Saturday, April 2, 2011

PSA Recurrence After Prostatectomy: The Good, The Bad, and the Ugly

A major milestone in the prostate cancer journey is obtaining a PSA level after treatment.  If a man has surgery, a procedure in which the entire prostate gland is removed, the expected result is a permanently undetectable PSA.  Because a successful surgery should remove all remnants of the cancer as well as the benign elements of the prostate, there should be nothing left to produce the dreaded PSA.  Patients derive a tremendous amount of satisfaction and relief in hearing that there PSA is undetectable, an unambiguous sign that their prostate cancer is gone.  For some men, however, the news is not as great.  At some point after surgery, 15-40% of  men hear the dreaded news that their PSA is not undetectable and that, most likely, there cancer has returned.  What many patients do not know is that not all PSA recurrences are created equal.  Some types of recurrences are much more worrisome than others and require very different treatment approaches.  In this post I will try to define PSA recurrence and attempt to differentiate the different types of recurrences.

Defining a PSA recurrence seems pretty obvious at first glance.  After all, PSA after prostatectomy should be 0.  Any other number is considered a PSA recurrence. In reality, things are not that simple.  First, we have to differentiate PSA recurrence from PSA persistence.  A first PSA test obtained 1-3 months after prostatectomy should be 0.  However, any PSA value other than 0 is not considered a PSA recurrence at this time.  The reason for this is that the PSA has not recurred but, rather, has persisted. Although this difference in terminology may seem like nothing more than semantics, it makes a tremendous difference in terms of prognosis and understanding the status of the prostate cancer.  Patient who have a persistent PSA after prostatectomy almost always have metastatic disease.  While imaging tests like a bone scan or CT scan may be negative, a persistent PSA indicates that some cancer cells are lurking somewhere in the body that are simply too small to identify on imaging tests.  These cells are then labeled micrometastatic disease.  Unfortunately, patients in this situation can no longer be considered curable.  Instead, they often get palliative hormonal therapy which, fortunately, can often keep those few micrometastatic cancer cells from significantly growing for many years. These patients may also qualify for clinical trials.

Unlike PSA persistence, PSA recurrence occurs when a postoperative PSA at first goes to 0 and then begins to rise after some period of time.  However, at least technically speaking, not all rises in PSA have been considered recurrences.  Historically, a PSA rise to 0.4 after surgery has been considered a recurrence.  Rises in PSA lower than this have been considered insignificant, possible due to some left over benign prostate tissue.  More recently, the value of 0.2 has been chosen.  Although these definitions seem pretty arbitrary they actually have significance because they determine when the patient has recurrent cancer and, in turn, when they should start salvage therapy.  With the advent of ultrasensitive PSA, much lower PSA values have been recorded and some doctors have initiated salvage therapy at PSA levels significantly lower than 0.2.

As I mentioned earlier in this post, a PSA recurrence has different implications on the status of prostate cancer and subsequent prognosis depending on several factors:

1)      Time from Surgery: Many studies have demonstrated that the longer the time between surgery and PSA recurrence, the less chance that the recurrent cancer is aggressive and likely to spread.  The consensus seems to be that 3 years appears to be a critical cut off point.  One study demonstrated that for men with otherwise good risk factors, those that had a PSA recurrence more than 3 years after surgery had a 13% greater chance of surviving their prostate cancer 15 years later as compared to those men with a PSA recurrence within 3 years of surgery( 94% versus 81% survival at 15 years).

2)      Gleason Score of Prostate Cancer:  The Gleason score is a measure of how aggressive the cells of prostate cancer look under the microscope.  It generally ranges from 6-10, with higher scores being associated with more aggressive cancer.  Men with Gleason scores above 7 who have a PSA recurrence after prostatectomy are at higher risk for metastasis and death from prostate cancer.  For example, a study demonstrated that men with recurrence of a Gleason 8 or higher prostate cancer within 3 years of prostatectomy had a 19% higher chance of surviving their prostate cancer within 15 years than those men with a recurrence of Gleason 6 or 7 prostate cancer within 3 years of prostatectomy( 62% versus 81% survival at 15 years).

