What Warning Signs Should I be on the Lookout For?
If you have prostate cancer, your PSA score by itself is often not a very accurate indication of your condition before you begin your primary treatment, whether you have proton therapy, seeds or surgery. By contrast, PSA readings taken after your primary treatment are frequently highly indicative of whether your treatment is successful or not. That is why your doctor will want you to have your PSA taken every three months for a year or two after treatment.
What sort of PSA readings indicate that your treatment has been successful? Obviously, if you never had hormone therapy and your PSA reading is say, less than 1 ng/mL at your first three month checkup after treatment, that is very favorable. You’re doing great if every one of your 3 month checkups produces a PSA of less than 1. But many, perhaps most of us do not have a PSA that drops right to the bottom after three months and stays there.
So what if your PSA does not drop very much at your first 3 month checkup? What if it actually goes up at your first check up? What if it bounces up after 3 months? Does that mean your proton therapy was a failure? Not necessarily.
Readings 3 months after treatment are rarely if ever conclusive. By itself, the first reading means very little. Instead, your doctor will look at your first three or four PSA readings to determine if there is a trend or a pattern of PSA readings. Now, let’s take a look at some patterns showing successful treatment results.
The first slide depicts the median patterns of a group of men following their treatments at the University of Florida proton center during the first two years. It comes from a study published online (in press) in 2010. PRO1 is the low risk group, PRO2 is the medium risk group and PRO3 is the high risk group. See how gradual the patterns are over the first two years after treatment ends (the line marked “RT end”). The exception is PRO3 the high risk group because they’re put on hormone therapy at the end of their treatment, so their PSA drops much faster.
Just because your pattern is different to the first slide does not mean your treatment has failed. Quite the contrary. You can have a far different reading and trend, but still have a favorable result. The second slide is taken from an Australian study published in 2009. It shows changes in readings over the course of one year. Note the big jump in the first 3 months from a PSA of 12 after treatment, up to 20 at the first reading. (So you think you’ve had it bad!) But then the next reading shows a drop to about 8, and then a gradual declining plateau. As long as the pattern drops, things are OK. So a big jump in the first couple of readings does not automatically mean your treatment failed, especially if a large drop follows. This slide shows a successful treatment so far.
The third slide shows changes in readings over nine years. Note that the first reading shows a drop from 12 only to 10 after the first post treatment reading. But then the PSA plunges to about 2 on the second reading. Between year 1 and year 2, the reading hits bottom, but then starts to go up, but never exceeding a PSA of about 2. By the middle of year 3 a plateau is reached, which stays consistent. Here again, we have a successful treatment.
Conclusions from Non-HT slides are summarized. Three take aways:
- You don’t need to lay awake a night or two before your first PSA reading after protons worrying, or even before your second, third or fourth PSA reading. So stop worrying before each checkup!
- Normally, a pattern does not develop overnight. It can take as long as two or three years.
- Plateau patterns are best.
WITH HORMONE TREATMENT
Now for a couple of slides showing patients on short term hormone therapy (6 months or less.) Look at the huge drop from a PSA of about 22 down to near zero for the first post-radiation treatment. This is a typical of what happens to your PSA when you start on Lupron. When you get off Lupron, your PSA bounces, but this one hardly bounced at all after ending Lupron. It’s pretty flat and stable reading, which is a favorable pattern for a cure.
The last Lupron slide shows a comparable pattern, just not as dramatic.
Two points to make on the HT slides. First, if you have HT before beginning protons or radiation, your chances of success are doubled if your PSA after HT is below a 0.5 reading, according to a study done by our own Dr. Choi and Dr. Lee, and which is summarized on the slide above.
Second, once the HT is out of your system, then consider yourself like a non-HT patient and follow the results we’ve discussed above.
One final comment: We don’t have enough space here to feature PSA patterns where the treatment was not successful, primarily because these vary all over the lot, and much more explanation is needed. However, even in that instance, the PSA gives a lead time of a least one year before problems start to show up. Thus, your doctor has lots of time to work out a treatment plan to deal with those problems.
Dave Stevens from March 1, 2012.