74 yrs male ,active
Ca prostate-Gleasons -7 ,organ confined disease,treated with radical prostatectomy in 99.Postop PSA decreased to 0
Presently PSA-0.69(Dec'09),0.9(Mar10)Earlier reports show a very gradual rising trend over the last 2-3 years.
is asymptomatic .Is worried as he is a medical professional and wants answers in view of rising PSA.What do you think the answers are?
I will observe.repeat Psa in 3 month .Although biochemical relapse earlier gleason 7 and long time since surgery .consider salvage rt if doubling time ,imaging later show only local disease.or other wise doubling time less than 3 month,metastasis ,sympotamatic progression consider hormonze.hope all the time the psa assay same tech.
Hi Hari,
I agree with what Rajesh said, observe. Make sure you do PSA from same lab.
''At what PSA levels does the concentration indicate that the patient has had a recurrence of cancer?''
For Chan, and the scientists and physicians at Hopkins, the number to take seriously is 0.2 ng/ml.
''That's something we call biochemical recurrence.
http://www.phoenix5.org/Basics/psaPostSurgery.html
Gleason score, preradiotherapy PSA level, surgical margins, PSA doubling time, and seminal vesicle invasion are prognostic variables for a durable response to salvage radiotherapy.
Reference: Stephenson AJ, Shariat SF, Zelefsky MJ, et al. Salvage Radiotherapy for Recurrent Prostate Cancer after Radical Prostatectomy. JAMA 2004;291:1325-1332
This gentleman has an early biochemical relapse, Treatment options:
1. Observation
2. Salvage RT
You could perhaps organise a Bone scan and MRI Pelvis to r/o any visible disease.
Most of the times these are negative (But we usually do them, for medicolegal reasons, to avoid being sued by pts)
The rationale and justification for these investigations is , you rule out regional and distant mets, hence offer local salvage RT which is one of the Std Rx options for such fit and well pts.
The outcome of Salvage RT is better when PSA < 2 ng / ml , as opposed to when it is > 2 ng/ml
Hence, offering Salvage RT at this point in time is not unreasonable
This is interesting. PSA failure 10 years after prostatectomy.
I had a similar case once, 6 years post-prostatectomy with PSA=0.0, then in Year 7 a rising PSA with a PSA doubling time of 2-3 months. It defies all our accepted patterns.
What does it mean? local failure? very slow metastatic deposits? Who knows!
My management would be guided by the anxiety level of the patient after a discussion of what we don't know. You can't deny him local radiotherapy, and thankfully now the toxicity profile is low. You might be wasting your time, but then we waste our time so often in lung, oesophagus, stomach, pancreas, brain and many other cancers!
I don't have any argument with observation with 3/12 PSA until a pattern is clear. But then you have to do something!
I think its time we practice some evidence based oncology rather than eminence based or patient based oncology.
Let me put this in the least complicated way in a 6 step process to a lay man oncologist not practising Uro-oncology.
1.First of all patients who have undergone a radical prostatectomy, the American Urologic Association (AUA) defines a biochemical recurrence as a serum PSA ≥0.2 ng/mL, which needs to be confirmed by a second determination with a PSA ≥0.2 ng/dL
2.Then once you fulfill this, an oncologist (me) should look at
a) Time of relapse since surgery
b) Gleason score
c) PSA dobling time
3. After this, you can have a rough estimate about the pattern of relapse, the metastasis free suurvival & 10 and 15 year likelihood of prostate cancer specific survival. I use the " POUND TABLES " for this which was generated at the John Hopkins unit. (Please do not confuse them with Partins table which you may be aware of)
http://docs.google.com/View?id=dfmbsqpf_15gbt2tbfb
4. If you find this information difficult to comprehend, get this basic facts right in your mind
RULE A: For pts with short PSA-DT and a Gleason score ≥8 disease are at particularly high risk of having systemic disease hence a higher risk of dying from prostate cancer and are unlikely to achieve long-term disease control from local-only salvage therapies.
RULE B: For pts with long PSA-DT and a Gleason score <7 disease, there is a high likelihood of disease in prostate bed (local relapse), hence lower risk of dying from prostate cancer and are likely to achieve long-term disease control from local-only salvage therapies.
5. The moment you detect something on MRI imaging - possible prostate bed recurrence, lymph node, etc —-> That pt is doomed, as you are too late, but of course you can still offer salvage RT to prostate bed as there may be few pts who may benefit from RT.
Thus, in fact its not unreasonable to offer Hormones in the latter scenario as an option.
6. Once you the oncologist are able to comprehend this piece of information, you tell this to your patient and make assessment of benefit Vs Harm with Salvage RT, of course you take into account the probability of other co-morbid conditions like MI, COPD, etc which will kill the patient before his prostate cancer kills him, and of course at the very end patient preference as to how keen/enthusiastic is he to have further treatment.
I hope my simple efforts in thinking in a logical evidence based fashion have benefited a few of you busy oncologists, and may have updated your knowledge base and you thinking process.
Please feel free to ask for any further references or studies which i m happy to bombard at you any time.
Over and Out !!!
Rohit Malde
Data doesn't even answer the first question! The case is not clear cut … yet.
1999 PSA=0.0? after prostatectomy
12/2009 PSA 0.69
03/2010 PSA 0.9What is the PSADT?
- 0>0.9 in 11 years (PSADT= 18.8m)
- 0.69>0.9 in 3 months (PSADT= 7.7m)
the next issue!
RULE A: For pts with short PSA-DT and a Gleason score ≥8 disease …
RULE B: For pts with long PSA-DT and a Gleason score <7 disease …What happens for Gleason score = 7?
that's what I meant anyway!
I don't have any argument with observation with 3/12 PSA until a pattern is clear. But then you have to do something!
that is, you have to decide it is local or disseminated and manage accordingly.
Ask the presenter of this case to give you all the recent PSA readings. I guess HM has just given us 2 readings. There may be plenty more readings from 2008, 2007, 2006 etc.
My apologies RULE B includes Geason score 7 (printing error on my behalf)
This pt is a medical professional and seeks answers.
So you probably ought to offer some imaging to answer whether he has a simple biochemical relapse OR a radiogically visible recurrent cancer.
If the investigations are negative (including a Bone scan) : The options need to be discussed as the probability of RULE B seems to fit in here.