3)      PSA Doubling Time: The PSA doubling time appears pretty self explanatory.  The term refers to the time it takes for the PSA to double in value.  To calculate this number you need a few PSA values spread at least 3 months apart.  You also need to use a fairly complex formula to get the exact value.  For our purposes, a rough, eyeball assessment will do just fine.  For example, by looking at a series of PSA values we can roughly estimate if the PSA is doubling every month, every 6 months, or every year, etc... Studies have demonstrated that PSA doubling time is one of the most important prognostic factors used to evaluate a PSA recurrence after prostatectomy.  Let’s look at an example:  If a man has a PSA recurrence more than 3 years after prostatectomy for a Gleason 6 prostate cancer and his PSA doubling time is more than 15 months, his chance of surviving the prostate cancer at 15 years is 94%.  If that exact same man has a PSA doubling time of less than 3 months, however, his chance of surviving prostate cancer at 15 years is only 19%.  As you can see, the importance of the PSA doubling time cannot be overstated.


These 3 factors are vital in evaluating a man with a PSA recurrence after prostatectomy not only to determine prognosis but, also, to figure out what future treatment needs to be undertaken, if any.  A man with a PSA recurrence more than 3 years after prostatectomy for a Gleason 6-7 prostate cancer and a PSA doubling time of greater than 15 months has a 94% chance of surviving his prostate cancer at 15 years.  In contrast, a man with a PSA recurrence less than or equal to 3 years after prostatectomy for a Gleason 8-10 prostate cancer and a doubling time of less than 3 months have <1 % chance of surviving for that same period of time.  As you can imagine, most men find their situation somewhere in between these two extreme scenarios. 

Men with favorable factors most likely have a local recurrence of the cancer in the part of the pelvis where the prostate was located.  This type of recurrence tends to move more slowly and can be cured with radiation therapy with some success.  Some men, depending on their overall health and age, may not even need any treatment for this type of low risk recurrence.  Men with high risk factors, in contrast, most likely have metastatic disease.  This type of recurrence is usually more aggressive and not responsive to local therapy.  Instead, men with this type of PSA recurrence are usually treated with palliative hormonal therapy to try to control rather than cure the recurrent cancer.  Others may opt for clinical trials to try novel treatments to battle the more aggressive cancer.

The take home message of this post is to NOT treat all PSA recurrences the same.  While a PSA recurrence is obviously disappointing and frightening it is not always as bad as you might think.  Many recurrences are very manageable and still offer the possibility of cure. Some recurrences may not even need to be treated.   Men with PSA recurrence should discuss their specific risk factors with their urologist in determining an appropriate treatment course. 

Check out my new Book: 

  Prostate Doc’s Guide to Life After Prostatectomy


Share your Prostate Stats and learn from those of others!

This blog is not a medical practice and cannot provide specific medical advice. This information should never be used to replace or discount the medical advice you receive from your physician.

53 comments:

  1. You wrote: "a study demonstrated that men with recurrence of a Gleason 8 or higher prostate cancer within 3 years of prostatectomy had a 19% higher chance of surviving their prostate cancer within 15 years than those men with a recurrence of Gleason 6 or 7 prostate cancer within 3 years of prostatectomy..." I think you meant LOWER, not higher. (higher Gleason = lower survival).

    What do you think of the ultra-sensitive test, post RP? I know some reputable centers, such as Hopkins, do not tend to recommend it, presumably because of the anxiety it can cause. But other docs seem to think it is useful because it can show early signs of recurrance, allowing for earlier salvage treatments? What do you think? Do you routinely use ultra-sensitive psa?

    Also, what you do think of adjuvant versus salvage RT? How does a patient decide whether to wait for evidence of recurrance or do adjuvant RT? Seems some recent studies have suggested better outcomes with ART.

    ReplyDelete
    Replies
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      Delete
  2. Correction:

    Gleason Score of Prostate Cancer: The Gleason score is a measure of how aggressive the cells of prostate cancer look under the microscope. It generally ranges from 6-10, with higher scores being associated with more aggressive cancer. Men with Gleason scores above 7 who have a PSA recurrence after prostatectomy are at higher risk for metastasis and death from prostate cancer. For example, a study demonstrated that men with recurrence of a Gleason 8 or higher prostate cancer within 3 years of prostatectomy had a 19% LOWER chance of surviving their prostate cancer within 15 years than those men with a recurrence of Gleason 6 or 7 prostate cancer within 3 years of prostatectomy( 62% versus 81% survival at 15 years).

