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Five months post-op and PSA is 0.142

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User
Posted 31 Aug 2021 at 15:14

Seeking some insights from the experienced men and women on here, please....


My story in brief; random PSA done by GP late last year was mildly elevated at 4.9 (repeat 'normal' at 3.5). No symptoms. Positive mpMRI, negative PSMA pre-op. Transperineal biopsies had detected 3+4 on one side only. At op (April 2021) 4+3 on both sides and localised. Margins clear, apex narrowly clear (<0.1mm) - surgeon performed an "aggressive nerve sparing procedure" with Neurosafe but yet to reap the benefit of that.


Post-op PSAs 0.152ug/L at six weeks, 0.120ug/L at three months and last week's result was 0.142ug/L. Surgeon "not overly concerned as it does seem stable although I was expecting it to go a bit lower. I think we should repeat it in 3 months time. If we do get concerned then we can always look to do another PSMA PET scan but I don't think we are at that stage yet".


Any thoughts? Are these sorts of levels post-op 'normal'? Is an 18% rise (albeit from a low base) over two months 'okay'(ish)?

Edited by member 02 Apr 2023 at 10:42  | Reason: Not specified

User
Posted 31 Aug 2021 at 21:01
If you were my brother or partner, I would be hitting the roof! You should have been referred to oncology already - your PSA is some 10 times higher than it should be so you clearly still have active cancer cells and need adjuvant radiotherapy or more detailed scans to look for mets. It seems to me that your urologist may have a bit of an ego and doesn't want to acknowledge that the surgery failed.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 28 Feb 2023 at 14:39

I had salvage RT without the possible benefits of a PSMA scan. After 33 sessions the PSA did drop for a while but the rose again, a PSMA scan last year found a pelvic tumor which had further SABR treatment.


I would say the purpose of salvage RT is curative and for some it is successful. Changes in treatments mean failed SRT like my case, mean other attempts can be made to cure before moving on to control.


Hope all goes well.


Thanks Chris 

User
Posted 20 Mar 2023 at 20:28
Interesting that your MDT team have decided not to perform salvage therapy until they could detect something on a scan. I would be interested to know on what research they have based that decision. PSMA scans are not great at detecting prostate bed recurrence because of the noise associated with the bladder (According to one of the oncos I have seen).





User
Posted 04 Feb 2024 at 13:05

It’s been a while since last post and not feeling very optimistic about whether salvage R/T (SRT) two years after RARP has been at all helpful. My PSA was never very high to begin with - one abnormally high at 4.9 that subsequently fell back on repeat to 3.4 a week later.


Now 9 months since completion of SRT and my PSA which persisted post-RARP, then started climbing (which led to repeat PSMA-scan showing avidity in prostate bed and pelvic nodes) and so SRT earlier this year.


Been checking PSA six weekly (on advice of specialist nurses here). Results below:-
Immediate pre-SRT PSA was 0.334 20/3/2023. SRT ended 05/05/2023


Results since:-


0.365 16/06/2023
0.274 21/07/2023
0.193 23/10/2023
0.160 04/12/2023 NADIR by the looks of it
0.202 15/01/2024 Next PSA due in three weeks…


I have an appointment soon with the oncologist. What do you reckon are the key questions to ask now with the PSA going up yet again?

Edited by member 04 Feb 2024 at 13:09  | Reason: Not specified

User
Posted 01 Sep 2021 at 02:16
Wise words from our Matron above.

Your PSA should be undetectable following prostatectomy, so the fact that it is not and is increasing shows you still have a problem which follow-up treatments will hopefully sort out.

Don’t wait any longer, and seek out an oncologist toute-de-suite. I presume you went privately for your surgery.

Best of luck.

Cheers, John.
User
Posted 30 Jan 2023 at 19:40

Your PSA readings seem to have been rising quite slowly but this latest reading is a significant jump. As Lyn said in 2021 you still have active cancer cells in there and you PSA should now high enough to get a PSMA PET scan. There is no guarantee that the scan will show up any indications of PCa but it is better to know what you are targeting with SRT than going for a shot in the dark. However sometime you don't have any option other than a shot in the dark.


