PSA and time of day?

User

Posted 30 Sep 2024 at 19:09

Six months ago, following MRI then biopsy, I was diagnosed with Gleason 7 (3+4) PCa (see my profile for more specifics). I was advised by several consultants that there was "no rush" for surgery at the time (RARP surgery being the most suitable pathway for my circumstances). Instead, I was to have follow up PSA tests to monitor things over time.

I had been under the impression over this time that a trending increase in PSA was a sign that the disease was progressing. So I was duly content to monitor as my PSA appeared to be on the slight downwards trend between January and June this year. Then at the end of August, it doubled. Action stations... I'm now booked for surgery in November. However, I've just had two further PSA tests (yes - I have an understanding and accommodating consultant who is happy to repeat the PSA test) and it is back down to the same level it was a year ago!

I'm wracking my brain for any factors involved (illness, diet, and so on) and the only factor I can draw a correlation with is time of day. The later in the day that I have had a PSA test, the lower the result. Now obviously I am a sample of one and it would be considerably circumspect to draw any conclusion from this observation but I wondered if anyone else had found the same thing?

There is scientific literature to suggest there may well be a diurnal variation to PSA levels - to the degree that it can influence decisions on whether to proceed with a biopsy. And I'm now seeing such variations potentially play a part in whether to proceed with surgery for myself.

I'm not negating PSA levels being a useful diagnostic tool - but they are a proxy measure and one that, in my experience, can fluctuate so widely in a day that I believe decisions being made off the back of them should not be made without this contextual knowledge. As such, in my own case at least, I am instead left making surgery decisions purely emotionally.

Has anyone else, especially those on Active Surveillance, observed any time of day variation in their own PSA levels?

User

Posted 13 Oct 2024 at 11:55

Best of luck and the surgery went smoother than having my tonsils out. That new DaVinci SP is epic as are the surgeons using it. Keep us posted and don’t worry as I was having kittens beforehand and there really isn’t anything to worry about and less traumatic than biopsy etc

User

Posted 17 Oct 2024 at 22:21

Hi JP77

It’s not uncommon for the MRI not tell the whole story. My PCa was more extensive on the day of the op than the MRi had shown.

if you are seeing a private consultant maybe ask about NeuroSAFE during the RARP. It’s been widely available privately for a number of years and also being rolled out on the NHS. Means the surgeon can make an informed decision on nerve sparing given that a pathologist can check your prostate as soon as it’s removed and before you are closed. In my case there was further suspect tissue seen in the frozen sections under the microscope so the surgeon was able to take additional tissue there and then.

Edited by member 17 Oct 2024 at 22:26 | Reason: Not specified

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User

Posted 02 Oct 2024 at 10:36

PSA naturally fluctuates during the day and can also be influenced heavily by vigorous exercise, DRE and ejaculation etc it’s a useful test but I wouldn’t get too caught up in the mechanics given biopsy has shown that cancer is present.

I was diagnosed with 3+3 prostate cancer post biopsy. Being mindful that in ~44% of cases upgrading of cancer is likely post surgery histology I decided not to delay intervention….even though my initial clinical team said AS was an option.

i took a second opinion of a top London professor and moved immediately to retzius sparing RARP with neurosafe.

just as well I did as histology showed the cancer was much more extensive than biopsy/mri had depicted. My surgeon said my timing had been prudent as there was significant spread near the bladder neck and as a whole the cancer was very close to going T3.

personally I wouldn’t delay knowing there are definitely grade 4 cells present.

as will all cancers the sooner you act the less chance there is for mets.

Edited by member 02 Oct 2024 at 11:48 | Reason: Not specified

User

Posted 02 Oct 2024 at 11:23

Mark, do other things affect PSA results ? My post treatment results often fluctuated. If tested during a trial I was on the blood was tested within 30 minutes, if tested at 0800 at my GP surgery they sat in the test tube until 1300 and then went on a six mile journey to the same hospital lab.

I now have my bloods done at around midday at a regional phlebotomy service, the bloods are picked up at 1300 and go off to the hospital lab.

Hope all goes well for you.

Thanks Chris

User

Posted 02 Oct 2024 at 11:43

Hi Mark,

During two years of AS, my PSA remained relatively stable fluctuating between 5.4 and 6.6. Which is remarkable, as according to my biopsies, my cancer progressed from Gleason 6(3+3) to Gleason 9(4+5)?

User

Posted 02 Oct 2024 at 12:16

When looking for a PSA trend, readings are supposed to be at least 3 months apart, and one reason for this is to try and make sure the size of any trend change is significant compared with noise variation.

User

Posted 09 Oct 2024 at 14:43

Thanks all - I've just spoken to my surgeon and now have a date scheduled for RARP.

The reason I originally posted though was to raise a question around the perception of the PSA tests in monitoring PCa progression during Active Surveillance, prior to surgery (which is a specific pathway - I appreciate that PSA is also useful in other cases, such as initial diagnostics and to monitor potential recurrence post surgery).

I have personally observed a big change week to week recently (from 10 to 4.9 to 5). My concern would be if anyone was undergoing quarterly PSA tests during Active Surveillance, with the understanding that a dramatic change of PSA over a longer period would be an indicator to elect for RARP, that they rely on a single data point for that change. In my case, I have had three quite different results in the last 3 weeks - so depending on what result I choose from the last few weeks, I could have seen a change in 12 months that represents a doubling in PSA or no significant change at all.