    Men with recurrence of Gleason 8 cancer have a LOWER chance of surviving than men with Gleason 6-7 prostate cancer.

    Sorry if there was confusion.

    Prostate Doc

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  3. I do not use ultrasensitive PSA as I feel that it does not provide much more than stress. I think treating recurrent cancer within normal PSA parameters should lead to good success. I believe that adjuvant versus salvage RT is a complicated decision but, for my patients, I usually wait at least until they regain continence prior to initiating XRT.

    Prostate Doc

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  4. I was diagnosed in June, 2010 after two negative biopsies..On the third 12 core biopsy, one core showed Gleason 9, two cores G-6, one core G-7..I had robotic surgery on Sept 3, 2010. Positive margin, positive vesicle, (1) negative nodes. My PSA never went lower than 0.9 I guess you call that "persistent", first time I have heard that term..My docs (3 or 4 of them) all agreed my cancer was probably still localized and SRT was worth doing. Two radiation oncologists insisted I also be put on HT for two years as part of the salvage treatment..I completed 40 RT sessions, 72Gy on Feb 10, 2011. PSA at that time was undetectable. So SOMETHING is working...

    You seem to think persistent PSA after surgery almost guarantees distant metastasis and my radiation treatment was little more than a transfer of wealth...Taking another Eligard shot is NOT something I'm looking forward to, a recent study suggests that 6 months works almost as well as a year and I'm tempted to just coast along for a while and see how my PSA behaves..My R-doc does not like that idea at all.

    What do YOU think??

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  5. Fairwind: unfortunately I cannot comment on specific cases. However, generally speaking, the presence of prostate cancer in the seminal vesicle is associated with distant metastasis in 50% of cases. Nonetheless, studies have shown some benefit of radiation for men with seminal vesicle disease, albeit in those men whose postoperative PSA comes down to 0 after surgery. Hormonal therapy has been demonstrated by numerous studies to be beneficial in conjunction with radiation therapy in tackling locally advanced prostate cancer. European studies favor 2 years whereas recent US studies have advocated 6 months. All depends on who you want to believe. I hope that helps.

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  6. Should I be concerned if my psa went from undetectable @3months post surgery to 0.06 @6 months post prostatectomy ? I had a Gleason score of 6 and cancer was encapsulated within the prostate post pathology. Any action that is generally recommended at this point? Next steps?

    ReplyDelete
    Replies
    1. Hi. I have a similar situation. Wanted to see how you were faring and what treatment you decided on.

      Thanks.

      Delete
  7. BT: While I cannot comment on specific cases, I can say that the ultrasensitive PSA that was used to identify your PSA of 0.06 is a mixed blessing. While it sometimes does identify prostate cancer recurrence early, it can also identify benign prostate tissue that may have been left behind. As such, most urologists do not classify a prostate cancer as recurrent until a PSA is > 0.2. Most will wait until at least this value before proceeding to salvage therapy. That being said, some will jump on salvage therapies with lower PSAs in men with high risk cancer.

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  8. My psa post surgery has maintained at <0.05 for the past 2 1/2 years, until my last test where it measured 0.06. Does this rise indicate the presence of cancer?

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  9. Tom: While I cannot comment on individual cases, I can make the following comments. PSA detected at a value less than 0.1 is considered ultrasensitive PSA. This PSA is a mixed blessing because, although it can pick up recurrent prostate cancer very early, it can also detect the presence of left over benign prostate tissue that is completely insignificant. That is why many urologists use the normal PSA with a threshold of detection of 0.1. In addition, cancer recurrence is defined as a PSA level of 0.2 or 0.4, depending on who you want to believe. Values lower than these are technically not indicative of a cancer recurrence. That being said, some urologists turn to ultrasensitive PSA for patients with very high risk disease because they want to jump on the slightest hint of recurrence. That is why, as I mention in the post, it is so important to keep in mind other factors like stage, Gleason score, tine from surgery, margins, etc. Your urologist should be able to put all of your information together to give you a more clear idea of what the chances of recurrent cancer are for you in the context of this new, albeit tiny, rise in PSA. Hope that helps.