My first PSA reading post op was 0.28. I had a PSMA when my PSA was around 0.45 but it didn't show anything up. It started to rise rapidly after that so my Onco recommended SRT to the prostate bed with six months of HT. A shot in the dark approach but as I had a positive margin on the prostate histology it was a pretty educated guess. I just have to hope there is no further lymph node involvement. My PSA is currently undetectable but that is down to HT.

User
Posted 20 Mar 2023 at 20:20

Hopefully your radiotherapy team should be giving you a lot of information of what to expect along the way. If not, do ask. Side effects don't kick in straight away but at around session ten your bowels are probably going to start getting a bit loose and volatile. Holding the full bladder will start getting more difficult as your bladder gets irritated. They may give you Solifenacin to help this. You are going to start feeling tired. The extent of these symptoms is going to vary from person to person. My bowels took a good four months to settle down and I'm still a lot more gassy than I used to be (that said, I'm eating my normal diet). The other thing I found is my continence has deteriorated and still isn't where it was prior to RT (I finished my sessions at the end of October last year). My next PSA test is tomorrow, so fingers crossed.

User
Posted 02 Apr 2023 at 11:23

"There seems to be scant evidence, too, about dose ranging in radiotherapy - why 66Gy over 33 fractions? What happens if less is given? More does not seem to make a difference. Why not less - were dose ranging studies ever done in prostate cancer?"


Actually, there is a whole raft of research data for this. 66GY over 33 fractions is apparently your oncologist's preference. Standard for many years was 74Gy over 37 fractions; more recently, research has shown that 19 or 20f at 3Gy or 3.2Gy is just as effective but with fewer side effects. You would need to ask your onco why he chose 33f in your case

Edited by member 02 Apr 2023 at 11:24  | Reason: Not specified

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 02 Apr 2023 at 12:01

Originally Posted by: Online Community Member


...I'd welcome thoughts on the value of having a second opinion at this stage and/ or review of previous scans and pathology as I am really unclear now what stage of disease I have or what it means for my prognosis. 



Once you have started on RT you do not want to be stopping or interrupting it. The cancer cells must not have a chance to recover.


I can't see much value in reviewing old data. Once this treatment is finished, you may or may not be cured. What your scans or pathology were pre treatment is now irrelevant. If you end up with a PSA of 0.0 that is great, if not - well cross that bridge when you get there.

Dave

User
Posted 02 Apr 2023 at 12:05

Salvage RT doses are slightly lower than radical radiotherapy doses.


How was the original RT dose arrived at? That has an interesting answer.


The experimentation was done in France using rams. The idea was to treat their testicles as a cancer, and to treat them with radiotherapy such that they were sterilised without doing any further harm.


The single dose (fraction) required to sterilise ram testicles did a lot of skin damage and tissue damage around the testicles. So what they did instead was to spread the dosing over multiple fractions. This eventually arrived at the standard 2Gy per fraction, as a dose which didn't cause serious skin damage, but would accumulate in the target organ over several fractions do achieve the desired effect (sterilising rams in this case).


Radiotherapy has changed since then, with the current use of VMAT (treating the prostate continuously while moving the radiation source in a full circle around the body) meaning skin doses are way below the 2G/fraction which is achieved in the target organ, and usually no skin damage occurs. Also it was found that prostates benefit from higher dose per fraction than most other organs. This lead on to hypofractionation (using fewer doses of higher power). However, the basic 2Gy/fraction derived from the French ram tests still survives for many treatments. In the context of prostate cancer, 2Gy/fraction is used when the target includes other tissues such as lymph nodes, bladder, etc, and always in the case of salvage treatment to the prostate bed where there is no prostate. When the target is just the prostate, 3Gy/fraction (20 fractions) has become standard, and SABR/SBRT with 7 or more Gy/fraction (about 5 fractions) is rolling out in some centres. If you can avoid the radiotherapy going through other organs as in the case of brachytherapy, HDR is typically done as 15Gy x 2 fractions.


Lower total dose is needed the shorter the period over which it's given and higher dose/fraction, for the same treatment effect. This is demonstrated at the two extremes with HDR brachy needing 30Gy total over a period of 24h, and LDR brachy needing about 170Gy over a period of 200 days, these two being similar treatment effect. You can also see this with the classic EBRT: 37 (7½ weeks) x 2Gy fractions = 74Gy total, and 20 (4 weeks) x 3Gy fractions = 60Gy total being the same treatment effect.

