Post-Brachytherapy Treatment PSA Spikes to 6.0 - Not So "Golden"

UCSF scoring system for Gleason scores and biopsy results.

Within hours of posting the results of my post gall -bladder surgery follow up check (declared "golden" by the surgeon) my primary physician called and left a message about wanting to refer me to the Urological Associates here in COS. This is because the last test - 3 days ago - had disclosed a PSA spike of 2.23 ng/ml to 6.0. I immediately phoned her office back and said that I preferred no specialist referrals at this time, certainly until after I had contacted my oncologist at UCSF (San Francisco).

Even with that contact I referenced the work on salvage therapy by Dr. Kent Wallner, see e.g.

http://brane-space.blogspot.com/2014/01/rising-psa-after-radiation-therapy-dont.html

And also that I was prepared to wait further (given in some cases the post-brachytherapy PSA doesn't finally come down until after 5 years.). In any case, I told him I do not plan on having any salvage therapy whether that be surgery, or further radiation or god forbid anti-androgen therapy. The latter is a nightmare for the men who have it, diminishing their physical capabilities, as well as mental and emotional.  As I told Janice, I'd rather live another 3-5 years with my mental faculties intact (including not suffering from depression or having to take anti-depressants) than live 15 more years as a mental, physical and emotional vegetable.  (Another alternative in the mix is to have another PSA test, the "free PSA". Studies have found when it's less than 24% there is almost a 90 percent chance the cause is cancer or in my case, returned cancer.)

I know my primary doc, however, is an over-achiever and alpha female committed to "perfecto" stats for all of her patients. (Well, she was at least happy my a1c - approaching diabetic levels at 6.3 five months ago -  has gone down to 5.5. because of rigorous exercise and avoiding all sweets, sugary stuff) But as I made clear,  no more  needle biopsies especially given the residual scar tissue from the high dose (1920 cGy) Brachy radiation, and after just having had a gall bladder surgery. No further biopsy referrals unless based on the new fusion-guided method, e.g.

https://health.clevelandclinic.org/2014/09/fusion-guided-biopsy-a-smarter-way-to-look-for-prostate-cancer/

This, as opposed to the standard needle biopsy (which I had in July 2012 - see my post then) which is antiquated by comparison. As noted in the Scientific American Handbook on Prostate Disorders (by H. Ballentine Carter, M.D.):

"Standard biopsies often detect indolent or inactive tumors, that won't spread beyond the gland and become deadly. More worrisome, first-time standard biopsies miss up to 35 percent of dangerous tumors that require treatment."

The UCSF document (Brachytherapy for Localized Prostate Cancer) notes that: "The biology of the cancer makes it likely to recur even after the best treatment." It adds that the cancer "may also change into a different form, say from an adenocarcinoma to small cell cancer".

And if the worse comes to the worst? Let's say I do get that fusion guided biopsy and it shows the cancer is still relatively localized. Then I will adopt a "wait and see" approach rather than rush into anything. If, however, it has metastasized from the original four localized areas and is ready to "burst the capsule" I will have to consider options available - so long as those options don't radically degrade life quality.. I'm also ok with doing nothing, as long as I can get a few years of life quality and critical organs aren't threatened -  or there's a chance to prevent invasion of lymph nodes. All other factors being equal I am ok with a few extra years of quality life as opposed to 12 or 15 of not so great quality.

Heck, I have revised my living will and am now in the process of revising my existing last will and testament. (Which, btw, every sensible American ought to have unless they want the state to grab everything!) Death does not terrify me, and in any case there are much worse outcomes - maybe living longer but developing Alzheimer's disease as my mother did. She lived to be 91 years of age, but the last 15 were mostly survived in a haze, with her unable to acknowledge where she was, or what she had just said five minutes earlier.

In the end, it's all relative and we each have to pick our own terms of surrender ...or not.

See also this informative site on dealing with biochemical recurrence:

http://www.harvardprostateknowledge.org/how-to-handle-a-relapse-after-treatment-for-prostate-cancer

See also:

http://brane-space.blogspot.com/2015/12/testosterone-blocking-cancer-drugs.html

Rising PSA After Radiation Therapy ? Don't Be Rushed Into "Salvage" Therapy!

