Was the Cancer Cryotherapy Successful? Good Question (The PCA-3 Test)

On arriving at UC Health in Aurora on Oct. 11 for my 4 month post op assessment, following the prostate salvage cryotherapy treatment in June, see. e.g.

 

http://brane-space.blogspot.com/2017/06/fighting-prostate-cancer-at-90-c-my.html

I was optimistic that the  PSA test would reveal a reading lower than  2.0 mg/ dl which was the level one month after the therapy. We had to arrive by 1: 30 so I could first go to the on site Oncology hematology lab for the PSA and % free PSA test.. I had to wait about 30 minutes and this meant the results would be roughly an hour delayed in getting to the urology professional assistant (Kristen) with whom I had to meet by 2:30.  

The test was done expeditiously by a medical tech and she said it would immediately be sent for analysis.  Meanwhile I went up to the 2nd floor Urology center to wait to be called for my appointment with Kristen. 

On being called right on time, I first had to have weight and BP taken by the RN assistant, then turned in a sheet with ratings for different urological -sexual functions, e.g. frequency of urination, retention of urine, erectile quality etc.  This data was then entered by her into a computer for the Urological PA to access.

Ten minutes later, Kristen appeared with her computer screen open and we went through the responses. She remained concerned about the urinary and erectile difficulties but assured me this was often a side effect of the cryotherapy - especially for older patients undergoing a salvage treatment (i.e. a second treatment, usually after a primary radiation treatment).  In my case, the primary treatment - the HDR brachytherapy done in September, 2012 at UCSF.

Again, she reiterated the erectile issues were not merely sexual but the importance of getting blood into the tissues, to remain healthy.  Hence, she prescribed a  low dose (5 mg) PDE inhibitor .  Recall the chemical pathways here: the cavernous nerves close to the prostate gland secrete nitric oxide which stimulates release of an enzyme (cyclic GMP) inside the smooth muscle cells. This promotes relaxation of smooth muscles and erection. An enzyme known as PDE5 prevents this,  else there may be a prolonged erection. Hence, a PDE5 inhibitor works to suppress secretion of the PDE5 enzyme.

About fifteen minutes later after the free PSA and PSA test results arrived on her laptop, she informed me of the results: 2.09 PSA and 4.8 % free PSA.  As she explained to wifey and me these results were not sanguine, especially the latter. In the case of free PSA you want the % as high as possible to indicate most of the prostate specific antigen is bound up with normal prostate cells.  The combination of the two results, she noted - using an on site software program developed by Dr. David Crawford - yielded a 55 percent probability the PSA was due to malignant cells.

This then led to her doing a urine test called the PCA-3, which is well explained by this UK site,

http://www.cancerresearchuk.org/about-cancer/prostate-cancer/research-clinical-trials/research-diagnosing-prostate-cancer/pca3-test

Noting:

"The test is in two parts. You have a rectal examination and then a urine test. A rectal examination is where the doctor puts a gloved finger into the back passage (rectum). It is possible to feel the prostate gland by doing this. You need to have a rectal examination because this massages the prostate gland and helps the PCA3 to go into the urine. You have to give the urine sample straight after the rectal examination. You normally get the results within a few days"

So with this in mind, she had me prepare and bend over her examination table, warning me in advance this would entail not only the usual DRE but also a prostate massage to force the biomarker into the urine tract.  Hence, there would be a degree of discomfort.  In this she wasn't kidding, and  while the entire procedure lasted just  over three minutes it felt like three hours.  While not painful like a trans-rectal biopsy it was definitely no 'walk in the park' - even a short one.

As she massaged the gland she told me what she felt, including "lumpiness" which was a "result of the cryotherapy".  She said that the process of the massage should also relieve pressure on the nerves as well as pushing fluids into the urinary tract.

Immediately following the procedure she handed me the specially labelled cup to produce a urine sample, using the bathroom across from the exam room. I confess it took seven or eight minutes to produce a stream of urine even adequate to get 1/3 the cup filled.  She later explained this was normal and was a result of the massage.

With the sample delivered, we left - prescription in hand - and booked the next three month visit on the way out. As I mentioned to wifey, I just hoped the numbers - including from the PCA-3 test- would be much better next time. Else, what was the point of going through yet another prostate cancer treatment?

Any positives? Anything? Well, after turning in on the night of the procedure I experienced the first nocturnal emission in nearly fifty years.  While irritated about having to change underwear, sheets, I did consider that the prostate massage -though extremely uncomfortable- did produce at least one  seeming positive "return".  In fact, on four successive nights I also experienced nocturnal erections that had been absent since the cryotherapy on June 20.  As wifey joked, "the trick is to translate them into day time erections".  Well, one step at a time!


See also:

https://emedicine.medscape.com/article/1948091-overview
 

And a detailed published paper on the PCA-3:

http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1677-55382011000600006

PSA Increases: Is It Time to Be Worried?