Edited by member 02 Apr 2023 at 12:35  | Reason: Not specified

User
Posted 02 Apr 2023 at 14:48

Originally Posted by: Online Community Member
2Gy/fraction is used when the target includes other tissues such as lymph nodes, bladder, etc, and always in the case of salvage treatment to the prostate bed where there is no prostate. When the target is just the prostate, 3Gy/fraction (20 fractions) has become standard,


 


That may be true at some hospitals but not all. John's SRT was to prostate bed, nearby lymph nodes and the bottom of his bladder - he had 20 fractions at 3.2Gy - judging from various members on here, onco preference clearly comes into play 

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 20 Jun 2023 at 19:29
You may perhaps not understand the way that RT works. It doesn't kill cancer cells directly; what it does is to damage the DNA of ALL the cells in the areas targeting. Normal cells can repair their DNA, but in cancer cells the repair mechanism is usually faulty, and so eventually the damaged cell dies. The key word here is "eventually" - the process can take a year to 18 months, so do expect an instant fall in your PSA; it will probably be a slow and steady fall.

Best wishes,

Chris
User
Posted 04 Feb 2024 at 16:08
Questions I would ask are:
Did the SRT include pelvic lymph nodes?
If not, if there is a recurrence are you eligible for SABRE treatment of any nodes that may eventually show up?

I would also be thinking about a second opinion, your team have consistently taken a non standard approach eg. Waiting until recurrence was detected on a scan instead of treating immediately your PSA didn't go to zero and not having Hormone therapy with the SRT. These decisions may have been correct for your case but I would want to check so you can have confidence in whatever treatment decisions may come next.

PS what are of the UK are you in?
User
Posted 04 Feb 2024 at 20:44
It can take 18 months for the RT to take full effect so your PSA may rise & fall a few times before you really know whether it has been successful.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
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User
Posted 31 Aug 2021 at 21:01
If you were my brother or partner, I would be hitting the roof! You should have been referred to oncology already - your PSA is some 10 times higher than it should be so you clearly still have active cancer cells and need adjuvant radiotherapy or more detailed scans to look for mets. It seems to me that your urologist may have a bit of an ego and doesn't want to acknowledge that the surgery failed.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 01 Sep 2021 at 02:16
Wise words from our Matron above.

Your PSA should be undetectable following prostatectomy, so the fact that it is not and is increasing shows you still have a problem which follow-up treatments will hopefully sort out.

Don’t wait any longer, and seek out an oncologist toute-de-suite. I presume you went privately for your surgery.

Best of luck.

Cheers, John.
User
Posted 30 Jan 2023 at 18:49

I haven't posted since August 2021. Been under regular review by surgeon and oncologist


Review by MDT and Urology oncologist since last post with repeat PSMA (April and October 2022) scans not showing any 'avidity'. Last seen by oncologist in November 2022 when PSA was 0.280 with a plan to repeat PSA in three months (i.e. Jan 2023) and repeat PSMA scan in six months. Oncologist said radiation not indicated/ recommended in the absence of any evidence of lesions on scan.


PSA re-checked last week and has jumped to 0.480ug/ L. Have written to oncologist this evening again to query whether the PSMA scan should be brought forward.


I feel that in the absence of any obvious evidence of recurrence (or persistent?) PCa, the specialists are reluctant to initiate other treatment. If scans are negative (again), is it not simply shooting in the dark?


Clearly anxious given further rise in PSA and realise that in this 'grey' zone with further negative tests, that there is no clear guideline on what should be done.


Would welcome replies from anyone in a similar, 'uncertain' situation... thanks. 


 

User
Posted 30 Jan 2023 at 19:40

Your PSA readings seem to have been rising quite slowly but this latest reading is a significant jump. As Lyn said in 2021 you still have active cancer cells in there and you PSA should now high enough to get a PSMA PET scan. There is no guarantee that the scan will show up any indications of PCa but it is better to know what you are targeting with SRT than going for a shot in the dark. However sometime you don't have any option other than a shot in the dark.