    ReplyDelete
  10. My husband had radical prostrate surgery in 2004 - the cancer had penetrated the prostate wall and was in the pelvic tissue. His gleason score was 8. In 2010 his PSA went to .2 and over the last two years it has climbed to .9. It was a one year doubling time. They just found a 1.1 centimeter mass in the area of the prostrate where his original surgery had been. Is there a way to determine a prognosis based upon this information?

    ReplyDelete
  11. My brother is 58 years. RAdical Prostatectomy 7 years ago due to agressive adenocarcinome (seminal vesicle +).Submitted to local radiotherapy and than hormonal therapy due to PSA increase (<2.0). In the last 2 years, radiotherapy (2x) for a vertebral metastasis and, recently, for a rib. Unfortenately, the last scintigraphy showed a new vertebral metastasis (L1). Is it safe to go for a new radiotherapy cycle? Does chemotherapy has a role in this phase? Is there any new therapy to try in a multicenter study? Thanks a lot.

    ReplyDelete
  12. Nancy: While I cannot give specific advice on this blog, I can say the following. PSA recurrence over 5 years after prostatectomy and a 1 year doubling time are both fairly good prognostic indicators in the context of a PSA recurrence but, of course, certain other factors for every individual case need to be kept in mind. As for the mass in the area of the prostate, it really depends on whether this mass is prostate cancer or not. Sometimes masses in the prostate bed can be biopsied to determine this. OF course, your doctor can make the best determination of this as he/she knows your husband's details.

    Prostate Doc

    ReplyDelete
  13. MMO: While I cannot speak to the the safety of repeat radiation (more appropriate for a radiation oncologist to determine this), I can say that numerous treatments are available for metastatic prostate cancer including chemotherapy, hormonal therapy like Lupron and Casodex, novel hormonal therapy like Zytiga, and immunotherapy. You should have your brother discuss the options with his oncologist.

    Prostate Doc

    ReplyDelete
  14. Chuck

    Had prostatectomy 6/12/12 with grade 8 tumor. PSA results of 6/28 showed level of 0.270. Is this time frame too soon, and will a PSA test prior to 8/6/12 have any significance at all?

    ReplyDelete
  15. Chuck: While I cannot comment on individual cases, I can say that it is better to generally wait at least a month before checking PSA after prostatectomy as it takes a while for the PSA in the bloodstream to dissipate.

    ReplyDelete
  16. Post prostatectomy, if the seminal vesical pathology is postive, you say there is a 50% chance of distant metastasis. Do you know the most common location of that metastasis?

    ReplyDelete
  17. my friend had a gleeson score of 7, and underwent a prostatectomy, he was advised a PSA test in 2 weeks and the reading was 0.4, does this mean there is a recurrence ????

    ReplyDelete
  18. After prostectomy in combanation with long acting lupron my PSA was ,1 9 months after the lupron wore off, and PSA was .01, three months .02 three months .03 with a t2c glease score 10 a concern. PS I am in the Punch trial. 6 does of chemo pre op.

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  19. above should have been <1 after nine months with lupron

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  20. yes <1 after surgery, took nine months for lupron to where off. No I'm seeing rises after every three months, good or no so good?

    ReplyDelete
  21. I had a RP a year ago, (UK). Gleason score after surgery was 4 + 3 = 7, but I have read this is equivalent to an 8. The histology report said cancer cells were close to the margin and complete removal could not be guaranteed. Post op PSAs at 3 months, 6 months and 9 months were "less than 0.01" i.e. undetectable. Presumably this is the "ultrasensitive" test. PSA at 12 months is 0.02. What is the significance of this?

    ReplyDelete
  22. Doctor, you have said there are 3 factors impacting the chance of survival after 15 years that are used to determine prognosis and future treatment: recurrence timeline, Gleason scope, PSA doubling time. The stats you have provided are at the extremes of 1% - 94%. Where can I get granular statistical data on how these 3 factors combine to indicate survival rates at 15 years?
    Appreciate your response on this. Many thanks.

    ReplyDelete
  23. I had a radical prostectomy 12/2011 Gleason score 3+4 with focal 5. My first PSA value after three months was .03, six months later .1,six months later .7 and my last after 3 months was 1.1 Is that considered doubling and what does it signify.

