Guest guest Posted July 22, 2009 Report Share Posted July 22, 2009 I underwent brachytherapy in Sept 07. At the time my stats were stage t1c, gleason 3+3, psa 5.5. Subsequent psa's were Dec 07 4.0 May 08 3.0 Dec 08 2.0 May 09 2.5 Jul 09 3.4 After checking at 6 month intervals, in May 09 psa went up, so we checked again in July. It now has gone up to 3.4. Doctor wants to check again in 3 months, along with an office visit. I aware of psa bounce about 1.5 years out. It may be normal, but I am concerned, especially with the last one going up 0.9. Are there any other factors that could be causing the psa increase besides cancer? Having had brachytherapy, surgery is now not an option. Should I be looking into other options, or is it too soon to get overly excited? Appreciate any feedback. Thanks, Ken Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 22, 2009 Report Share Posted July 22, 2009 > I underwent brachytherapy in Sept > 07. At the time my stats were stage t1c, gleason 3+3, > psa 5.5. > Subsequent psa's were > Dec 07 4.0 > May 08 3.0 > Dec 08 2.0 > May 09 2.5 > Jul 09 3.4 > > After checking at 6 month intervals, in May 09 psa went up, > so we checked again in July. It now has gone up to > 3.4. Doctor wants to check again in 3 months, along > with an office visit. > > I aware of psa bounce about 1.5 years out. It may be > normal, but I am concerned, especially with the last one > going up 0.9. Are there any other factors that could > be causing the psa increase besides cancer? Having had > brachytherapy, surgery is now not an option. Should I > be looking into other options, or is it too soon to get > overly excited? > > Appreciate any feedback. > > Thanks, > Ken Ken, I am not an expert on any of this. You need expert advice. At this point, if the doctor you are seeing is still the radiation oncologist I think it is time to seek advice from other specialists. I should think the next logical step would be a medical oncologist who specializes in prostate cancer, if you can find one. The commonly accepted evidence for failed radiation is three successive rises in PSA, tested at least three months apart. You've had two. If the next one is up, that's a particularly bad sign. As I understand it, there have been cases of three rises that then went down again on the fourth test, but the chances of that happening are said to be low. IIRC one doctor told me they were maybe 5%. It is possible that the PSA levels you are seeing are due to prostatitis, inflammation of the prostate. This is often associated with radiation and especially so with brachytherapy. On the other hand, your " nadir " , i.e., the lowest PSA that you had, never got as low as we'd like. That may indicate that the cancer was not cured by the radioactive seeds - either because the placement of the seeds was ineffective with some part of the tumor not receiving a sufficient dose, or because the tumor was resistant to the radiation, or because there were extensions or metastases of the tumor outside the prostate. There are other options for " local " treatment, i.e., treatment of the prostate itself but as I understand it, success rates are not high. Local treatment can only work if the recurrence is local, that is if the cancer is still localized within the prostate bed. As I understand it the options are: 1. Surgery. Surgery is still possible. Some surgeons will do it. Sometimes they are even successful. However most surgeons will not attempt it because the success rate is low and the complication rate is high. Surgery after radiation very often leaves the patient in worse condition than before the operation. If I remember correctly, the U.S. National Cancer Institute sponsored a surgery after radiation trial but discontinued it because of the high rate of failure and complications. 2. HIFU. I have read that HIFU can be used after failed radiation. I don't know whether that's true, how successful it is, or what the complications are. But I am pretty sure that some HIFU practitioners do it. I suspect that the total experience with this is too low to have any reliable long term information about how well it works for salvage treatment. 3. Cryosurgery. Same story as HIFU. It's not a well established technique. I believe it can be attempted after failed radiation, but I don't know what the success or complication rates are and don't know if anyone knows. All of these first three options, surgery, HIFU and cryosurgery, have no chance at all if the disease has spread outside the prostate. When the PSA is low, this is very hard to tell. Bone scans don't reveal small bits of cancer around the body. A medical oncologist is the right guy to ask about whether any tests are likely to tell you whether the disease is localized or not. 4. Hormone therapy. This is the option that the great majority of men are offered after failed primary therapy. It used to be said that a patient should wait until just before the development of symptoms before trying hormone therapy. Many doctors still advocate that. Some other doctors now advocate early hormone therapy, claiming that it extends life more than late therapy. A research doctor who treated me told me that the latest evidence supports early hormone therapy. The idea is that it's never a good idea to have more cancer in the body than less. However the issues are still in dispute. 