My first PSA reading post op was 0.28. I had a PSMA when my PSA was around 0.45 but it didn't show anything up. It started to rise rapidly after that so my Onco recommended SRT to the prostate bed with six months of HT. A shot in the dark approach but as I had a positive margin on the prostate histology it was a pretty educated guess. I just have to hope there is no further lymph node involvement. My PSA is currently undetectable but that is down to HT.

User
Posted 10 Feb 2023 at 13:13
Thanks, Chris. PSMA scan on the 18th and oncologist has scheduled a review on Feb 22nd.

Does anyone know if there are any ongoing clinical studies looking at this grey zone with scans remaining (possibly falsely) negativebut PSA persisting then increasing post 'curative' prostatectomy?

The proverbial horns of a dilemma....
User
Posted 28 Feb 2023 at 12:44

PSMA scan positive with avidity in the prostate bed and also at left ureter adjacent to bladder. Is this classed as a metastasis? Having gone through 'curative' prostatectomy, I am now being scheduled for intensive (again "curative") radiotherapy ( x5/ week for 6.5 weeks). Am not clear if this should be classed as 'curative' or is it now just salvage radiotherapy?


Any practical suggestions for this next stage of treatment from anyone who has had similar intensive R/T after a radical prostatectomy?

Edited by member 28 Feb 2023 at 13:24  | Reason: For clarity

User
Posted 28 Feb 2023 at 14:39

I had salvage RT without the possible benefits of a PSMA scan. After 33 sessions the PSA did drop for a while but the rose again, a PSMA scan last year found a pelvic tumor which had further SABR treatment.


I would say the purpose of salvage RT is curative and for some it is successful. Changes in treatments mean failed SRT like my case, mean other attempts can be made to cure before moving on to control.


Hope all goes well.


Thanks Chris 

User
Posted 28 Feb 2023 at 18:42
Adjuvant RT and salvage RT are intended to be curative. RT given only to reduce symptoms is called palliative RT. You are not in the palliative care group.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 01 Mar 2023 at 16:52
Thanks, Chris and Lyn.

Oncologist today said they would not have intervened earlier (i.e. gone blind) but continued with PSMA scans and PSA monitoring until the situation became clearer.

Surprising to see onscreen how much obvious change had occurred between the negative scan in October '22 and the positive one in Feb '23. So, the team is "now able to target SRT" and 50:50 odds given for curative RT by oncologist. I thought/ had hoped the odds would be better. It's funny how a lot of people say PsCa is 'one of the good ones' to have - I guess they mean 3+3 or less? It may not be as dramatic as some other cancers but it does very much seem to play the long game...

Does anyone know if it is possible to assess how long a tumour (graded 3+4 pre-op and upgraded to 4+3 post op) might have been present before diagnosis? Especially frustrating when asymptomatic and suspected only after a one-off abnormal PSA of 4.9 that dropped to 'normal' (3.4) a week later and pre-op was a pretty unspectacular 3.2? So much prognostic weight seems to be given to high pre-op PSAs (> 10) but clearly other factors beyond this must be key or even more important?

Speaks to why better/ earlier detection/ intervention are so important, It calls for 'smarter' screening - but of what? Hopefully, too, when we know what gets the little bugger going, prevention might become an option. Wouldn't that be great for our sons and grandsons?
User
Posted 20 Mar 2023 at 17:30

Pre-radiotherapy repeat PSA this morning. First R/T session (of 33) this afternoon which seemed very innocuous. Any practical suggestions/ advice on how best to manage the R/T process as it progresses incl. side-effects from those who've had to go down this route post-surgery? Thanks in advance.

User
Posted 20 Mar 2023 at 20:20

Hopefully your radiotherapy team should be giving you a lot of information of what to expect along the way. If not, do ask. Side effects don't kick in straight away but at around session ten your bowels are probably going to start getting a bit loose and volatile. Holding the full bladder will start getting more difficult as your bladder gets irritated. They may give you Solifenacin to help this. You are going to start feeling tired. The extent of these symptoms is going to vary from person to person. My bowels took a good four months to settle down and I'm still a lot more gassy than I used to be (that said, I'm eating my normal diet). The other thing I found is my continence has deteriorated and still isn't where it was prior to RT (I finished my sessions at the end of October last year). My next PSA test is tomorrow, so fingers crossed.