    ReplyDelete
  24. I has seed implants in 1999. After a couple of years my psa dropped to .04 and it remained there for 10 years. It then increases to .07 and in 2 years, with psa's every 3 months it has increased to .93. I am consulting with my doctor and it is his staff that has take every psa for 14 years. He wants to wait until the psa rises a bit and see if he can see cancer with a mri, a newer hi-resolution mri.I calculate that the psa has increased 23 times in about 2 years and though the number is low the rate of increase is extremely rapid. What course of action would you advise. Steve in Seattle

    ReplyDelete
  25. I had a prostate RP in Jan. 2011. Gleason score 7 (3+4). My PSA has gone from 0.6 to 2.9 over 3 years. No doubling in less than 1 year. The doctor knows there is a piece of prostate tissue left on the rectum wall about 2cm long. He has taken 3 biopsies of that tissue in 3 years and all were negative. He wants to take another biopsy this year and maybe start radiation, or hormone therapy.

    My question is as follows: If we know prostate tissue is there, and we know PSA is produced by the tissue, and it so far shows no cancer, why should I get radiation treatments or hormone injections?

    ReplyDelete
  26. Question
    I am 64 with a Gleason score 9. I had RP July 2013 and after op my PSA was <0.03 but in December 2014 it was 0.08. I was told I could not have a scan until PSA had reached 0.2. If the cancer has come back and had spread through out my body, what is the chance of me living another 5 years.

    ReplyDelete
  27. I am confused about the differences between the PSA test in the US and the UK. I am in the UK. I had a nerve sparing prostatectomy in March 2012. Lab report stated a Gleason of 7, BUT 4 plus 3, not vice versa! Margins - neither posiive or negative. They said cells so close to margins they couldn't guarantee they had all been removed.
    PSA at 3 months was less than 0.01 ng/ml - ultransensitive? - considered undetectable. Same at 6 months and 9 months. - delighted!
    At 12 months, horror, it was 0.03. It hovered between 0.03 and 0.02 for 2 years - relieved.
    In May 2015 it rose to 0.05, - horror, in July 2015 0.04 relieved,
    In early January 2016 it was 0.07, horror, mid February 0.06 relieved.
    I had no choice the ultrasensitive test, but you can see I'm on a roller coaster. It would almost be a relief to be told I DID have a recurrence and do something about it!
    If it's true that anything less than 0.1 is NOT considered a recurrence then that is a comfort.
    They keep telling me that the surgery may have left benign tissue behind, more likely with nerve sparing.
    Since otherwise I am healthy, younger (65) and fully functional in ALL departments, this creeping rise in (still very low) PSA is basically a nightmare. Would it be better to live in the US?

    ReplyDelete
  28. In some patients the medial lob of the prostate grows into the bladderwall.During open surgery the urologist usually sees it but with the Da Vince robotic prostatectomy the urologist may overlook it.This may lead to confusing psa results.My own psa one day before surgery was 2.37.My psa at 3 weeks POST-surgery was forty-five.At 9 months post-op it was a happy 2.4.At 12 months post-op it was a frightening 7.7.Now at 2 years post-op it is a stable 4.3.I never received radiotherapy and am still refusing it.BUT REMEMBER never there was no cancer found in my dissected prostate according to my pathological report

    ReplyDelete
  29. Sorry.The previous comment must read:REMEMBER that no cancer was ever found in my dissected prostate according to the pathological report and my initial gleason score was 6 and my stage T1c.

    ReplyDelete
  30. This comment has been removed by the author.

