PSA persistence after Radical Prostatectomy

Stephen, I was in a different situation ,I had a poor histology but my post-op PSA was low and took two years to go above 0.2. I was refused a PSMA test before my salvage RT, there was something in the bed but a PSMA scan five years later detected cancer out side the area of salvage RT.

I had several CT and bone scans in the last year that did not show anything, but the PSMA scan lit up a pelvic tumor.

I will leave the scholars interpret your histology and comment on treatments.

Thanks Chris 

https://community.prostatecanceruk.org/posts/t28848-New-to-this-site--anyone-has-an-idea-of-what-is-going-on-here 

This guy had some odd PSA levels but they seem to have settled.

Edited by member 25 Dec 2022 at 18:55  | Reason: Additional info

Stephen, I was in you situation after my prostatectomy at the end of April with persistent PSA of 0.5.  All my margins and lymph nodes were clear and they found less cancer than suggested by the biopsy.  I also had a pre op PSMA scan which was clear.  However my pre op PSA was >70 so I was high risk going into it.  

Afterwards I had a PSMA scan which highlighted two pelvic lymph nodes.   Based on this my treatment regime consists of:

- Docetaxel chemo (on cycle 2)

- Radiotherapy to follow chemo.  Full pelvic radiation followed by extra treatment to identified lymph nodes. 

- 3 years ADT (Decapeptyl 3 monthly injections with Abiraterone to be added)

The combo of ADT, Abitraterone, and Chemo is known as triplet therapy and has been shown to be beneficial when used early in the treatment cycle.  So far my PSA has come down to 0.07, but as you can see these is quite the road ahead.  The professor treating me writes papers in this area and is up to speed with all the latest thinking. We both agreed the best approach in my case was to be as aggressive as possible now.  

I really would get the PSMA scan if you can because the results of that have directly impacted my treatment and have given the radio folks targets to aim at.  It is a standard scan for situations like ours where there has been a recurrence.  All the best. 

Pre op I was Gleason 7 and T3a.  Post op I was upgraded to Gleason 9 and pT3b.

My post op PSA was 0.014.  It rose to 0.015, 0.019 and then one year later, 0.023.

I took a chance and paid for a PSMA scan.  I knew that with such low PSA readings it might not pick up anything.  But it did.  And this changed the salvage radiotherapy field of treatment.

I have since had PSA of >0.006.

Your post op PSA is higher than mine was and I confess I don't understand the implications of that, but I really do recommend a PSMA scan.

to all in the community. Thankyou so much for the input and personal stories of your journeys with prostate cancer, the support and information has been invaluable.

I will book a PSMA PET Gallium scan within the next month as you all recommend. I understand the pros and cons of finding disease not treatable by radiation.

I hope to keep my oncologist onside throughout this process. "Jellies" raised the issue of triplet therapy with ADT, Abiraterone and chemo with Radiotherapy. I have to ask at my next visit how my Gleason score of 7 [4+3] is influencing the oncologist to decide on treatment. I do not think that we are as aggressive in treatment [triple therapy] as in the UK.

This is an immensely difficult time for me and I can't thank you all enough for taking the time to reply.

Happy Holidays to everyone.

https://pubmed.ncbi.nlm.nih.gov/33443584/

Conclusions and relevance: In this network meta-analysis, as add-on treatments to ADT, abiraterone acetate and apalutamide may provide the largest overall survival benefits with relatively low SAE risks. Although enzalutamide may improve radiographic progression-free survival to the greatest extent, longer follow-up is needed to examine the overall survival benefits associated with enzalutamide.

This study from Jan 21 suggests that abiraterone and Apalutamide are the most effective add on treatments to ADT for metastatic castrate sensitive patients.  I have not started additional treatment to Decapeptyl ADT yet but will ask my onco about it when I see him next week.  But I was expecting to start abi shortly.  

@LynEyre maybe that comment refers to effectiveness for castrate resistant patients? 

Ref triple therapy.  In my case there is a high risk of additional mets (had one suspect hilar node biopsied plus very high PSA starting off) plus age and good health played into the decision for early chemo.  My onco said this was a judgement call in my case. Agree it does not necessarily transfer to other cases. 

Edited by member 31 Dec 2022 at 12:30  | Reason: Not specified

Here are my timelines.  I'm in Ireland which is a different medical system to the UK.  I have supplementary private cover which is common here but public timelines and treatment is not much different for cancer.  

May-Aug: Took 12 weeks post op to confirm persistent PSA.  Two PSA tests at 8 and 10 weeks plus 2 weeks to get PSMA scan and meet consultant urologist who did my operation.

September: Referred to two medical oncologists one for radiotherapy and the other for hormone therapy.  Met both within 2 weeks.  I would have been put straight on HT but had to had a biopsy of a suspect lymph node which was done in 2 weeks.

October: Biopsy was negative so first HT jab was beginning of October.

November: Started chemo at end of Nov.  Radiotherapy will follow this.

So here it takes about 2 weeks to see a consultant and about the same (or maybe a month) to get a PSMA scan.  My advice is to call around to get to see a medical oncologist and a PSMA scan as soon as possible.  You would be amazed what making calls and explaining your situation does.  I have always found that people in the medical profession understand when you are a genuine case and will try to accommodate you asap.  Don't take what the computer says as the answer until you talk to people.  Just this week I got a chemo session and a blood test pulled forward 2 weeks from making a few polite calls and talking to people.

The PSMA scan really is required to give any chance of a diagnosis of your case.  Normally you want to do the PSMA scan before HT so that any suspect areas can been seen before the HT shrinks them.  Before my operation I paid $2k for a private PSMA scan which was not covered by insurance is maybe that is an option?  The oncologist will be able to review your scan so you can do this separately if it will be quicker. The urologist who did your operation should be able to give a referral.  Apart from waiting for a scan you should be on HT asap and then other treatments (normally radiotherapy if no distant mets identified) will be on top of that. 

If you do not have any treatment your PSA will continue to increase so I would not be at all happy waiting over two months in your situation. To put in context, those 2 months I met 2 consultants had a PSMA scan, a hilar node biopsy, started HT and had a plan for chemo and radio.  Since going on HT my PSA has gone from 0.8 to undetectable and my other treatments are front loaded to try to cure it with obviously no guarantees.

Best wishes and good luck getting things organized.  It is a stressful time but it gets a bit better once you get a plan in place.