5. Chemotherapy. There are a few medical oncologists now advocating early chemotherapy after primary treatment failure. Most oppose this because of the dangers and side effects. However early chemo has now become fairly common in breast cancer treatment, and has been demonstrated to extend life more than late treatment. But you need an expert medical oncologist to discuss this with. 6. Supplements. If I were you I think I would gobble pomegranate extract capsules. A recent study claimed that they slowed PSA doubling rate from 15 months to 60 months in one clinical trial. There are other supplements that also might help. A good medical oncologist who follows this stuff could advise you better than I could about which ones are worth trying. Cancer is a tricky disease. It is caused by mutations in DNA that damage the mechanisms in cells that regulate cell division and locality. But different people have different mutations. I speculate (I'm a layman at all this, not an expert) that among 100 patients with prostate cancer, when we get down to the specifics of exactly which genes are damaged and exactly how, we might find 100 different pathologies. In addition, each person has some peculiarities in his immune system and in other systems that are involved in cancer progression. So, with our current state of knowledge, I don't think it's possible to know how any particular patient will respond to any particular treatment until he's tried it. Therefore I think I would look for a medical oncologist who has an open mind, one who has tried many different kinds of treatments and who is willing to work with you to try different things and see what is helping and what is not. Even hormone therapy, the standard treatment for failed primary therapy, has variations - single, double and triple ADT, intermittent ADT, intense ADT followed by periods of lighter ADT (e.g., finasteride only), and so on. The bad news for you is that your PSA is rising. It may not be cancer, but it may well be. The good news is: the cancer is still small, your Gleason score was not high, there are bunches of treatments available. Even assuming that you do have cancer and not prostatitis, there is still a strong possibility that you'll be alive ten years from now, or maybe more. Our own Terry Herbert was diagnosed over a decade ago and is still here and still free of symptoms. Best of luck. Alan Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 22, 2009 Report Share Posted July 22, 2009 > I underwent brachytherapy in Sept > 07. At the time my stats were stage t1c, gleason 3+3, > psa 5.5. > Subsequent psa's were > Dec 07 4.0 > May 08 3.0 > Dec 08 2.0 > May 09 2.5 > Jul 09 3.4 > > After checking at 6 month intervals, in May 09 psa went up, > so we checked again in July. It now has gone up to > 3.4. Doctor wants to check again in 3 months, along > with an office visit. > > I aware of psa bounce about 1.5 years out. It may be > normal, but I am concerned, especially with the last one > going up 0.9. Are there any other factors that could > be causing the psa increase besides cancer? Having had > brachytherapy, surgery is now not an option. Should I > be looking into other options, or is it too soon to get > overly excited? > > Appreciate any feedback. > > Thanks, > Ken Ken, I am not an expert on any of this. You need expert advice. At this point, if the doctor you are seeing is still the radiation oncologist I think it is time to seek advice from other specialists. I should think the next logical step would be a medical oncologist who specializes in prostate cancer, if you can find one. The commonly accepted evidence for failed radiation is three successive rises in PSA, tested at least three months apart. You've had two. If the next one is up, that's a particularly bad sign. As I understand it, there have been cases of three rises that then went down again on the fourth test, but the chances of that happening are said to be low. IIRC one doctor told me they were maybe 5%. It is possible that the PSA levels you are seeing are due to prostatitis, inflammation of the prostate. This is often associated with radiation and especially so with brachytherapy. On the other hand, your " nadir " , i.e., the lowest PSA that you had, never got as low as we'd like. That may indicate that the cancer was not cured by the radioactive seeds - either because the placement of the seeds was ineffective with some part of the tumor not receiving a sufficient dose, or because the tumor was resistant to the