    ReplyDelete
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  38. My health was horrible before I decided to try the Protocol Of taking Dr Ebhota herbal mixture. I felt there was no hope for my health and I was doubtful to try the Protocol thinking it wouldn’t work because I have visited so many hospital but same result. However, I was convinced by my friend to try the herbal medicine because I wanted to get rid of HPV/WART. The herbal mixture that was given to me was really quick and easy to take, and since I have be taking it for less than 3 days I have less outbreak. But within one week i was fully cured from WART/HPV. The herbal medicine really work and I will like to share this great herb doctor contact with you all email him drebhotasolution@gmail.com or whatsapp +2348089535482. Pls try and help yourself out of warts completely today. he also c My health was horrible before I decided to try the Protocol Of taking Dr Ebhota herbal mixture. I felt there was no hope for my health and I was doubtful to try the Protocol thinking it wouldn’t work because I have visited so many hospital but same result. However, I was convinced by my friend to try the herbal medicine because I wanted to get rid of HPV/WART. The herbal mixture that was given to me was really quick and easy to take, and since I have be taking it for less than 3 days I have less outbreak. But within one week i was fully cured from WART/HPV. The herbal medicine really work and I will like to share this great herb doctor contact with you all email him drebhotasolution@gmail.com o r whatsapp +2348089535482. Pls try and help yourself out of warts completely today. he ure DIABETIES ULCAL CANCER etc.He also told me that he has solution for the flowing.1 Cancer cure2 Diabetes cure3 Ringing ear4 Herpes cure5 Warts cure6 HPV cure7 Get your ex back8 Pregnancy herbal medicine9 Prostate enlargement10 Hepatitis B11 Disability12 Kidney problem Etc.

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  39. Dr. Iyabiye it’s a herbal specialist he specializes in curing different kinds of diseases/virus like: HEPATITIS, CIRRHOSIS DISEASE, STAPHYLOCOCCUS and many more. I was once a hepatitis victim and I got healed by his medication, contact him if interested and get cured. I am a testimony to his medicine. Contacts: (+234-815-857-7300) (iyabiyehealinghome@gmail.com)

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  40. A GREAT THANKS TO DR.WEALTHY FOR CURING ME FROM GENITAL HERPES I AM SO HAPPY TO GIVE THIS TESTIMONY ARE YOU SUFFERING FROM THIS SICKNESS HERE IS DR WHO CAN HELP
    I can’t believe my genital herpes is really cured, oh is by this time last year I start feeling bad about my life, I feel pain everyday of my life am very happy now that am really cured I couldn’t have do this on my own I wish is not God that help me with my helper I was searching the internet about this sickness last 3month when I found about great doctor wealthy, the man that keep his words I write the man email about my problem immediately I get a reply from him asking me to fill a form which I immediately did and send back to him after some mins he reply me that he have work on my cure that I need to provide some materials, which can enable him to work on my cure which I did on the next day of it, after some hours he inform me that he have getting the things needed for the cure and he is about to go on with the curing spell he called me again after 50mins that he is done with the cure that I should check my body and also go for test I cant believe I was negative a big thanks to him am very happy now with my family you can also get your self cured too from this sickness by contacting him through his email: wealthylovespell@gmail.com or whatapp +2348105150446 follow his instagram @wealthylovespell1 He also have a herbal cure for 7 other DISEASES;
    1.HIV
    2.SHINGLES
    3.VIRAL HEPATITIS
    4.INFLUENZA
    5.IMPOTENCE,
    6.BARENESS/INFERTILITY,
    7.ANTHRAX
    8 HPV
    Contact him today and you will have a testimony…Good luck!

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  41. My health was horrible before I decided to try the Protocol Of taking Dr. Omola pure herbal mixture. I felt there was no hope for my health and I was to try the Protocol, thinking it wouldn’t work because I have visited so many hospital but same result. However, I was convinced by a Instagram friend to try the herbal medicine because I wanted to get rid of Herpes virus. The herbal mixture that was given to me was really quick and easy to take, within 2 week I was fully cured from Herpes. The herbal medicine really work and I will like to share this great doctor contact with you all email him dr.omolaherbalhome@gmail.com or WhatsApp +2348118116254 you won't regret it, I promise.