After another increase in PSA, now to 2.8 (from 2.5) after only 3 months, yes I have begun to panic. In the ideal world it would have been going down, down, down and the 2.5 reading would have just been a "flare" as my radiation oncologist at UCSF put it.  But am I about to hit the 'chicken switch' and run for a urologist, or for 'salvage therapy'? HELL NO!  Not after pouring through dozens of technical papers  (mainly in the Journal of Radiation Oncology) since the test result came back.

To sum it all up: radiation, namely HDR brachytherapy, e.g. see my description of the treatment at UCSF in 2012 here: http://brane-space.blogspot.com/2012/09/thge-longest-dayand-then-some.html

takes much longer than surgery before a true PSA nadir is hit. Generally from 36-40 months, and in one article noted in the Oncology Times, a time of 5 years was assessed as proper before one could compare "apples to apples", i.e. with a typical prostatectomy nadir of 0.1 ng/ml. Five years is a long damned time!

Now enter a voice of reason in Kent Wallner, M.D., Associate Professor in the Radiation Oncology Dept, at the University of Washington Medical Center, who as early as 2001 reported three confirmed cases of men who had "temporary, self-limited PSA rises as well as post-implant biopsies showing "histological evidence of persistent  cancer" . All 3 declined to have salvage therapy (i.e. anti-androgen therapy, salvage prostatectomy or salvage radiation treatment). The hum dinger?Despite refusing further treatment all saw their PSAs fall.

In a subsequent interview, Wallner observed he was "met with skepticism" when describing the cases.  He said this was because:

"it defies common sense to have a rising PSA and a positive biopsy and not have cancer".

True, but again, mayhap the Medical Industrial complex doesn't know everything after all, and despite all their proclaimed 'insider' knowledge of what ought to happen after a radiation treatment, they are still on the short end of the learning curve.

As an aside, all of this pretty well confirms Medical author Shannon Brownlee's take, in her book 'Untreated: Why Too Much Medicine is Making Us Sicker and Poorer' (2007, p. 202):

"The evidence suggests that PSA testing is not saving any lives, and even it is the large numbers of men who are treated unnecessarily are paying a terrible price. They're the equivalent of civilian casualties in our war on cancer.".

Again, I reiterate, yes I did have treatment - under pressure from my wife, my urologist, my primary doc and others. BUT......as a fellow Intertel member emailed me (soon after I wrote about the experience in the Intertel Regional Newsletter 'Port of Call') I might also have lived with only minor problems (the cancer stage was T1c) and croaked eventually  of something else. This is because 97% of prostate cancers are slow growing. (Incredibly, 99% of males autopsied who are 79 years of age or older are found to have prostate cancer .....and most never knew about it!)

So now AFTER treatment (and many of the still lingering side effects like burning urination) I am to go back for more? Uh unh! Don't think so!

And I am validated by Dr. Wallner's research. Wallner has noted that since up to one third of men will have rising PSAs sometime after brachytherapy (possibly for a number of reasons including inflammation or enlargement because of the radiation effects - thus imitating BPH) " a fairly large percentage of them might have unnecessary biopsies and unnecessary surgeries."  (Oncology Times, Vol. 23, No. 10, 27-30)

Wallner acknowledges that his study lacks a denominator, because "not every man has a biopsy following brachytherapy" (with good reason, as the cells are in a 'mess' from the radiation, and the gland is still affected, so the histological skills to discern cancer are much much greater than for an ordinary biopsy). Most of the literature I've seen argues it would be foolish to even think of a biopsy before about 3 years AFTER treatment. There is simply too much room or error, and getting false positive or false negatives.

Wallner (ibid.) documents his following 6 men (beyond the original three) who had PSA bumps and also positive biopsies but "whose PSA levels have since fallen and are consistent with long term cancer control".

He added:

"This is a real problem because common sense would tell us we've got to operate on these people. But because there's no clear answer we should think long and hard before recommending a salvage prostatectomy ."

Indeed. And while we're at it, let us bear in mind that often in science the failure of a simple common sense signifies massive ignorance in an area. In physics, for example, it is "common sense" that a dart fired at a board with two apertures or holes can only transit one or the other, not both. Yet at the quantum level the electron violates this script all the time in the classic two-slit diffraction experiment. Hence, the danger in using common sense as a guide, including in the medical arena.

