. It might be that the onco wants to check that it was indeed an adenocarcinoma. 

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

User
Posted 31 Aug 2020 at 20:50

Originally Posted by: Online Community Member
Would they no't have zapped the lymph nodes next to the one that had the visible cancer in it also as a precaution though?

 

That isn't how SBRT works - it is designed to target one small affected area. It doesn't have a wide field that can be designed to include other bits of the body. 

Also, I think you are imagining that it spreads from one lymph node by jumping to the next one nearest to it but it doesn't work like that. The cancer cells flow around the body in the lymphatic fluid & lymph nodes pick up the cells to try and 'clean' the system so one affected node in the chest may be accompanied by affected nodes in the armpits and/or groin.

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

 
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