User
Posted 20 Mar 2023 at 20:28
Interesting that your MDT team have decided not to perform salvage therapy until they could detect something on a scan. I would be interested to know on what research they have based that decision. PSMA scans are not great at detecting prostate bed recurrence because of the noise associated with the bladder (According to one of the oncos I have seen).





User
Posted 02 Apr 2023 at 10:35

Thanks chrisbromsgrove and francij1....


I have been turning this over - a lot - in my head and am really not happy with the delay in initiating further treatment with salvage R/T or possibly earlier adjuvant R/T. I had my op privately two years ago (April Fool's Day 2021) and really do question now whether I have really had any proper MDT consideration since then. I've been told MDT was involved but, really, was it?


Also, with nodal involvement now showing up on the pre-salvage PSMA scan, does this mean I am Stage IVa? Pathology changed the GS from 3+4 to 4+3 and one of the margins was narrowly clear < 0.1mm...


To boot, I started having GI symptoms early on during first week of salvage treatment. This weekend, (after 10 treatments only - another 23 to go), I feel pretty crappy - no pun intended. I am having to go urgently to the toilet about 8 times a day (including twice last night). There is a lot of mucous and since yesterday some blood is clearly visible too. As a result, I've been reading up on radiation proctopathy/ proctitis and it is not a pretty story. Having had the prostatectomy means that my gut is even more exposed to the damaging effects of radiotherapy to the prostate bed (no prostate to 'buffer' the rectum) and pelvic nodes.


There seems to be scant evidence, too, about dose ranging in radiotherapy - why 66Gy over 33 fractions? What happens if less is given? More does not seem to make a difference. Why not less - were dose ranging studies ever done in prostate cancer? 


I'd welcome thoughts on the value of having a second opinion at this stage and/ or review of previous scans and pathology as I am really unclear now what stage of disease I have or what it means for my prognosis. Curiously, my PSA which had gone up to 0.480 in January 2023 dropped ahead of SRT to 0.334 on 20th March (historically the 6 week post op value was 0.152, then what (in retrospect) was a pretty pathetic nadir of 0.120 in June 2021. This was followed by the 'watch and wait' approach by surgeon and oncologist while the values were:-


0.142 24 Aug 2021


0.132 24 Nov 2021


0.218 30 March 2022


0.198 7 June 2022


0.282 18 Aug 2022


0.280 27 Oct 2022


0.480 27 Jan 2023 and the value immediately before SRT started on 20 March, 0.334


Have I been April Fooled for the last two years - feels like it at the mo......

User
Posted 02 Apr 2023 at 10:40
As a PS to the above, does anyone have experience of the value of genomic testing?
User
Posted 02 Apr 2023 at 11:23

"There seems to be scant evidence, too, about dose ranging in radiotherapy - why 66Gy over 33 fractions? What happens if less is given? More does not seem to make a difference. Why not less - were dose ranging studies ever done in prostate cancer?"


Actually, there is a whole raft of research data for this. 66GY over 33 fractions is apparently your oncologist's preference. Standard for many years was 74Gy over 37 fractions; more recently, research has shown that 19 or 20f at 3Gy or 3.2Gy is just as effective but with fewer side effects. You would need to ask your onco why he chose 33f in your case

Edited by member 02 Apr 2023 at 11:24  | Reason: Not specified

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 02 Apr 2023 at 12:01

Originally Posted by: Online Community Member


...I'd welcome thoughts on the value of having a second opinion at this stage and/ or review of previous scans and pathology as I am really unclear now what stage of disease I have or what it means for my prognosis. 



Once you have started on RT you do not want to be stopping or interrupting it. The cancer cells must not have a chance to recover.


I can't see much value in reviewing old data. Once this treatment is finished, you may or may not be cured. What your scans or pathology were pre treatment is now irrelevant. If you end up with a PSA of 0.0 that is great, if not - well cross that bridge when you get there.

Dave

User
Posted 02 Apr 2023 at 12:05

Salvage RT doses are slightly lower than radical radiotherapy doses.


How was the original RT dose arrived at? That has an interesting answer.


The experimentation was done in France using rams. The idea was to treat their testicles as a cancer, and to treat them with radiotherapy such that they were sterilised without doing any further harm.