Dr. Wallner hypothesizes that a repeat biopsy might be positive because of residual tumor in the prostate.  As he describes it (ibid.):

"We know it takes a couple of years to clear cancer after high dose radiation, so for the first two years or so you can see residual cancer in the prostate.  But you don't know if it is viable or not."

This again makes eminent sense, because the effects of radiation occur over time, not all at once as in the case of radical surgery. Hence, the medical industrial complex ought to be sensible enough to realize that and hold back - but that's not in their nature. Like gunslingers of the old West they want to 'kill' any sign of the 'bandit' - even though he's basically moribund and on his last legs.

Wallner is backed up by Bradley R. Prestidge, M.D.,  a radiation oncologist at the Cancer Therapy and Research Center in San Antonio. He points out (ibid.):

"The older literature is fraught with misreadings of biopsies done too soon. within 12 to 18 months post radiation treatment. Cancer cells take a while to die off and even though some may look like cancer architecturally, they are not dividing."

Dr. Prestidge went on to point out that especially after brachytherapy, y prostate cells labeled 'indeterminate' on biopsy "may look cancerous because of background radiation effect."

His recommendation: Patients, urologists and oncologists "should not rush into this".

Indeed.

Dr. Wallner's main take away: he would personally wait three years for the PSA to decline after brachytherapy.

He concedes this is a "tough option" because "some men will indeed have recurrent cancer".

But he adds:

"If I had done a salvage prostatectomy on these men (in his original study) I would have done them a great disservice."


Footnote:

In a study of 779 men following Dr. Wallner's , Frank Critz, MD, and colleagues, found that the median PSA rise was 0.4 ng/ml above the median pre-bump PSA of 0.7 ng/ml. For 10 to 20 percent of these men, the rise was 2.0 ng/ml during the bump. In one case the PSA level reached 15.8 ng/ml before dropping.

The median time to the rise was 18 months from the time of implant, and in 92 percent of men it was observed within 36 months.

Dr. Critz defined a bump (which he called a “bounce” in his report) as a PSA rise above 0.5 ng/ml with a subsequent fall to less than 0.5 ng/ml, for men who had a post-treatment PSA nadir of 0.5 ng/ml or less. For men with a pre-bump PSA of greater than 0.5 ng/ml, a bump was a rise of 0.1 ng/dl or more with a subsequent fall below the pre-bump PSA level. He noted, however, that one percent of men have a bump with the very first PSA assay taken after treatment.

The mechanism of PSA bounce after radiotherapy and its relevance to long-term survival were unknown, Dr. Critz said, in an interview for the OT. But he noted that curative surgery for prostate cancer differs from curative radiotherapy, in that time must be allowed after successful irradiation for malignant and benign prostate epithelium to disintegrate.

It may be this process that causes a clinical or sub-clinical prostatitis and leads to the temporary PSA rise.

Perhaps it's time  (before making generalizations about treatments) the medical community do much more study and research on the effects of radiation - at different doses - on living tissues, including cancerous tissues!

Addendum: 1/ 26:

An email received this morning from my radiation oncologist, Dr. Hsu, acknowledged my research and that he agrees what we're seeing is a PSA "bounce".  He also said that the original PSA reading of 2.0 ng/ml was not the nadir. So, this may well be a 2-3 year wait!

Mail Brane Blog: Readers Seeking Answers to Questions

Q.  Ok, I'm curious. In your Sept. 28 Mail Brane Blog the second questioner('Davante')  asked if he could go to FLA and "teach your cracker brother some manners". There's a link to his racist blog in your response but when I click on the link I get a message:

"Sorry, the blog at mytalkandthoughts.blogspot.com has been removed.  This address is not available for new blogs."

So what happened to it? - Julie, Ann Arbor, MI

A. I have been informed by a reliable source that Mike voluntarily removed it as he was "appalled" at the hate he'd spewed out again.  Of course, he's done this on at least two occasions earlier before changing his mind and resurrecting it again. So, who can say what the real reason is? My theory is - if he did take it down on his own - it was more likely a result of being blistered with comments, emails complaining about the content. He simply got tired dealing with all the flack so simply pulled the whole blog.

