What Does PSA Count 0.08 Actually Mean in My Case?

[Chris W]

I had a radical prostatectomy on 26 March 2016 and despite my MRI scan showing that the cancer was contained within the prostate, the histology report showed that the cancer had in fact spread outside of the prostate capsule (extra capsular extension) and that there was involvement of 2/24 lymph nodes, 1 from each side of the pelvis.

I had a blood test on 10 May 2016, 6½ weeks after my radical prostatectomy, that showed a PSA count of 0.08. My appointment date with Consultant Oncologist Dr Money-Kyrle has also been confirmed for 11 July 2016.

Internet research and the fact that Dr Money-Kyrle does not feel any urgency to see me regarding the possibility of radiotherapy treatment suggests that I should be delighted with my PSA result. I would, of course, prefer a professional opinion with regards to my possible outcomes:

1. What is my best possible outcome, i.e. is there a possibility of a cure without any need for radiotherapy? Estimated likelihood in % terms?

2. What is my next best possible outcome, i.e. is there a possibility of a cure with radiotherapy treatment? Estimated likelihood in % terms?

3. What is my worst possible outcome, i.e. could the cancer metastasize and reduce life expectancy? Estimated likelihood in % terms?

Many thanks in anticipation.

[professoreden]

Chris

Unfortunately, up-staging and up-grading of prostate cancer, as was seen in your case, is not rare and occurs in 5-30% of men, depending on which surgical series from the published literature you read. The advantage of surgery over radiotherapy as the initial treatment is that armed with knowledge of the definitive stage and grade one can better predict the future and with a target PSA of less than 0.1 we can have a very clear idea of when we need to intervene.

Your PSA of 0.08 at 6.5 weeks looks very good but the reason you have been referred to an Oncologist is that your final histology showed that you have 2 risk factors for recurrence: extracapsular extension (giving you a stage of T3a) and the involvement of 2 lymph nodes. The issue that needs to be discussed now is whether to monitor you with PSA levels and give you radiotherapy only if your PSA level rises (salvage radiotherapy) or to give you radiotherapy within the next few months (adjuvant radiotherapy) to lower the risk of future recurrence. We know from 2 high-quality studies that adjuvant radiotherapy decreases the risk of recurrence but we also know that it causes temporary side-effects in all men and in 20% of men troublesome side-effects persist. What we don't yet know is which is better, but in the absence of any compelling evidence to demonstrate the superiority of either approach there has been a large shift towards salvage radiotherapy.

To answer your questions directly:-
1. the likelihood of cure without any further treatment according to the Memorial Sloan-Kettering Hospital nomogram and using your specific cancer parameters is 54% at 10 years from your operation with a 98% probability of survival at 15 years. This is the worst-case scenario as if your PSA were to rise in the future you would be offered treatment and these numbers would be more favourable.
2. If you had adjuvant radiotherapy now, or salvage radiotherapy when your PSA reached 0.1, combined with hormonal therapy your probability of cure using the same nomogram would be 84% at 6 years after the completion of radiotherapy.
3. Unfortunately, your cancer has already metastasised to your lymph nodes. The worst outcome, using the figures given above, is that you succumb to prostate cancer within the next 15 years but the risk of this is only 2%.

The aim now is to maximise your probability of cure or, if cure is not possible, of disease control as well as maximising your quality of life.

Feel free to come back to this forum with more questions if you have them.