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    Post-Surgical PSA Levels
    AlaninVA posted:
    I had a radical prostatectomy in December 2007; according to my surgeon, pathology was "very favorable." Post-surgical PSA tests are revealing a rising PSA as follows: 0.02 (Jan 2008), 0.07 (Sep 2008), 0.09 (Feb 2009), 0.13 (Mar 2009). Two questions: (1) At what point is a PSA level following RP no longer considered "virtually undetectable?" (2) At what point does a post-surgical PSA level become cause for concern? Although my surgeon acknowledges that my PSA levels are trending upward, he is very optimistic that this is due to some remaining benign glandular cells and it's unlikely that this represents a recurrence and/or metastasis. He recommends a "watch-and-wait" approach with additional PSA tests every three months. Although I have complete faith in my surgeon, I'm understandably troubled by this recent turn of events. Anyone out there with a similar experience to share? Thanks...!
    Galileo1962 responded:
    With standard testing, less than 0.1 is considered undetectable. I'm not sure with the ultrasensitive tests you were having, but at any rate, the point is moot. Your PSA is detectable and you appear to be having biochemical failure. That's where there's no clinical sign of disease other than the rising PSA. I think you should get a second opinion, and don't delay. I would consult with a good radiation oncologist about whether or not you are a candidate for salvage radiation. What was your PSA just prior to surgery? Did you have positive or negative margins? I'm assuming by "very favorable" it's meant that there was no indication of seminal vesicle or lymph node involvement. What was your Gleason after surgery (the one determined by the pathologist looking at your prostate)? IF you need salvage radiation, you're best off getting started before your PSA hits 0.5. Another cut point is 1.0. There are differences in outcome in men who get started at 0.5 compared to those who start later, and between those who start before 1.0 and those who start later. With salvage radiation, the earlier the better--and I think some urologists miss that point. Remember, in a recurrence, your urologist's job is to get you to another specialist, and then he's done. You would then be in the hands of a radiation oncologist and/or a medical oncologist. The usual line of demarcation is 0.2--that's where most doctors would say it's a recurrence. Good luck!
    tarhoosier1 responded:
    Alan: Welcome to the board. Sorry for the motivation for the visit. Your concern is understandable. First, you state your surgeon said the post surgery pathology was "very favorable". Have you the pathology report itself? Obtain it, if you must, and read it and understand it fully. Question the surgeon-urologist at next meeting and satisfy any confusion. This is a must. Your comments indicate the surgeon left some prostate tissue in your body which can, indeed, produce psa in a benign situation. Only the pathology report can confirm the tissue issue, and margins as well. If your psa is taken and read by the same method and same lab at each time, then a serial rise and a recent level above 0.1 is certainly detectable. I question the "virtual" qualification given in your (his) comment. It is true that your psa is quite low, though it is moving in the wrong direction, and rate and direction are all in such a case. If you need more input, and it certainly appears your anxiety and psa would merit it, the best resource for you is to visit with an oncologist, preferably one who specializes in prostate cancer, to provide you with another opinion. This makes no reflection on your surgeon, his competence or reputation. Your disease specifics such as Gleason, age, and all the other characteristics which you do not mention here, will be considered by this oncologist in making recommendations. This path is really the only one since the surgeon is now out of the picture, as far as further treatment is concerned. His work is done, unless you have additional post surgical complications he needs to continue with. If such a specialist oncologist is found, and major metropolitan areas usually offer such a choice, then a balanced, experienced opinion is available, without resorting to us, for example. Adding such a professional to your "team" completes your work and puts you in the best seat with experienced navigators for this journey. I had psa persist after surgery, followed my own advice, after a year, and am comfortable with my decision. I continue to be seen by both doctors for their respective skills.
    876ty; responded:
    While not identical, there are parallels between my situation and yours that are worth mentioning. First let me say that I agree you are dealing now with recurrence. Any detectable PSA following surgery is recurrence almost by definition. My primary therapy was radiation rather than surgery so my definition of recurrence is different, but it eventually became certain that mine has also recurred. The question becomes is it local (in the prostate), locally advanced (in periprostatic tissue, lymph nodes or seminal vesicles), or metasticized. That is a difficult question to answer, but without an answer, I question advice you have seen regarding moving to another local treatment such as radiation. You might consider working with an institution that can use appropriate imaging to answer the question. If nothing else, try to better charachterize your cancer using data prior to your surgey such as stage, Gleason, number of positives, percent positive tissue in your biopsy samples, PSA velocity, and PSA doubling time. Then use the various nomagrams that are available to better determine your logical course of action. Having done this myself, it was determined by imaging that my PC is not in my prostate so there is no advantage to considering any local therapies (surgery or chryotherapy in my case) and the very real side effects I would most likely experience. And good luck!
    sfschicago responded:
    I have a simliar concern. I had a radical prostatectomy in April 2002, 7 years ago. My PSA was 6.2, my Gleason was 7. The pathology showed that my margins were clear. For 6 years my PSA was less than .1 (there was no finer detail). This year my PSA is .1 My internist said that I shouldn't be concerned but to retest in a month. Again it is .1 What should my next course of action be, if any? It seems odd that the number would go up after 7 years. Could this be a rounding error? Thanks for any advice you can give me.
    tarhoosier1 responded:
    SFS: It would be good if you would start a new discussion with your concern so that others could be alerted to it. Your psa is not an absolute marker of progression at this point. Several rises above 0.1 usually is the definition of recurrence. Actually recurrence is all too often the case, perhaps 20-40% of men. Even at seven years post op this is seen, sometimes even later. Another man posted on another site and he recurred at ten years, watched it for two years, had radiation and then after another 4-5 years it rose again. Other men have a psa that wanders around for years. The G7 indicates there was an element of G4 present, always a concern. We do not know if your psa will continue. No one does. A change to the ultrasensitive measure may provide more precise readings, though still at a very low level. This would resolve the rounding question for you. There is no difference in cost for the greater precision assay. There are other ways to slow a gently rising psa that are nearly benign: diet, Proscar or Avodart, vitamin D, pomegranate, celecoxib, and some others. All those I mention have Trial success at Phase I and II level, some in Phase III testing now. I think that any action on your part towards a definitive treatment would be well into the future. Your situation bears watching. Many men use a trigger of 0.5 to initiate salvage treatment with radiation. Others consider the rate of change rather than the absolute value. If you truly want the best advice then see an oncologist, preferably one who specializes in prostate cancer, though this may be some time in the future. If some decision is necessary it will not be that of the internist or urologist as their work is done as far as diagnosing and recommending treatment. It is gratifying that the internist recognizes the value of repeat testing in cases of concern and is not rushing into a decision.
    oscar1369 responded:
    any rise at all should be taken seriously, i personally would not wait another minute.find another doc. i had prostate cancer in 05/03/2006 and radical prostatectomy on06/02/2006 and my psa has stayed at .01-.02 any rise above that is a cause for concern: period fyi my gleason score was at 7. grade 3 and 4 good luck keep us informed.
    prostatecancerwife responded:
    I agree with Galileo. My husband's PSA went up to .03 and we were told to have the radiation. But he was given hormone treatment for 6 months first. The doctor said it would help make the cancer cells more susceptible to the radiation. So far, so good! :grin:

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