radiation, or because there were extensions or metastases of the tumor outside the prostate. There are other options for " local " treatment, i.e., treatment of the prostate itself but as I understand it, success rates are not high. Local treatment can only work if the recurrence is local, that is if the cancer is still localized within the prostate bed. As I understand it the options are: 1. Surgery. Surgery is still possible. Some surgeons will do it. Sometimes they are even successful. However most surgeons will not attempt it because the success rate is low and the complication rate is high. Surgery after radiation very often leaves the patient in worse condition than before the operation. If I remember correctly, the U.S. National Cancer Institute sponsored a surgery after radiation trial but discontinued it because of the high rate of failure and complications. 2. HIFU. I have read that HIFU can be used after failed radiation. I don't know whether that's true, how successful it is, or what the complications are. But I am pretty sure that some HIFU practitioners do it. I suspect that the total experience with this is too low to have any reliable long term information about how well it works for salvage treatment. 3. Cryosurgery. Same story as HIFU. It's not a well established technique. I believe it can be attempted after failed radiation, but I don't know what the success or complication rates are and don't know if anyone knows. All of these first three options, surgery, HIFU and cryosurgery, have no chance at all if the disease has spread outside the prostate. When the PSA is low, this is very hard to tell. Bone scans don't reveal small bits of cancer around the body. A medical oncologist is the right guy to ask about whether any tests are likely to tell you whether the disease is localized or not. 4. Hormone therapy. This is the option that the great majority of men are offered after failed primary therapy. It used to be said that a patient should wait until just before the development of symptoms before trying hormone therapy. Many doctors still advocate that. Some other doctors now advocate early hormone therapy, claiming that it extends life more than late therapy. A research doctor who treated me told me that the latest evidence supports early hormone therapy. The idea is that it's never a good idea to have more cancer in the body than less. However the issues are still in dispute. 5. Chemotherapy. There are a few medical oncologists now advocating early chemotherapy after primary treatment failure. Most oppose this because of the dangers and side effects. However early chemo has now become fairly common in breast cancer treatment, and has been demonstrated to extend life more than late treatment. But you need an expert medical oncologist to discuss this with. 6. Supplements. If I were you I think I would gobble pomegranate extract capsules. A recent study claimed that they slowed PSA doubling rate from 15 months to 60 months in one clinical trial. There are other supplements that also might help. A good medical oncologist who follows this stuff could advise you better than I could about which ones are worth trying. Cancer is a tricky disease. It is caused by mutations in DNA that damage the mechanisms in cells that regulate cell division and locality. But different people have different mutations. I speculate (I'm a layman at all this, not an expert) that among 100 patients with prostate cancer, when we get down to the specifics of exactly which genes are damaged and exactly how, we might find 100 different pathologies. In addition, each person has some peculiarities in his immune system and in other systems that are involved in cancer progression. So, with our current state of knowledge, I don't think it's possible to know how any particular patient will respond to any particular treatment until he's tried it. Therefore I think I would look for a medical oncologist who has an open mind, one who has tried many different kinds of treatments and who is willing to work with you to try different things and see what is helping and what is not. Even hormone therapy, the standard treatment for failed primary therapy, has variations - single, double and triple ADT, intermittent ADT, intense ADT followed by periods of lighter ADT (e.g., finasteride only), and so on. The bad news for you is that your PSA is rising. It may not be cancer, but it may well be. The good news is: the cancer is still small, your Gleason score was not high, there are bunches of treatments available. Even assuming that you do have cancer and not prostatitis, there is still a strong possibility that you'll be alive ten years from now, or maybe more. Our own Terry Herbert was diagnosed over a decade ago and is still here and still free of symptoms. Best of luck. Alan Quote Link to comment Share on other sites More sharing options...
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