The Role of PSA Testing: From Early Detection to Monitoring Survivorship

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• Active Surveillance (AS) is typically for men with low-risk, slow-growing prostate cancer. The goal is to avoid or delay treatment side effects (e.g., from surgery or radiation) while closely monitoring for any signs of disease progression.
• Actual “reduction” or disappearance of cancer during AS is rare; more commonly, the cancer remains stable or grows very slowly. If it shows signs of progression (rising PSA, worsening biopsy findings), active treatment is recommended.

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• Non-Detectable PSA: Many labs consider <0.1 ng/mL “undetectable,” though some use ultrasensitive tests (<0.02 ng/mL).
• Worry Threshold: A widely used definition of biochemical recurrence is a PSA level ≥0.2 ng/mL on two separate tests, or a steadily rising trend above 0.1 ng/mL. Talk with your doctor if PSA starts increasing after surgery.

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• Erectile Dysfunction (ED) is a common side effect after prostate removal (radical prostatectomy). Nerve-sparing surgical techniques can preserve erectile function for many men, but recovery can take months to years. Younger men with good baseline function typically recover more effectively than older men or those with preexisting ED.

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• The number of radiation treatments (fractionation scheme) can vary: traditional protocols might last ~39–45 treatments, while moderately hypo fractionated courses can be ~20–28 treatments.
• Needing 21 treatments alone does not automatically indicate a more aggressive cancer. It’s just one of several standard protocols for localized or locally advanced prostate cancer.

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• Total PSA measures all forms of prostate-specific antigen in the blood (protein-bound and free).
• Free PSA is the unbound portion. The ratio of free-to-total PSA can help distinguish benign conditions (such as BPH) from potentially malignant prostate lesions.

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• MRI/Ultrasound Fusion Biopsy merges detailed MRI images of the prostate (to locate suspicious areas) with real-time ultrasound. This “fusion” approach improves accuracy, allowing doctors to better target suspicious regions rather than doing random systematic biopsies.

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• PSMA PET is more sensitive than older imaging tests but isn’t 100%. Small lesions may remain below detection limits, and some prostate cancers may not express high levels of PSMA.
• A mild PSA rise might also be due to benign prostate remnants or lab variability. Confirm trends with repeated testing and talk to your doctor if PSA continues to climb.

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• Multiple Methods:
  • Track PSA trends (velocity, doubling time).
  • Use imaging (PSMA PET, MRI) to spot recurrence.
  • For patients on ADT, checking testosterone levels can confirm adequate hormone suppression.
• High Gleason scores signify aggressive pathology, so close surveillance is essential, regardless of PSA level.

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• Early disease: Often no symptoms.
• Locally advanced: Possible urinary frequency, weak stream, nocturia (frequent urination at night), pelvic discomfort.
• Metastatic disease: Bone pain (hips, back), fatigue, weight loss.
  Routine screening and follow-up can help catch prostate cancer early, even without symptoms.

  Answer:

  • Early disease: Often no symptoms.
  • Locally advanced: Possible urinary frequency, weak stream, nocturia (frequent urination at night), pelvic discomfort.
  • Metastatic disease: Bone pain (hips, back), fatigue, weight loss.
    Routine screening and follow-up can help catch prostate cancer early, even without symptoms.

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• Historically, 4 ng/mL was used as a universal cutoff, but many physicians now look at PSA trends, age-specific ranges, family history, and other risk factors.
• Some experts prefer a lower threshold (e.g., 3 ng/mL) for younger men or those at higher risk (e.g., African American men, strong family history). It’s an individualized decision.

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• Recurrence Mechanisms: Microscopic disease may have spread before surgery, or the surgical margins may not have been completely clear.
• ED Recovery Post-Radiation+ADT (androgen deprivation therapy): Hormone therapy lowers testosterone, contributing to ED and low libido. Normal function can return gradually once ADT stops, but it can take months to over a year, depending on baseline function and age.

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• Post-Treatment PSA Schedule often goes like this:
  • Every 3–6 months for the first 2 years,
  • Every 6–12 months for years 3–5,
  • Annually (or as needed) after 5 years.
• Actual intervals vary with individual risk factors and physician preference.

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• Common Side Effects:
  • Urinary: Frequency, urgency, discomfort.
  • Bowel: Diarrhea, rectal irritation or bleeding.
  • Sexual: Erectile dysfunction can appear or worsen.
  • Fatigue: Typical during treatment.
    These effects can be temporary or, in some cases, long-term.

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• Genetic Screening might show you lack certain hereditary mutations (e.g., BRCA, etc.) but it cannot rule out developing prostate cancer.
• A Gleason 8 indicates high-grade cancer, which warrants more aggressive treatment and close follow-up, regardless of genetic status.

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• Obesity can make surgery more challenging and may affect treatment planning for radiation.
• Being overweight or obese is associated with a higher risk of certain complications and possibly worse outcomes, though many factors play a role.

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• Urine-Based Tests (e.g., MiPS, PCA3) are in use or under investigation, but they typically serve as supplementary tools alongside PSA and imaging. They are not universally adopted or considered a complete replacement for biopsy.

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• After 25 years of undetectable or near-zero PSA, the likelihood of recurrence is extremely low. Many doctors still recommend annual or occasional PSA checks for peace of mind, but the risk is minimal.

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• Some surgeons/oncologists recommend adjuvant radiation if high-risk features are found (positive margins, advanced stage) even if PSA is undetectable. Others prefer salvage radiation only if PSA rises to a threshold (often ≥0.1–0.2 ng/mL). Discuss specifics with your care team.