The single dose (fraction) required to sterilise ram testicles did a lot of skin damage and tissue damage around the testicles. So what they did instead was to spread the dosing over multiple fractions. This eventually arrived at the standard 2Gy per fraction, as a dose which didn't cause serious skin damage, but would accumulate in the target organ over several fractions do achieve the desired effect (sterilising rams in this case).


Radiotherapy has changed since then, with the current use of VMAT (treating the prostate continuously while moving the radiation source in a full circle around the body) meaning skin doses are way below the 2G/fraction which is achieved in the target organ, and usually no skin damage occurs. Also it was found that prostates benefit from higher dose per fraction than most other organs. This lead on to hypofractionation (using fewer doses of higher power). However, the basic 2Gy/fraction derived from the French ram tests still survives for many treatments. In the context of prostate cancer, 2Gy/fraction is used when the target includes other tissues such as lymph nodes, bladder, etc, and always in the case of salvage treatment to the prostate bed where there is no prostate. When the target is just the prostate, 3Gy/fraction (20 fractions) has become standard, and SABR/SBRT with 7 or more Gy/fraction (about 5 fractions) is rolling out in some centres. If you can avoid the radiotherapy going through other organs as in the case of brachytherapy, HDR is typically done as 15Gy x 2 fractions.


Lower total dose is needed the shorter the period over which it's given and higher dose/fraction, for the same treatment effect. This is demonstrated at the two extremes with HDR brachy needing 30Gy total over a period of 24h, and LDR brachy needing about 170Gy over a period of 200 days, these two being similar treatment effect. You can also see this with the classic EBRT: 37 (7½ weeks) x 2Gy fractions = 74Gy total, and 20 (4 weeks) x 3Gy fractions = 60Gy total being the same treatment effect.

Edited by member 02 Apr 2023 at 12:35  | Reason: Not specified

User
Posted 02 Apr 2023 at 14:48

Originally Posted by: Online Community Member
2Gy/fraction is used when the target includes other tissues such as lymph nodes, bladder, etc, and always in the case of salvage treatment to the prostate bed where there is no prostate. When the target is just the prostate, 3Gy/fraction (20 fractions) has become standard,


 


That may be true at some hospitals but not all. John's SRT was to prostate bed, nearby lymph nodes and the bottom of his bladder - he had 20 fractions at 3.2Gy - judging from various members on here, onco preference clearly comes into play 

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 05 Apr 2023 at 17:31
Thanks, Lyn and Andy for such detailed information. It's clearly a very complex area and one, I suspect, will evolve with time and correlation of outcomes with radiotherapy regimens. The centre-to-centre variations mentioned by Lyn brings me back to my original query on dose-ranging - as opposed to some overall total to be achieved in various ways - at least for EBRT. I can see the difficulties in doing such studies in men but as so often in Medicine, what works in the lab or in an animal (mouse, rat, primate or maybe even a ram) may not translate directly to the human species.

That said, as my skin is becoming a bit sensitive, I'm pleased not to be a French ram! 2Gy a pop looks as if it might be my own cutaneous cut-off!

Onwards and upwards - only another 20 sessions (40Gy) to go....
User
Posted 19 Jun 2023 at 10:55
So, haven't posted since April (salvage radiotherapy started March 20th)

Had my 33 zaps of 2Gy a pop (66Gy total) which finished on May 5th. Had my first post-salvage radiotherapy PSA test on Friday June 16th, so six weeks after last dose of R/T.

Pre-R/T values had been

20th March 2023 prior to first dose of R/T - 0.334 ug/L (it had been 0.480 in January 2023)

16th June 2023 six weeks after end of R/T - 0.365 ug/ L

Doesn't look great, does it? Any thoughts, anyone?
User
Posted 19 Jun 2023 at 20:38

Hi Jimmeydee. I hope you are steadily recovering from the RT side effects. Bowel issues do tend to linger. I am assuming your SRT has not included six months of HT. Otherwise your PSA would be more or less undetectable at this stage. As far as the RT is concerned it is still very early days. The radiation doesn't kill the cancer cell outright. It  damages the DNA to such an extent it can't repair and can't divide and eventually dies. The next test should start to show some results.

