Video: Interpreting PSA After HDR Brachytherapy | Ask a Prostate Expert, Jeffrey Demanes, MD

Ask a Prostate Expert, Jeffrey Demanes, MD | Transcription

Alex: So, the last thing I want to ask about that I think is probably the most important question because patients—I know when I talk to patients they get obsessed with PSA. Like what's my PSA and is it supposed to be—how high is it? And, you know, because once they hear from their doctor when they go into their family practitioner or whoever they're getting their PSA tests that the PSA is rising, that's a major red flag and that's usually when they call us. So, when it comes to brachytherapy, where does the PSA—you were mentioning that PSA doesn't like, you know, nadir down to zero like surgery, so what numbers would the PSA be? And obviously, I imagine that depends on the size of the prostate.

Dr. Demanes: It does. I mean, ideally, we'd like to see the PSA go down to less than one and stay there. However, patients who have larger prostates may not be that low and there's some mystery to it that I don't quite understand, but it takes several years for the PSA to go down to its lowest level (we call the nadir) in some cases, and that has to do with prostate cells tend to turn over very slowly. They don't divide quickly like mucosal cells or blood cells, so you don't see things—the injury that has happened—you don't see it, and they continue to function while they're still not dividing, so the time it takes for the PSA to go down can be quite long and during that period there can be some inflammatory changes, so you see the PSA bumping up and down. A benign bounce or a spike is very common. So you'll see it. Somebody might have a PSA of 12 and then it goes down to 2 and then it goes down to 1, and then 18 months later all of a sudden it's back up at 3 and now they're all concerned that their disease has recurred. Well, that happens in about half the cases. So I have to tell the man, just, kind of stay calm, repeat the PSA every three months, and in almost every case the PSA eventually went down and stayed down. 

Now, there are a few percentage in the cases that we properly selected for this treatment approach where they failed treatment, and of course, their PSA eventually continues to go up. I try and tell the men that if the PSA is in the range of 5-10, it doesn't really make that much difference when you start systemic treatment—the salvage treatment—so don't get too excited about it. Chances are, this is a bounce. If it's not a bounce, we will address it effectively. Figure out whether the disease is persistent in the primary, which happened in only 1 out of 448 cases that we were able to document disease in the prostate. So it's highly effective. There might be disease someplace else. So, most of the guys I'm telling not to worry and to wait and let's just see how things go. A few of them, we have bad news and we have to address it. Fortunately, we have highly effective therapy that Dr. Scholz and the group know very well how to try and...

Alex: Yeah

Dr. Demanes Yeah.

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