Well, a recent complete blood panel ordered by my primary care doc turned up generally terrific results - including 178 for cholesterol, 143 for trigylcerides, 43 for HDL cholesterol and 29 mg/DL for VLDL cholesterol. The one bummer in the mix was for the PSA (prostate specific antigen) which had gone up to 2.5 ng/ mL from 2.0 last December. Thus, in a period of just over the year from the brachytherapy HDR treatment, my PSA had gone up as opposed to continuing a steady decline down. I emailed my radiation oncologist immediately, and his take was that it appeared to be a "benign PSA flare" - but I needed to send him my PSA test results now every three months.

Evidently, this PSA "bounce" - called such in most of the literature, occurs in 25-33% of men following any kind of treatment, whether radiation or radical surgery (prostactectomy). Generally then, it will go down by 18 months (for radiation therapy) to 1.0 ng/mL and stay there or decrease. A "treatment failure" on the other hand, is defined as three or more successive increases in the PSA after radiation, especially if these exceed the limit of 2.0 ng/mL total increment.

Treatment failure is serious, since it means the cancer may well still be there as well as resurgent, and ready to create havoc once more. The options - after you've received the primary treatment, say high dose rate radiation as I have, aren't too wonderful or promising. Basically, in most cases, some type of cryogenic treatment (freezing the prostate), or anti-androgen hormone therapy (i.e. female hormones administered) and now, after some improvements in "morbidity" - a kind of 'salvaging prostatectomy" - where a last ditch surgery is attempted.

As I told wifey yesterday, none of these will be chosen as any option should I be deemed to have "treatment failure". I sure as hell am not getting any surgery now, having elected the radiation therapy, and especially with the considerable risks still in play and the fact that surgery on the radiated gland requires much, much higher level of competence as well as technical skill - including operating any da Vinci robot. Anti-androgens are out, after reading about their effects on one hapless guy (Victoria Hallerman's hubby in her book, How We Survived Prostate Cancer. She religiously documented how he constantly broke down in tears, was dogged by muddled, emotional thinking and basically poor judgment. This is all on top of the other effects, including enlarged breasts, etc. So thanks, but no thanks!

Fortunately, the odds remain in my favor, and I don't plan to toss the towel in so soon. As one site at McIver Clinic notes, with their own study - "The 10 year PSA relapse-free survival was 94% for the patients with low risk prostate cancer who were treated with Iodine monotherapy. " I like those chances, and they are surely as good for the UCSF Helen Diller Cancer Center- where I received my (Ir-192) brachy hdr treatment a year ago.

Now, the question becomes: How low does the PSA fall after radiation treatment? According to the same site:

There is no absolute threshold for the PSA nadir (lowest value), but our center uses 1.0 ng/ml as a goal for successful treatment. There is tremendous variation in the time it takes to reach a nadir after radiation. Some patients reach a nadir after a few months while others can take a few years. There is no absolute PSA nadir value that is accepted for success or failure or treatment. Many patients reach a PSA of <0.1 ng/ml and most are below 0.5 ng/ml.

This suggests I need not hit any panic button yet, and likely not for at least a few years, maybe up to 5 - if Dr. John C. Mulhall's take is accepted. Now, what is a PSA "flare"? The same site defines it:

A “bump” or “Bounce” that occurs 18 to 24 months after radiation. The levels can go up to 20 ng/ml. The evaluation reveals no recurrence. These “bumps” in the PSA occur in nearly 30% of patients. The cause of the flare or bump is not known. In most bumps, the PSA rise is temporary and then falls in a quick fashion – up and down over a 6 – 9 month period. A PSA bounce can be confused with a PSA failure.

Again, nothing to be overtly alarmed about, so far as I can tell, though yes, one would want to monitor changes over time. This is why the oncologist asked me to get tested now at 3 month intervals. Given this, how does PSA level as indicated in testing, relate to recurrence of the cancer? The site again:

Prostate cancer patients who have a lower prostate specific antigen (PSA) nadir (the lowest PSA value) after radiation therapy are less likely to have the cancer return than patients with a higher PSA nadir. The longer the PSA continues to fall and the lower its ultimate lowest value (nadir) the better the patient's chances of disease-free survival. In our patients, those that had ultimately had PSA at or below 0.5 ng/ml did not have a recurrence. Those that achieved a 1.0 ng/ml at 1 year did not have a recurrence.

The same FAQ notes that the nadir itself may not be reached for three years. Hence, there is time on my side before action becomes critical- or delay, inaction has grave consequences. How much - who can say? But I'd allott at least another 3-4 years before getting panicky. By then, perhaps - if recurrence has been concluded by my oncologist- I might seek further treatment. But at this stage, I have no plans to do so. After all, the bible says "three score years and ten" is allotted to a man, not that I am a bible believer, but with rising Alzheimers and what's going on in the world, also the approach of savage climate change, hey - who knows? Clocking out "early" may be the best thing!