Expert Advice that I have received so far……

I cannot give patient care advice by email.
Common present day positions:
The PSA cutpoint used to be 0.4, then the assay became ultra sensitive and measured down to < 0.1. then it became even more sensitive to the numbers you see now.

It may be that some men have levels < 0.1 or 0.2 that then never go up over time (False Positives as they say). (I have seen this)
It is also believed that if you radiate someone after surgery with a PSA of 0.1- 0.2 there is no difference in success than if it was 0.05 or even lower.
Dr Yu makes sense, some even use 0.2 – 0.3 prior to considering any additional treatment.
If you want another opinion you can get an appt with one of the urologists at UWMC or Virginia Mason who do prostate cancer surgery.
That is all I can do for you, but should be helpful.
Take care.


Your PSA appears to be creeping up, which is surprising given your favorable pathology report, except for the Gleason 4+5 grade. I recommend that you go to a Quest laboratory for a special PSA test called, “post-prostatectomy PSA with HAMA treatment.” This checks to see if you have any interfering antibodies in your blood that could be giving false-positive results. If there are no HAMA antibodies, and your PSA continues to rise, I would recommend early salvage radiotherapy. Please see my website ( and search on “HAMA” and “salvage radiotherapy” for further information. William J. Catalona, MD

I recommend that you have salvage radiation therapy if it turns out that your PSA is truly rising, although there are other options such as watchful waiting (you may miss your second chance to be cured) or hormonal therapy (not curative). You could be treated at any large, modern facility near where you live or work with IMRT (Intensity Modulated Radiation Therapy). Call the department of radiation oncology and tell them that need salvage radiation therapy for prostate cancer with IMRT and that you would like an appointment with the radiation oncologist who has the most experience in treating prostate cancer. William J Catalona, MD

I am out of town at a meeting right now. I will need to review your entire record to comment formally. But I can say that I never recommend radiation at a level that low because our lowest limit of detection is 0.03. This may well be nothing to worry about. We can communicate more in person.


From: Sylvester, John E.

Sent: Thursday, August 23, 2018 7:34 AM
To: Tinsley, Brian
Subject: [EXTERNAL] Rising psa

You should a radiation oncologist ASAP , regardless of what Dr Porter says.

Dr Alex Hsi is the best in the region

In paulsbo and also at evergreen hospital

Sent from my iPhone

John E Sylvester

21st Century Oncology, Inc.

8946 77th Terrace East

Lakewood Ranch Florida 34202

941-907-9473 Fax

> www.21co.com

Mr. Tinsley,

Thank you for your interest in First Dayton CyberKnife. Dr. Hughes is indeed an expert in SBRT.
I shared with him your email and this is his response:

“There is no reason to “freak out.” The PSA levels are certainly consistent with no evidence of disease. The sensitivity of the PSA test is not accurate to even 2, let alone 3 decimal places. I would not worry about salvage treatment unless the PSA is in the 0.4 ng/mL range, if ever. CyberKnife is not appropriate but rather IMRT with concurrent androgen deprivation therapy.”

He also recommends that if you continue to have concerns or any returning/increased symptoms to see your trusted urologist as soon as possible. There can be several causes of a slightly variable PSA or urological symptoms.

All the best,

Kathy Corbett, CMM, CMOM
Practice Administrator
(937) 293-2273
2632 Woodman Center Court

Dayton, OH 45420

Thanks Brian. The Hopkins thoughts are good ones. Specifically, your PSA is less than 0.1 so you shouldn’t be worrying about salvage treatment at all. If it rises to somewhere between 0.1 and 0.5, you should seek in person consultation as to (1) whether salvage treatment is needed and (2) exactly what salvage treatment if so.


Ps my pleasure. Wish I could say more but without seeing you formally as a patient my hands are tied. My “good luck” was meant in a positive way – I hope everything turns out well. Jim is a great surgeon. Best,


The Gleason 4+5 is worrisome, but the PSA level <0.1 is reassuring. Although there was focal extracapsular extension, the margins were negative, as were the nodes.
As such, I would recommend following the PSA at 3-6 month intervals (not monthly).
Ultrasensitive PSA at the 2 to 3 decimal level is not predictive at this very low result.
If the PSA rises to 0.1, I would then recommend consideration of PET/CT scan (ideally PSMA PET if available). Depending on this study, if local recurrence, then IMRT to the prostate bed and local recurrence along with androgen deprivation.

Hope this helps.

Dr. Richie

Focal T3a with clear margins behaves similar to T2c.

Sent from my iPhone

On Oct 5, 2018, at 8:06 PM, Tinsley, Brian wrote:

   External Email - Use Caution

Hi Dr. Richie,

Dear Brian Tinsley,
thanks for getting me involved in the management of you father’s disease. I am sorry to have to state that I am formally retired, I am 80 years old as your father and discontinued any form of practicing.
I feel that your father has been treated very well. My advice is to follow his PSA and rectal examination. I would also recommend an MRI scan and a bone scan to have baseline information available in case of further signs of progression. Considering the side effects of the possible next forms of treatment, I recommend to consider endocrine treatment or/and radiotherapy only if progression occurs. PSA alone should be an indicator for further diagnostic steps if a more rapid doubling time occurs.
I recommend to take a look at the recent book by Patrick Walsh on prostate cancer.
Good luck and best regards, Fritz H. Schröder
===================================================================================================================Never TOO low but 0.014 is low. Depends on other factors – Tumor aggressiveness, your age, etc. Tumor genomics (Decipher) can be helpful as well.

Happy to discuss at length in clinic. I have patients who fly in from around the country to discuss these delicate issues.

Stephen Freedland

Yes that is too low.

I would consider 0.10 or higher a Psa recurrence

Best wishes

On Sep 8, 2018, at 12:33 PM, Tinsley, Brian wrote:

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Hi Dr. Paul,

Do you think a PSA of 0.014 is too low to be evidence of BCR?


> Brian J