Q. Reading your assorted posts on the framing of Oswald by the CIA, the Oswald doppelgangers and so on, has my head spinning. Can a conspiracy really be this complicated? - Oscar W., London, Ontario

A. Of course! The mistake too many make is assuming simplicity along the same theoretic lines as for physical theories. Obviously, we opt to have physical theories,( i.e. quantum theory, Newtonian gravitation etc.) that are simple and elegant, minimal hypotheses and no loose strings, because these are also more amenable to mathematical formalism. Thus, the widespread presumption that any viable physical theory needs to be a hallmark of simplicity - not complication.

But let's be realistic here: human beings are not inanimate, unconscious objects like planets and moons in defined orbits,  or billiard balls - say that collide according to Newton's 2nd and 3rd laws of motion- making their future paths predictable. Humans by their nature possess the capacity for duplicity, formulation of self-determined agendas and concealed motives as well as the ability to misdirect others toward their (hidden) agendas. In any conspiracy of any magnitude (say like assassinating a President), therefore, one fully expects such devious capacities to overwhelm straight line logic - given the conspirators already know any would-be investigators would start off with that form of approach.

Hence, for the conspiracy to be ultimately successful, it would have to cover all the (ex post facto presumed linear logic) bases in advance, and build in misdirection at multiple junctures. The use of Oswald "doppelgangers" (actually impostors, and at least one physical double - deployed in Big D itself) accomplishes this. Yes, it is liable to make certain heads "burst"  and others spin- but then those heads, brains are too wedded to pedestrian and prosaic (what I call linear) logic anyway. They will always be the first to throw their hands in the air, and say 'I give up - this is too complicated' and opt to chose the simplest alternative, albeit totally wrong - which is the lone assassin bollocks.

This is why seriously pursuing something like the JFK assassination is not for everyone. The false leads, framing complexities, arcane CIA mischief -  false names, cut outs, constellation of differing files-documents as well as covert operations, narratives are usually too much except for deep politics mavens. Most Americans, sadly, can barely keep pace with our standard politics, far less deep politics. But those of us who want to get to the bottom of this dastardly crime of the century aren't easily dissuaded, nor are we easily distracted by lone assassin bunkum, tales or fake  "revelations" (which supposedly REELZ-TV plans to put on tonight). We know better, through long years of experience and having been already led down many dead ends and into false leads.

Basically then, there are few options for anyone really interested in the case:

1) You can hurl yourself into it and dig up thousands of files, documents and pore through them like the rest of us (researchers) have.

2) You can take the easy path, and just accept the simple (but wrong) lone assassin narrative - sticking with the likes of Gerald Posner, Vince Bugliosi, Philip Shenon etc.

3) You can adopt an "agnostic" approach and just say the case is too difficult to find any reasonable resolution, but knowing in the back of your mind, many of us already have (to within perhaps 95% probability).

Q.  I was shocked to read in your Sept. 25 blog of the persistent after effects from the radiation treatment for your prostate cancer. I would have thought given such significant effects the psa would surely have dived but in your blog post of Nov. 2 you say it's gone up.  How is this possible?- Anne, Dublin, Ireland

A. Sadly, Anne, no one knows the answer. All anyone can do is guess. Who knows why some 10 percent or so of patients hit the psa nadir within months of treatment, and it never goes back up? And why others (like me) experience a "PSA bounce" and then have to closely monitor the PSA over time for signs of "treatment failure". No one really knows and this is why more longitudinal studies over time for the different treatment modalities are badly needed.

One more interesting aside: When I had the PSA test done at LabCorp, I had to sign a form agreeing to pay for the test ($127) if Medicare didn't, given Medicare regards those in my "condition" as no longer needing it!  Now, this is strange, but maybe not. It suggests that Medicare regards the fact that once you've had treatment as ending the matter. Hence, a series of PSA tests - with rising numbers - led you to get treatment, but now that you've had treatment you need no further tests. Of course, this takes no account at all of the possibility of treatment failure or that the numbers can go back up. But given Medicare's solvency problems I guess it's understandable, so I expect to probably have to pay!


