I'm awaiting my 6-week post RP Ultra Sensitive PSA results (uPSA), so at after about 200+ hours of research prior to my treatment decision, I find myself taking a deep dive into yet another aspect of this disease - post surgery PSA. This thread came up in my search results and I'd like help clear things up as it appears this is a subject not easily understood. Probably due to the varied degrees that Urologists keep up with the latest data, which for the most part is easily accessible to us patients.
There are variances depending on your data source, but the general consensus in the Urologic Medical Community is that Biochemical Recurrence is defined as a reading of => 0.2 followed by a consecutive reading of > 0.2 post surgery. (For post Radiaton, it's 2.0 above your lowest reading - which can take 2+ years to reach your low.)
The problem is, while studies have shown adjuvant radiotherapy (getting radiation after surgery because you had high Gleason and/or T3 disease, no matter how low your PSA is) does not provide a significant benefit over early salvage radiation therapy. Further recent studies are showing that earlier is better for salvage radiation to maximize the chance it will be curative. This is one of many studies that discuss it if you want to educate yourself as it shows the different Hazard Ratio multipliers for all the different prognostic factors. Only the Gleason Score higher than 6 has a higher HR than the pre-salvage RT PSA.
https://ascopubs.org/doi/10.1200/JCO.2016.67.9647 (if you're not in the mood to read a long article, check out the second link I reference)
In my opinion, in the context of determining the need and timing for salvage radiation therapy, any Oncologist that wants to still "wait and see" when you've hit 0.1 is not up to date on the latest research.
There's tons of recent data out there. This article best sums it up in the Risk Factor Score Chart. As you can see, if you get your salvage RT super early, at 0.05, you only add 2.5 to the score. O.1 is only 2.5 more points. But as you go up to 0.2, now you are adding 5 points and have quadrupled from the 0.05 level. If you wait until your PSA reaches 1 to get your salvage radiation, you add a whopping 50 points to the score.
https://prostatecancerinfolink.net/2016/08/25/probability-of-remaining-recurrence-free-after-salvage-radiation/
In many cases you could go from a 0.05 to 0.1 or 0.2 in between PSA tests and then there will be a lead time before you can actually get treatment. So it turns out, predicting very early on with high confidence if you are going to very likely have a recurrence can be critical to maximize the chance your salvage radiation will be curative.
"...first post-op uPSA ≥0.03, Gleason grade, and T-stage independently predicted cBCR. First post-op uPSA ≥0.03 conferred the highest risk (HR 8.5, p<0.0001)... Defining failure at uPSA ≥0.03 yielded a median lead-time advantage of 18 months (mean 24 months) over the conventional PSA ≥0.2 definition... "
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4527538/
"In men with a PSA <0.1 ng/mL following RP, a ten-fold lower cutoff (0.01 ng/mL) stratified BCR-free survival and was a significant independent predictor of BCR as were pathological features."
https://www.practiceupdate.com/content/ultrasensitive-psa-measurements-may-predict-long-term-biochemical-recurrence-free-survival-following-radical-prostatectomy/29264
And as you can see from this study, the number of patients that were free from biochemical recurrence at 4 years was ZERO if their initial uPSA reading was => 0.02! In both high-risk and low/intermediate NCCN risks groups.
https://academic.oup.com/jjco/article/47/1/74/2527621
So from the data, we know, that if you have an initial uPSA after surgery of 0.02 you have a very high chance of biochemical recurrence - not for sure, but likely. If your uPSA is up to double that and goes up to 0.04 from there, you pretty much plan on a recurrence. Combine that with knowing your chances of salvage therapy being curative starts to significantly decline if you get your salvage therapy when your PSA has gone over 0.2. If your doubling times are long, then you have plenty of time to watch it creep up and get your salvage radiation scheduled before you hit a PSA of 0.2 but if your double times are short, then you probably want to be calling your Radiotherapy Oncologist when your PSA has hit => 0.04.
Waiting to make treatment decisions until you've hit an "old school" number of 0.2 defining "official" biochemical recurrence is not best practice these days based on the latest data. That is, if you want to maximize the chance you can still be cured.
Edited by member 15 Jul 2022 at 21:58
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