See this graph - depending on what of my most recent PSA tests (in the last 3 weeks or so) you choose would dramatically change the trend line. And I have anecdotally observed a negative correlation with time of day (it is lower later in the day), which is what this article is alluding to too.

Edited by member 10 Oct 2024 at 12:18 | Reason: updated link to graph to better show latest data points

User

Posted 09 Oct 2024 at 21:33

Good luck with your surgery Mark and all the best for the recovery

User

Posted 13 Oct 2024 at 09:40

Hi Mark et al,

Good luck with the surgery. I was also Gleason 3+ 4 and opted for AS. Re PSA - nothing in my experience of 2.5 years active monitoring suggest time of day has a bearing, but recent cycling, ejaculation etc certainly can. If it has jumped I'd get it checked pronto. Mine jumped to 12.4 in Jan; had an MRI and consultant said it was better than the one I was diagnosed after 2 year ago. it came down to 8 & then 7 in the 1-3 months after that, but was back to 12.7 in August and latest MRI reveals I'm now T3a which was a shock, so now looking at treatment PDQ. I think TechGuy makes a good point...

Andy

User

Posted 13 Oct 2024 at 11:12

Thanks for the comments everyone.

The thing that continues to confound me is the way my PSA appeared to double in 12 months, then went back to down to the "baseline" level 3 weeks later. And even more confusing is these 2 most recent *lower* readings (of about 5 - both in Sept) were taken after several long bike trips (70km+ each day, for 2-3 days each, *before* the lower blood tests - 7th to 9th Sept and 14th/15th Sept), whereas the one I had at the end of August (about 10), was after not riding for 3 weeks or so.

See this 12 month history of my PSA levels:

25th Sept 2023 - 4.99
4th Jan 2024 - 7.1
7th Feb 2024 - 6.55
11th June 2024 - 5.4
30th August 2024 - 10.7
20th September 2024 - 4.90
26th September 2024 - 5.0

Here's these points on a graph, which better illustrates what I'm saying. If I'd not had the PSA test on 30th August then there'd be no upwards trend at all. In fact, the trend would be downwards on this graph.

All I can personally correlate is time of day, which may be incidental but gives me pause to question the usefulness of PSA tests in monitoring disease progression in Active Surveillance. These readings can be influenced by many factors, as mentioned many times on this forum, but time of day is something I hadn't considered until this (and then I found some research indicating there might be a link too).

This therefore leaves me thinking not to be taking PSA readings as a direct measure of disease progression. And, to TechGuy's point, given they've already found some areas scored as 4 (i.e Gleason 3+4) in the biopsy, I'm simply going to go ahead with RARP as that is the most known course of action.

As a side note - I'm lucky to have found a good surgeon at Guy's and have been determined a suitable candidate for surgery with the best possible outcomes (single port / nerve sparing etc - more on that as I learn more, I'm sure). As many suggest on this forum, the best chances of a positive outcome from surgery come from earlier intervention. Quite the dilemma as to when to act though - and one that many here are wrestling with.

Anyway - I'm drawing attention to my own anecdotal observations that PSA trends in Active Surveillance should be taken in a broader context, as a proxy measure. Not, as I was initially led to believe, a clear signal of disease progression (or not).

PS - Good luck with the treatment @AndyWarks and keep us updated on your appointment @JP77

Edited by member 13 Oct 2024 at 20:05 | Reason: Punctuation

User

Posted 13 Oct 2024 at 11:55

User

Posted 17 Oct 2024 at 13:57

One thing that may be a factor is that PSA test results are a ratio and as such factors such as dehydration can affect these things in the same way that they do in drug reactions caused by a reduced blood volume. I am one year post Brachytherapy after having had Gleason 3+4 and T2a diagnosis following a biopsy. The finger and the MRI were both clear and I was pleased to have insisted on the biopsy as the consultant wasn't pushing it. My latest PSA had increased, but then I was told told off by the phlebotomist for being dehydrated and making it difficult to draw blood. I am due another next month so I will definitely be well hydrated and hope for a better PSA.

Edited by member 17 Oct 2024 at 14:00 | Reason: Not specified

User

Posted 17 Oct 2024 at 22:03

So I’ve been to meet the consultant this week and he agreed that I now need to have surgery. Just waiting on the date. However we came out of the meeting slightly confused as he directly asked “which nerves I would like to spare?” Has anyone else been asked this? I think this is such a difficult decision as I would like as many as possible to be spared! He did go on to explain that due to my age and the prostate being small that the MRI was not clearly showing the cancer and so he can’t use that as a guide for the nerve sparing. As it’s bilateral he wants to do his best to avoid recurrence, I wasn’t really prepared for it and so it will be discussed again. I’m also meeting with another consultant privately tomorrow to try and get a different explanation

Edited by member 17 Oct 2024 at 22:20 | Reason: Not specified

User

Posted 17 Oct 2024 at 22:21

Hi JP77

It’s not uncommon for the MRI not tell the whole story. My PCa was more extensive on the day of the op than the MRi had shown.

Edited by member 17 Oct 2024 at 22:26 | Reason: Not specified

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