Q. In your Oct. 30 post ('Pills Made from Poop') you wrote that your wife got c. diff. after taking amoxicillin, but then to relieve it she was put on another antibiotic called flagyl- which didn't work- so then she was put on vancomycin. What I don't get is how an antibiotic can cause c. diff. but then it takes an even stronger antibiotic to snuff it out. How can that be? Shouldn't the strongest antibiotic make the symptoms worse if a lesser one starts them off? - Andre, Santo Domingo, Dominican Republic

A. Sorry, antibiotics don't work in that particular way. First, there appears to be a category of antibiotics which predisposes one to c. diff. Amoxicillin is one of these, and there are others which you can learn about by googling: "antibiotics predisposing to c. diff".  Let's also grasp that the initial introduction of amoxicillin essentially killed off nearly all the good bacteria which allowed the bad bacteria, the c. diff. to spread. By this stage, then, with the harmful bacteria spreading, an antibiotic powerful enough to kill them is what's needed. These are flagyl and vancomycin. The only possible effect these could have is: no effect (i.e. on antibiotic resistant bacteria) or eliminating the bad bacteria enough to allow the good guys to proliferate again.


Q. Reading your post 'The United States Of Tex-Ass' on Oct. 26 was a wake up call since I now live in Dallas. I never realized what a hotbed of hate the city was back in 1963, and to me it might explain for why Kennedy was killed there. Are they any other sources about the city back then, say from online sites, that I can read about it? I plan to get 'Dallas 1963' but in the meantime would like to see some other stuff. - Jared, Dallas, TX

A. A recent set of articles - blog posts has been appearing by Russ Baker on www.smirkingchimp.com based on his bestseller, Family of Secrets: The Bush Dynasty, America’s Invisible Government and the Hidden History of the Last Fifty Years. 

These appeared in seven installments on smirkingchimp.com with full article accounts in a separate blog link at www.whowhatwhy.com.   You can read his Dallas account here:

http://whowhatwhy.com/2013/10/24/bush-and-the-jfk-hit-part-6-the-cold-war-comes-to-dallas/

It's headed up:  A Cauldron of Right Wing Americans, Right Wing Russians, and Nazis

 Be thankful you're not living in the Dallas of 1963!


Q. Why do you think the American congress is so reluctant to put a leash on the NSA, especially after they have spied on European allies and broken into Google's cloud sites to collect so much data? - Gerhard Remke, Bielefeld, Germany

A. My suspicion is that the spooks have tons of stuff on all congress critters, so effectively the threat of black mail is enough to halt any ability to pass effective control legislation now. I also suspect that they have loads of material on Angela Merkel, France's François Hollande and the UK's David Cameron.  Given this hidden leverage it was no surprise all the allies could be deterred from accepting Edward Snowden as a whistle blower refugee. The leaders were all too intimidated to do so. To read more from the actual author of this theory, see:
 http://www.smirkingchimp.com/thread/dave-lindorff/52437/what-s-done-abroad-can-be-done-at-home-too-is-nsa-spying-really-about-blackmail

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!

PSA Test Results Are Back: To Celebrate or Not?

Barely ten minutes ago a nurse phoned from my primary care doc and gave the results of the PSA test taken last Friday, and roughly 3 months after the conclusion of my prostate cancer radiation treatment. She reported the PSA as 2.0 - which is "within normal range". While wifey was ecstatic, and this was definitely a positive,  considering it had gone up to 6.1 in June (before the biopsy and radiation treatment in September, see e.g. http://brane-space.blogspot.com/2012/09/thge-longest-dayand-then-some.html) I noted we still had to wait to see what Dr. Hsu of UCSF made of it. Would he be satisfied with this first post-treatment result? We'd have to fax the lab report to him then see.

In the meantime, I am not hitting the panic button though I had hoped the PSA would have been closer to 1.5. But in a way it makes sense. As I noted before one can't compare a first PSA taken 3 mos. after radiotherapy (even high dose) with that taken after radical prostatectomy because in the latter case the whole gland is effectively removed, while in radiation it is left in. Thus, one still has production of prostate specific antigen by the remaining intact cells of the prostate, and one knows this is fueled by testosterone. (I haven't had a test for testosterone level, but if I had I am sure it would show close to normal levels.)