User
Posted 19 Jun 2023 at 20:51
RT without HT can increase PSA for a while due to cell death releasing PSA. Upshot is too early to tell, take comfort it has gone down from the Jan figure.
User
Posted 19 Jun 2023 at 22:11

Thanks, Chris - fingers crossed 

User
Posted 19 Jun 2023 at 22:14

Yep down from the Jan figure which was higher than the immediate pre-RT figure. Maybe I am being too impatient for the six week result? Yet to hear from the oncologist…

User
Posted 19 Jun 2023 at 22:48
6 week result is unreliable - it will be the result in 12 to 18 months that will be most important
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 20 Jun 2023 at 19:29
You may perhaps not understand the way that RT works. It doesn't kill cancer cells directly; what it does is to damage the DNA of ALL the cells in the areas targeting. Normal cells can repair their DNA, but in cancer cells the repair mechanism is usually faulty, and so eventually the damaged cell dies. The key word here is "eventually" - the process can take a year to 18 months, so do expect an instant fall in your PSA; it will probably be a slow and steady fall.

Best wishes,

Chris
User
Posted 04 Feb 2024 at 13:05

It’s been a while since last post and not feeling very optimistic about whether salvage R/T (SRT) two years after RARP has been at all helpful. My PSA was never very high to begin with - one abnormally high at 4.9 that subsequently fell back on repeat to 3.4 a week later.


Now 9 months since completion of SRT and my PSA which persisted post-RARP, then started climbing (which led to repeat PSMA-scan showing avidity in prostate bed and pelvic nodes) and so SRT earlier this year.


Been checking PSA six weekly (on advice of specialist nurses here). Results below:-
Immediate pre-SRT PSA was 0.334 20/3/2023. SRT ended 05/05/2023


Results since:-


0.365 16/06/2023
0.274 21/07/2023
0.193 23/10/2023
0.160 04/12/2023 NADIR by the looks of it
0.202 15/01/2024 Next PSA due in three weeks…


I have an appointment soon with the oncologist. What do you reckon are the key questions to ask now with the PSA going up yet again?

Edited by member 04 Feb 2024 at 13:09  | Reason: Not specified

User
Posted 04 Feb 2024 at 16:08
Questions I would ask are:
Did the SRT include pelvic lymph nodes?
If not, if there is a recurrence are you eligible for SABRE treatment of any nodes that may eventually show up?

I would also be thinking about a second opinion, your team have consistently taken a non standard approach eg. Waiting until recurrence was detected on a scan instead of treating immediately your PSA didn't go to zero and not having Hormone therapy with the SRT. These decisions may have been correct for your case but I would want to check so you can have confidence in whatever treatment decisions may come next.

PS what are of the UK are you in?
User
Posted 04 Feb 2024 at 18:08

Jimmy, do you know what tracer was used with your PSMA scan. My first scan was the 18f 100?, which picked up one lymph node tumor, 10 months later Gallium 68 tracer picked up the second lymph node tumor and showed some avidity in the first tumor. The G68  scan also said, no avidity shown in the prostate bed, but as we know, seeing nothing does not mean nothing is there. I did have 6 months of bicalutamide with my second SABR treatment.


My scans were at a much higher PSA  level than yours. I had the educated guess SRT, which appears to have been the right thing to do. 


It did take my PSA a lot longer than yours to rise following treatments. Near the beginning of my profile lists all my PSA results and major treatments.


Thanks Chris 


 

Edited by member 04 Feb 2024 at 18:09  | Reason: Bic

User
Posted 04 Feb 2024 at 20:44
It can take 18 months for the RT to take full effect so your PSA may rise & fall a few times before you really know whether it has been successful.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 04 Feb 2024 at 23:56

Originally Posted by: Online Community Member
It can take 18 months for the RT to take full effect so your PSA may rise & fall a few times before you really know whether it has been successful.


Lyn ,I have often given people the same advice about the 18 months result being the important one. In the situation Jimmy and I are in, is that still a valid observation. 


My PSA dropped for a while after SRT to the bed but started to rise presumably because the first lymph node had not been treated and was still growing. Again with the after treatment to the first node the PSA stalled, then shot up presumably because of the second node. 


Jamie said the next step was scan again at 1 or if the doubling time was 3 Months or less. 