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  42. There is a safe & effective Natural Herbal Medicine. For Total Cure Call    +2348025012866,  or email him   drrealakhigbe@gmail.com       For an Appointment with (Dr.) AKHIGBE contact him. Treatment with Natural Herbal Cure. For:Dengue Fever, Malaria. Painful or Irregular Menstruation. HIV/Aids. Diabetics. Vaginal Infections. Vaginal Discharge. Itching Of the Private Part. Breast Infection. Discharge from Breast. Breast Pain & Itching. Lower Abdominal Pain. No Periods or Periods Suddenly Stop. Women Sexual Problems. High Blood Pressure Chronic Disease. Pain during Sex inside the Pelvis. Pain during Urination. Pelvic Inflammatory Disease, (PID). Dripping Of Sperm from the Vagina As Well As for Low sperm count. Parkinson disease. Obesity, Lupus. Soreness/Injury  Cancer.  Tuberculosis.  Zero sperm count. Bacteria, Impotence Fertility,Protoplasmic, Diarrhea. Hepatitis A&B, Rabies. Asthma.  Quick Ejaculation. Gallstone, Cystic Fibrosis, Schizophrenia, Crubs, Cirrhosis,  Premature Ejaculation. Herpes. Joint Pain. Stroke. Cornelia Disease, Weak Erection. Ovarian problem,  HeartBurn, Erysipelas, Thyroid, Relapsing polychondritis,  Discharge from Penis. Bronchial Problem,  HPV.  Hepatitis A and B. STD. Smallpox, Staphylococcus + Gonorrhea + Syphilis. Heart Disease.  Pile-Hemorrhoid.rheumatism,  Impotence, thyroid, Autism, Depression,  Sepsis Bacteria,  Penis enlargement, Prostate Problem,  Waist & Back Pain.  Male Infertility and Female Infertility. Etc. Take Action Now. contact him & Order for your Natural Herbal Medicine:  +2348025012866  and email him    drrealakhigbe@gmail.com    Note For an Appointment with (Dr.) AKHIGBE.I suffered in Cancer for a year and three months dying in pain and full of heartbreak. One day I was searching through the internet and I came across a testimony of herpes cure by doctor Akhigbe. So I contacted him to try my luck, we talked and he sent me the medicine through courier service and with instructions on how to be drinking it.To my greatest surprise drinking the herbal medicine within three weeks I got the changes and I was cured totally. I don't really know how it happens but there is power in Dr Akhigbe herbal medicine. He is a good herbalist doctor.

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  43. Dr. Riaria cured my herpes virus that have been in my body since two years, ever since then my life has been incomplete, I have used so many drugs that was prescribed to me by doctors, but it didn't cure my herpes virus, i was checking for solution on the internet then I miraculously came across Dr. Riaria the powerful herbalist that  can cure herpes infection, then I contacted him through his email, I explained everything to him and he prepared a herbal medicine and sent it to me through FedEx, which I took for 14 days with the instruction he gave me, and when I did a test in the hospital my result came out negative it was the happiest day of my life that am cure from HSV 2,  are you also suffering from same virus or another diseases you can simply contact him via email: drriaria@gmail.com  you can also call or WhatsApp him on: +2349134987375.  

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  44. Am here to testify what this Dr Okolo done for me. i never believe in spell casting, until when i was was tempted to try it. i and my wife have been having a lot of problem living together, she will always not make me happy because she have fallen in love with another man outside our relationship, i tried my best to make sure that my wife leave this woman but the more i talk to her the more she makes me fell sad, so my marriage is now leading to divorce because she no longer gives me attention. so with all this pain and agony, i decided to contact this spell caster to see if things can work out between me and my wife again. this spell caster who was a man told me that my wife is really under a great spell that she have been charm by some magic, so he told me that he was going to make all things normal back. he did the spell on my wife and after 5 days my wife changed completely she even apologize with the way she treated me that she was not her self, i really thank this man his name is Dr Okolo he have bring back my wife back to me i want you all to contact him who are having any problem related to marriage issue and relationship problem he will solve it for you. his email is drokolosolutioncenter@gmail.com or via WhatsApp +2347031895935 he is a man and his great. wish you good time.He cast spells for different purposes like(1) If you want your ex back.(2) if you always have bad dream(3) You want to be promoted in your office.(4) You want women/men to run after you.(5) If you want a child.(6) You want to be rich.(7) You want to tie your husband/wife to be yours forever.(8) If you need financial assistance.(9) HIV/AIDS CURE(10) is the only answer to that your problem of winning the lottery

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  45. Hi, is a true life experience is not designed to convince you its a personal health experience, sometimes medical doctors take a different approach about herpes treatment. i has been stocked in bondage with herpes for two years and four months i has tried different means to eliminate this sickness because it surely has distract me even with the world, and i was told there is no cure, but only medicine for treatment all the possible ways i has tried was treatment, two months back i did some herpes research and i found amazing testimonies concerning natural herbal cure, and i go for it through the email address from the post just to give a try of herbal treatment, and i found it grate without delay i got cured with natural treatment from doc Twaha herbal cure his cure are powerful and shows out excellent result. and i think everyone suffering with herpes and others symptoms should also know about this cure from, drlregbeyen10000@gmail.com or WhatsApp him +2349038518881 thank you