The other thing one must bear in mind is that the effects of radiation are progressive. Most statistics show that by five years after radiation high dose treatment the effects are almost identical to those after radical surgery. In other words, my time line will disclose increasing effects- many of them negative - such as damage to the erectile tissue, blood vessels etc. as the effect of the radiation dose continues on the cells. Over this increasing time line, one ought to see a decrease in PSA, though as I also noted before there may be aberrations which occur - temporary blips upward- and then declines. A "treatment failure" is only reported when there is no further decline. When I hit the lowest PSA over a timeline, say two years, that will be defined as the "PSA nadir". If it pops back up, we call it a "PSA bounce". Ideally we don't see too many bounces!

The "cure rates" reported in most studies tend to depend on two factors: 1) the quality of the treatment, and 2) the average risk type of the patient. Note most studies are "retrospective" or ex-post facto, only concluded after the fact. This is consonant with both the nature of the disease and also the treatment, especially radiation. The problem is that accuracy is limited by variations in "risk types" for different institutions. (Oncologists do their best to match risk types from institution to institution but for a number of reasons the matching process is less than perfect, introducing uncertainty.)

In one of the most notable studies, completed by Dr. Patrick Walsh (who invented the modern form of radical prostate surgery) at Johns Hopkins, the 15-year cure rates as reported in the journal 'Urology' in 2007, were 85%, 63% and 40%. These were for low-risk, intermediate risk and high risk disease, respectively. (Let's also bear in mind that even the best surgeons in one study group left cancer behind in 10% of cases - as determined by the "positive surgical margin rate". This is the frequency, usually given as a percentage, of leaving cancer cells behind over a number of 'n' surgeries performed.

Meanwhile, in the most prominent reported study for (low dose) seed implant brachytherapy, in the International Journal of Radiation Oncology (2007), the cure rates were 86%, 80% and 68% for low, intermediate and high risk cancer.  (By all considerations my high dose rate brachy results ought to compare even more favorably!) In other words, the two methods compare very well at least from these two studies. (A futher interesting point is that a Johns Hopkins study has shown that relapses after surgery occur on average five years earlier than seed implants.)

In the end, it's a waiting game. Over more time, perhaps at least two years, the chief oncologist will be able to definitely say that the battle has been "won" or perhaps only drawn, or lost. Right now I am just elated to have a much lower PSA than I had 6 months ago, and will take that as a 'W'.

Post-Treatment PSA Increases: Another Cause for Concern?

                                                                

                              Original report from prostate biopsy in July 2012
                                                                             

                                   Remote brachytherapy afterloader which treated my cancer with high dose radiation in September, 2012.


Alas, the more one reads concerning the aftermath of radiation treatment for prostate cancer, the more one wishes he didn’t! Having now just completed my 1-month report on side effects to my radiation oncologist at UCSF I now am faced with getting a PSA test next month to check on the efficacy of the high dose brachytherapy treatment.

Googling- reading disclosed a number of disconcerting aspects:

- In some 17% or more of men (depending on the study)  there is an uptick in PSA following treatment at some point or what is called a “PSA bounce”.

- If this uptick is repetitive, i.e. the PSA doesn’t go back down to 0.2 ng/ml or less, it could signal “treatment failure” and the potential for further biopsies, treatments

- These further biopsies could cause the oncologist to prescribe surgery, hormone treatment (androgen deprivation therapy) or other further interventions.


All of this makes me nervous as hell, especially as any surgery (i.e. radical prostatectomy) would be hideously complicated given that after radiation (especially high dose) there is residual scarring that makes a clean extraction difficult if not impossible. The other alternative, hormone treatment therapy, is almost as disturbing with all kinds of effects no male in his right mind wishes to remotely contemplate! See also the video: http://www.prostatevideos.com/prostate-cancer/treatment-options-for-rising-psa-after-local-therapy/rising-psa-after-brachytherapy/


Hence, I am approaching next month’s PSA blood test with some degree of trepidation.

