At this afternoon’s visit to the doctor to review my August PSA results, he asked, “How are you doing?” I replied, “I’m hoping you’re going to tell me.” “With a PSA of 0.09, you’re doing fine.”
I have to admit that I wasn’t quite psychologically prepared for that answer. Nor was I really prepared for the conversation that followed. But before getting into that, the bottom line was just as I expected: Continue to monitor PSA on a four-month cycle, which has me back in the lab in early December.
This was a new doctor that I hadn’t seen before and he was definitely more seasoned than the last one that I had. Still, all those years of experience could have taught him some better communication skills. He talked in broad generalities and in circles—even in response to my direct questions—and that was more than frustrating.
On the topic of recurrence, he didn’t think that I should be so quick to assume that an increasing PSA is indicative of recurrent cancer. He offered up the possibility that it could have been some benign prostate tissue left behind after the surgery and has grown enough where it’s detectable on the PSA test. Or, it could be cancer.
On the topic of PSA tests in general, he reminded me that the really old threshold for biochemical recurrence was 0.4 ng/ml before it was lowered to 0.2 ng/ml. It seemed that he valued the ultra-sensitive PSA test only as it related to the post-surgery pathology. If the pathology was bad, he seemed to put more stock in the ultra-sensitive PSA; but if the pathology was good, he seemed less inclined to put stock in it.
In other words, if you had a 4+3 Gleason score, positive margins, seminal vesicle involvement, or lymph node involvement—or some combination thereof—he would be more likely to consider acting on a 0.09 ng/ml PSA. But it my case with a 3+4 Gleason, negative margins, and no seminal vesicle or lymph involvement, my sense was that his response to my 0.09 PSA was a pretty nonplussed, “Meh.” Or, if my PSA gets to “around 0.13 ng/ml,” we might start exploring treatment options.
On the topic of doing additional testing such as scans to see if there is cancer anywhere, he said that nothing would show up on a scan or MRI with a PSA of 0.09. I want to dig into that some more.
On the topic of salvage treatments, he thought that, given my pathology, the first step would be “a little radiation.” (I’m not sure if sprawling out on the beach for 7 weeks qualifies for “a little radiation,” but it may be worth asking.) He wouldn’t do ADT (hormone therapy) in conjunction with the radiation, again, given my pathology.
Lastly, at one point during the conversation, he quite confidently made the bold prediction that I wouldn’t die from prostate cancer. You think I’d be jumping for joy. I’m not. Perhaps its my experience as a seasoned patient that’s telling me to withhold judgment on that one for the time being.
All in all, this is good news. My lack of enthusiastically embracing it, however, comes from the fact that, rather than eliminating variables to consider, I feel that this meeting introduced a few more, and that just muddied the waters. Emotionally, at this point, I just want this stupid disease to pick a path and stay on it. I may also check with the VA to see if there’s any way I can pick one doctor that I can build a relationship with rather than this new-doctor-a-quarter routine.
Dan's Journey through Prostate Cancer 
Thanks for the update Dan.
You may recall a recent email exchange where I told you THT I had the same exact pathology as you, including the upgrade. And that my PSA had been
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Hi Ken… Looks like your message got truncated somehow when it was posted… Not sure what the rest of your thought was.
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Having one doctor is a good idea, but then you have only one set of eyes looking at the puzzle. I have one doctor and it’s gotten so that I kinda know what he’s going to say. I don’t know if that’s good or bad?
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Hi Eric. No I agree that there’s value in having other opinions. I guess I just get a little frustrated having to go through my entire history with each of them, and then try to assess where their heads are at during a relatively short consult.
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Oh yeah…that’s true.
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Sounds as if you are inadvertently getting a second opinion! You could then get a third and fourth opinion in the next two quarters. Add to that a fifth opinion from Dr Google. However I, like you, would prefer to build up a relationship. Interestingly I have had one oncology consultant but a variety of haematology consultants – whoever picks up the file first – but it seems the team discuss all the cases before the clinic. I have built up rather wider knowledge because of this I think.
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Thanks, Tim. Yes, I agree and actually do value getting diverse opinions on my case—it’s been happening for several years now. Like you, each has given me something new to think about, so it’s not necessarily a bad thing.
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Great news on the PSA!
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Thanks, Andrew. I’ll take it!
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I am so with you on this. He basically tells you he doesn’t know what’s going on or how to get closure except wait. Then he pronounces the cancer won’t kill you. How does he do that?! You are smart to be skeptical. The only prediction my oncologist will make is that I am going to die from something at some point in time.
On balance I do think it’s good news. I appreciate that you want closure, but it’s worth waiting years to finally get closure if the answer is that it’s gone. I’m so glad to hear he doesn’t want to start ADT or do radiation. Enjoy this time as best you can!
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Hi Jim. Yeah, it was a tad frustrating, but I get that he has to cover all of his bases. I agree that it is good news, all things considered. There was just something about him and the whole interaction that overshadowed that when I wrote my post yesterday. Doing better today.
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That makes sense, sometimes you just get an uneasy feeling. In my case more often than not it was right!
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Hey Dan I don’t know how my comment got aborted, maybe it was too long, I’ll try the short version…
Thanks for the update Dan.
You may recall a recent email exchange where I told you that I had the same exact pathology as you, including the upgrade. And that my PSA had been
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Ok, this is nuts. I posted and then I checked the post, and the entire post was showing, untruncated. Then I left , came back now, 15 minutes later, and it’s half gone again. Is there a character limit?
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Hi Ken. Yeah, I saw that. No character limit as far as I know.
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Hello Dan,
On top of prostate stuff, I also have glaucoma. I had the same ophthalmologist for 18 months, then suddenly a new guy whose observations, opinions and depth of technical details completely differ from the first one. I find this unsettling and it throws in doubts about competence of those on whose pronouncements I have relied.
As to the prostatectomy, 19 months on, I am now on four-monthly PSA checks instead of three-monthly, so I feel moderately secure about prognosis. The surgeon will see me only annually, but gave me his phone number following discharge from hospital in case I wish to ask/report anything. Even though I haven’t used it since removal of the catheter, I have felt strangely comforted simply by having it on my phone.
These are important aspects, not often acknowledged.
Best wishes,
Alex
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