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  46. I have been suffering from a deadly disease (Hsv) for the past 2 years now, I had spent a lot of money going from one places to another, from churches to churches, hospitals have been my home every day residence. Constant checks up have been my hobby not until this faithful day, I was searching through the internet, I saw a testimony on how Dr Ehimare helped someone in curing his (Hsv) herpes disease, quickly I copied his email which is drehimare3@gmail.com just to give him a test I spoke to him, he asked me to do some certain things which I did, he told me that he is going to provide the herbal cure to me, which he did, then he asked me to go for medical checkup after some days after using the herbal cure, behold I was free from the deadly disease, he only asked me to post the testimony through the whole world, faithfully am doing it now, please brothers and sisters, he is great, I owe him in return. if you are having a similar problem just email him on Drehimare3@gmail.com Or whatsapp him via +1 (267) 691-1087

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  47. I’d commend using Dr. Utu Herbal Cure topically for instant pain and itch relief as well as accelerated healing of lesions and permanently stopping herpes virus outbreaks. I have tried just about everything from acyclovir suppressive therapy to different natural oils, extracts, and other natural methods, some of which are EXTREMELY painful and exacerbate the problem (i.e. apple cider vinegar!). While vitamin E oil and suppressive therapies worked well for me, when I became pregnant I went back to trying to find a herbal cure. I was using vitamin E oil topically for a while but it was thin and difficult to use and only seemed to prevent further outbreaks rather than getting rid of it. I contacted Dr. Utu Herbal Cure through my friend. To my surprise, I could tell my outbreak was starting to heal within only a few hours! No more itching and pain! Dr. Utu Herbal Cure that I used was liquid herbs in bottles, so it was very easy to use. It simply whiffs, but it works so I don’t care! The best part of my testimony was that I successfully delivered a herpes-free beautiful daughter without further medications. Anyone who has tried Dr. Utu Herbal Cure knows just how quickly those treatments can add up to.
    Anyone can reach Dr. Utu through
    drutuherbalcure@gmail.com
    +2349072733661

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  48. A VERY SHORT STORY HOW I GOT CURED FROM HERPES SIMPLEX VIRUS (HSV2)
    Herpes simplex virus is said to have no cure, just as i was told by my family doctor that herpes can not be cured but can be controlled, Although i was a very stubborn person i never believed in what my doctor told me about herpes having no cure Am a very honest person who believe in nature and i also believed that there could be cure somewhere in the world, I kept my faith so strong and kept on doing my research till i finally came across Dr. Aza Blessed from west Africa He is one of the oldest herbalist after Dr. Sebi and total am a living testimony to his herbal cure to herpes, i became herpes Negative on the 17/05/2021 after using the herbal medication DR. Aza BLESSED mailed to me along with the prescriptions and today its been 2 years and herpes is not traceable in my body system, All thanks To Dr. Aza BLESSED For More Info on how to get cured Contact DR . Aza now on EMAIL : (drazaherbalcenter@gmail.com ) Or CALL/WHATS APP (+1(315) 795 1518 ) or his website:www.drazaherbalcenter.com ..

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  49. (COPD) is a lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible. The more familiar terms 'chronic bronchitis' and 'emphysema' are no longer used, but are now included within the COPD diagnosis. COPD is not simply a "smoker's cough" but an under-diagnosed, life-threatening lung disease and now all thanks to dr.Successful @ Dr.successfulcuringhome@gmail.com Or Dm him via whatsapp link https://wa.me/qr/UFTMANFGSLY4E1 Dr. Successful also have pure natural food and herbs for Herpes And Diabetes And Lot more. for more info
    visit his Facebook page: https://www.facebook.com/priestsuccessful
    Wishing you the best in hearth

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  50. Are you a diabetic type1 or 2 patient and looking for a cure? look no further and contact Dr. Oda for a pamanent cure once and for all. my name is Sarah and I'm a testimony to his medicine, it's been 11 years and I have been living a normal life and eating any food of my choice since I got cured by this doctor. His contact: drodasolution@gmail.com +234 805 761 6299

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