The PSA bump some men experience after brachytherapy for prostate cancer is puzzling enough- basically a PSA rise that's not a sign of recurrence (Oncology Times, 7/2000, p 1). The situation is rendered even more confused by a recent report of another phenomenon: post-brachytherapy biopsies that are positive but that don’t indicate cancer has recurred!

The two phenomena are causally related in that when an oncologist or urologist sees a rising PSA after prostate implant it often prompts a demand for repeat biopsy. But the author of one report in the August, 2001, issue of the International Journal of Radiation Oncology Biology Physics (Vol. 50:1207-1211) insists a rising PSA and a positive biopsy can be entirely coincidental. Kent Wallner, MD, Associate Professor in the Radiation Oncology Department at the University of Washington Medical Center and Chief of Radiation Oncology at Puget Sound Veterans Hospital in Seattle, reported three cases of men who had temporary self-limited PSA rises as well as post-implant biopsies showing histologic evidence of persistent cancer. The patients declined to have salvage prostatectomy, and subsequently all have had PSA levels fall.

In an “Oncology Times” interview, Dr. Wallner noted that he has met with skepticism when describing these cases, because it defies common sense to have a rising PSA and a positive biopsy and not have cancer, he said.

“We've known about the 'bump' for some years now, but this muddies the water even more. The positive biopsy along with the bump had not yet been described.”

Since approximately one third of men will have rising PSAs sometime after brachytherapy, Dr. Wallner said, a fairly large percentage of them might have unnecessary repeat biopsies. If positive, these could lead to unnecessary surgery.

To say this is distressing is putting it mildly! Then, to add to that, there seems to be –incredibly! – a movement afoot to judge treatment failure and post—procedure PSA results along the same lines as for radical prostatectomy! For one thing, in radiation therapy the prostate gland remains in place and hence the remaining (normal) cells will continue to produce prostate –specific antigen so it’s nuts or at least irrational to expect PSA level to decline to “undetectable” levels (i.e. < 0.1 ng/ml).

Moreover, on account of this fundamental difference, PSA levels will only over time tend to decrease to the levels seen relatively quickly after radical prostate surgery. Some papers cite a 2-year minimum to reach 0.1 ng/ml and another cites a median interval of 40 months – which may include PSA intermittent rises in between.

In their article, ‘PSA Kinetics After Prostate Brachytherapy: PSA Bounce Phenomenon and its Implications for PSA Doubling Time’ (Journal of Radiation Oncology Biological Physics, Feb. 2006, p. 512) Ciezki et al found in their post-procedure analysis of 162 patients who’d received prostate cancer brachytherapy treatment a “PSA bounce” by 75 or 46.3 %.


Interestingly, patients found to have experienced a PSA bounce (uptick in their PSA readings after procedure) were less likely to have been deemed to have a “biochemical failure” irrespective of the definition used for such failure.

What factors, if any, affect or may contribute to PSA level bounces post-treatment? They include:


1. Prostate size: the larger the size the more likely the patient is to have a PSA level rise

2. Patient age and isotope used: Those under 62 are more likely to experience a PSA spike, while those subjected to Iodine -125 radiation are 3 times more likely to see a PSA rise. It is less likely for those receiving dosage from Iridium-192 as I have.

3. Implant dose: the higher the dose received at implant the less likely the PSA rise since more cells will have been killed.

4. PSA Nadir: The PSA nadir following brachytherapy is a predictor for subsequent PSA spike. The nadir is the lowest measurable PSA before a spike would occur. Patients with a nadir of 0.2 ng/ml or less are less likely to develop a PSA spike (Merrick et al., 2002). The median time to achieve nadir is 27 months. When nadir occurs within this time frame, it indicates that there is little to no viable prostate epithelium present; hence, the absence of residual malignancy. A PSA spike, therefore, is uncommon after a nadir of less than 0.2 ng/ml is reached.


What will my strategy be in the event of a PSA spike, assuming such occurs? First, not to hit the panic button since as numerous graphs in oncology papers show, there’s about a 1 in 3 chance this will take place at some point. If further rises continue, I will decline any biopsies, since the paradox earlier noted is plausibly the basis. I also most certainly will decline any recommended surgery after the fact. If any other treatment is considered it’ll most like be the “intermittent hormone treatment” described in the earlier video link.

Anyway, we will see what happens!