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• PSA Fluctuation can occur due to benign prostatic hyperplasia (BPH), prostatitis, or normal lab variations. In older men with stable mild fluctuations and negative biopsies, watchful waiting or periodic monitoring is common.

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• A PSA “bounce” is relatively common within the first 1–2 years after brachytherapy (seed implants). PSA may temporarily rise, then settle again.
• If there’s a persistent upward trend well above your nadir (lowest point), or if it rises by 2 ng/mL from that nadir (Phoenix definition), your doctor might consider a PSMA PET or other imaging to check for recurrence.

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• Gleason Score ranges from 6 (low-risk) to 10 (high-risk). It’s based on how cancer cells look under a microscope.
  • 6 = Least aggressive (“low”)
  • 7 = Intermediate (3+4 vs. 4+3)
  • 8–10 = High risk

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• PSA alone is imperfect; some high-grade cancers produce relatively low PSA.
• Other markers of aggressiveness include PSA velocity, doubling time, Gleason score, genomic tests (e.g., Decipher, Oncotype DX), and imaging findings.

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• Seminal Vesicle Involvement (T3) is higher risk. Options may include:
  • Radical Prostatectomy (possibly followed by radiation + ADT), or
  • Definitive Radiation + ADT initially.
• The exact approach depends on overall health, patient preference, and physician advice.

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• Undetectable: Typically, <0.1 ng/mL (standard test). Some clinics use ultrasensitive (<0.02 ng/mL).
• Recurrence Concern: A PSA ≥0.2 ng/mL (confirmed) or a consistent rise above 0.1 ng/mL.

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• Yes and no: After radiation, biochemical recurrence is often defined by the Phoenix definition = PSA nadir* + 2.0 ng/mL.
• If you’re on ADT, PSA might be extremely low for a time. The threshold for concern is usually a significant rise from nadir.

*nadir is the lowest

Answer:

• Nerve Recovery after prostatectomy can happen, but complete regeneration if nerves are severely damaged is not guaranteed. Many men use PDE5 inhibitors, vacuum devices, penile injections, or implants to aid erectile function if natural recovery is slow or incomplete.

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• Symptoms/Side Effects for ADT + radiation can include:
  • Urinary/Bowel Issues from radiation (urgency, frequency, rectal irritation).
  • Hormonal Effects from ADT (hot flashes, low libido, fatigue, mood changes).
  • ED or exacerbated sexual side effects due to testosterone suppression.

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• Acoustic (Shock) Wave Therapy targets penile tissue to improve blood flow. It typically does not directly affect or “agitate” the prostate. Evidence for its efficacy in post-prostate cancer ED is still evolving; consult a qualified urologist.

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• Gleason 8 is high-risk prostate cancer, more likely to grow/spread aggressively. It often requires combination therapy (surgery + possible adjuvant treatments) or radiation + ADT, plus closer monitoring.

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• Radiation can be performed safely in kidney transplant patients, but requires careful coordination between your oncologist, urologist, and nephrologist. Immunosuppression and proximity of the transplant to the radiation field can be special considerations.

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• There is no consistent evidence that routine vaccines (COVID, flu, shingles) cause a lasting rise in PSA. It’s more likely that the cancer or other prostate changes (BPH, missed screenings) contributed. If concerned, consult your doctor about the PSA trend.

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• Chemotherapy (like docetaxel) is primarily used in metastatic or castration-resistant prostate cancer. In certain high-risk locally advanced cases, it may be added to standard treatments. It’s not typical for localized, low- or intermediate-risk disease.

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• If you had a radical prostatectomy only (and not on ADT), your testosterone often remains at your baseline since your testicles are intact. If you are on ADT, testosterone levels are intentionally kept very low (“castrate levels”).

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• MRI gives detailed anatomic information on the prostate region, while PSMA PET scans can detect small or distant metastases. They complement each other.
• CyberKnife (a type of SBRT) for localized disease can have low recurrence rates, especially if combined with short-term ADT in higher-risk patients. Exact percentages vary by factors like Gleason score and initial PSA.

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• Not necessarily. Many clinicians consider “undetectable” to be <0.1 ng/mL. A PSA <1 is “low,” but it doesn’t prove the cancer is completely gone; trends over time are more important.

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• Salvage Surgery after radiation is possible but technically more difficult and carries a higher risk of complications (incontinence, strictures). Some patients opt for focal treatments or other therapies instead, depending on the location and extent of recurrence.

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• Yes. Tumor (somatic) gene testing can detect mutations in DNA repair genes (BRCA1/2, etc.), which opens the door to targeted treatments like PARP inhibitors. This is more common in metastatic castration-resistant prostate cancer (mCRPC).

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• Routine annual PET scans are not standard unless there’s a rising PSA or other symptoms suggesting recurrence. Imaging is typically ordered based on clinical changes rather than by default.

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• <0.01 ng/mL is considered undetectable by ultrasensitive assays. That’s generally an excellent sign with no biochemical evidence of disease at this time.

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• Modern Surgical Technique: The prostate and surrounding tissues are removed in a way designed to minimize disruption. Robotic surgery offers precise dissection and minimal handling of the gland. While metastatic spread can occur, it typically happens before or independent of the actual surgical procedure.

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• PSA Bounce is common after brachytherapy (seed implants). Variation in the low range is not necessarily a sign of recurrence.
• A PSMA PET scan can be helpful if PSA continues a sustained climb beyond a certain threshold (e.g., nadir + 2.0), but isn’t routinely done for small, occasional fluctuations.

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• Alternatives include the Prostate Health Index (PHI), 4Kscore, or the PCA3 urine test. However, PSA remains the primary screening and monitoring blood test.
• “PSE” is not commonly used; you may be referring to one of these other tests.