Thanks Chris 

User
Posted 05 Feb 2024 at 00:41

Thanks, Lyn, 


18months seems a long time to me to hang about and wait to see what’s coming down the tracks! 


I have now been hanging on for three years from my original RARP to have an undetectable PSA. I still don’t understand the logic of ‘wait and see’ until 18months post SRT before deciding if all’s okay. Can you please say more? 


Thanks again. I really appreciate all POV as there is strength in all individual experiences and each ‘case’ adds to the collective understanding for all of us. 

User
Posted 05 Feb 2024 at 00:44

Thanks, Chris. Maybe I should have be clearer that I had SRT to the prostate bed as well as the pelvic nodes which I guess is why I currently feel in limbo with my persistent (and again rising) PSA…

User
Posted 05 Feb 2024 at 00:57

Should have been clearer! The salvage R/T Field included the prostate bed and pelvic lymph nodes. 


PSMA  tracer was Ga68.


Am on the OXON/ Berks border. 


Given the duration of cell turnover (and the fact that all cancer cells’ turnover/ multiply faster than non-tumour cells), I am really keen to understand the science behind ‘waiting 18months’ to see if SRT has worked. Does this really fit in with cell cycle/ kinetics/ turnover? 


 

User
Posted 05 Feb 2024 at 12:39

It is precisely because of cell cycle / kinetics. RT kills some cancer cells immediately but not all - its purpose is to damage the DNA so that the cancer cells can't replicate. That takes 18 months to have full effect because prostate cancer cells are rather slow at dividing & multiplying.


This is what PCUK says on the website: "After radiotherapy or brachytherapy, your PSA should drop to its lowest level (nadir) after 18 months to two years. Your PSA level won’t fall to zero as your healthy prostate cells will continue to produce some PSA.


Your PSA level may actually rise after radiotherapy treatment, and then fall again. This is called ‘PSA bounce’. It could happen up to three years after treatment. It is normal, and doesn’t mean that the cancer has come back."


https://prostatecanceruk.org/prostate-information-and-support/treatments/follow-up-after-treatment#:~:text=A%20rise%20in%20your%20PSA,have%20some%20prostate%20cancer%20cells.&text=After%20radiotherapy%20or%20brachytherapy%2C%20your,18%20months%20to%20two%20years.


"Conclusions
The present results suggest that the PSA nadir level within 18 months after radiotherapy may serve as an early parameter for long-term biochemical control according to ASTRO definitions following radical dose escalation by HDR-BT for prostate cancer. Excellent outcomes were associated with nPSA18 < 0.5 ng/mL"


https://www.sciencedirect.com/science/article/abs/pii/S1538472118304355


 

Edited by member 05 Feb 2024 at 12:40  | Reason: to activate hyperlinks

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 05 Feb 2024 at 12:55

No idea what this is saying but somebody might.


https://bmcurol.biomedcentral.com/articles/10.1186/s12894-023-01323-5


Thanks Chris 

User
Posted 05 Feb 2024 at 19:35

Thanks, Lyn


Science direct link does not take to full publication so will chase it otherwise as not clear whether the groups studied included post-prostatectomy patients who did not have only localised disease. 


Interesting to note, however, that 50% of patients reached their PSA nadir by 7 months (the median) so much earlier than 18months. 


I guess cell turnover and cell dynamics must also be affected by the aggressiveness of the cells meaning faster turnover with more aggressive disease? 


As I understand things, if opting for primary de novo radiotherapy (so intact prostate) then, yes, it can take considerable time to reach post R/T nadir. Even so, according to the truncated version of the linked article, 50% of men hit their nadir 11 months ahead of the magical 18 month mark. Or have I got that all wrong?!! Need to read the full article, I guess…

User
Posted 06 Feb 2024 at 01:25
But the RT would still have been working up to the 18 month mark - they only knew they had hit nadir at 7 months once they got to 18 months without going any lower. The point of the research was that a) the RT keeps on doing its thing for 18 - 24 months and b) there can be a bounce without that leading to a treatment failure.

I think one of the things that isn't clear is whether you had HT with the RT - I don't really get why some men have half the salvage treatment without the other half but if that applies to you, you could ask the onco what the normal tracking would be for a man that has SRT without HT.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
 
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