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    Rising Ultra Sensitive PSA after surgery
    SB44 posted:
    I had a robotic prostatectomy in May 2008. My PSA before surgery was less than 1.0 (but I was taking Proscar). My final Gleason was 4+4. Margins were negative. I get an ultra sensitive PSA every three months. My PSA has gone from less than .01 after surgery to .01,.02 and now .03. My doctor says that this is significant--it's not an artifact of the test--but that it's still too low and too soon to consider any further treatment. Also, there was benign prostate tissue left at the margins during surgery, which could cause the PSA. He says to keep getting ultra sensitive PSA's every three months and wait to see what happens. This is very stressful. I would appreciate any input on whether it's the best way to go and whether there is any way to deal with the stress. Thanks in advance.
    az4peaks2 responded:
    Hi SB44, - This is the bane of the Hyper/Ultra-sensitive PSA tests for routine PSA monitoring. I understand your Doctor's concern and 3 successive rises in 9 months is worrisome, but as he said, these are way to low to take any action on. or to pronounce a definite treatment failure.

    The long accepted "clinical" definition of an "undetectable" PSA is still "less than" 0.1 ng/ml (<0.1 ng/ml). On the Standard PSA assay, which only to the 10th of a nanogram, ALL of your post-treatment results to date, would have been reported that way.

    The problem with using more sensitive assays for routine monitoring, is just what you are experiencing, readings that cause unnecessary worry, but are not definitively reliable enough, on which to take action. You may be having a recurrence but at these low levels, the evidence is not sufficient for most experts to act and yet you, not the Doctor, must bear the stress of this uncertainty.

    Since, even if this rise is eventually, confirmed as a recurrence, no corrective action will likely take place until the PSA readings exceed 0.1 to 0.2 ng/ml at the earliest. If they stabilize at a very low level below 0.1 and no longer rise, no treatment is likely to be administered.

    So the logical thing to do at this point, as your is to continue to monitor the PSA at short intervals to better gauge their significance and act accordingly. Since there is little, if anything, that you can do to affect the results, worry can only impact your present serenity and not the potential outcome. Good luck! - (aka) az4peaks
    Gottano responded:
    With RP in early 2008 and PSA testing every 3 months, there should be at least 9 test results (maybe more depending on when you started). Since you only cite 3 values, it's not clear that the concentration has gone from 0.01 to 0.03. Actually, it may be the case that your PSA level is "bouncing around" at very low levels - not surprising if the surgeon definitely left some benign prostate tissue. If your urologist had told you after surgery, with a Gleason 8, that three years from now you would be asymptomatic (hopefully you are) with a PSA of 0.03 without further treatment, you would probably have been pleased. Maybe looking at your current situation from that perspective will help in dealing with the stress. Once your prostate is gone, I think it's a good idea to monitor PSA with an ultrasensitive test. At the very least, you won't be surprised if one quarter your level has gone from "not detected" to 0.1 or 0.2. I had robotic RP in 2009 (Gleason 9 with extracapsular extension and seminal vesicle involvement). PSA has gone from 0.04 to less than 0.01 and hit 0.01 and 0.02 in the interim. Are you still taking Proscar or undergoing any other treatment to delay progression?
    SB44 replied to Gottano's response:
    Thanks for the responses. I'm not taking Proscar or undergoing any other medical treatment (I haven't hear do taking Proscar when you not longer have a prostate). Here are my PSA's since surgery:
    Ultra Sensitive PSA Post Surgery
    March 2011 .03
    January 2011 .03
    September 2010 .02
    June 2010 .02
    March , 2010 .01
    December, 2009 .01
    October, 2009 .02
    July, 2009 .02
    April 7, 2009 .01
    January 2009 . .01
    October 2008 <.01
    July 2008 <.01
    Gottano replied to SB44's response:
    Proscar and the newer drug Avodart, as 5-alpha reductase inhibitors, prevent conversion of testosterone to DHT. DHT is considered to be more potent in stimulation of prostate and pc cell growth. It may be that these drugs can delay progression of prostate cancer by reducing DHT or some other mechanism (there are some older published papers on this for finasteride). One recent presentation, at the American Society of Clinical Oncology (2011 in Orlando, FL), discussed such a progression delay in PC patients on active surveillance (the REDEEM trial). Perhaps your doctor has some suggestions other than the standard - wait for PSA to get above a certain level then apply radiation/ADT. I'm not a medical professional, just someone in a situation similar to yours, but for 3 years out, things are looking pretty good for you. Best of luck.

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