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Is SRT still an option if my PSA stay high (7) after prostatetectomy

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Posted 4/15/2010 11:57 PM (GMT 0)
Would like advice on the following

Is SRT an option if my PSA after DaVinci Prostatectamy is high (7,
as high as before surgery). My uro does not think so, since it
it unlikely that the cancer is still only next to the prostate.

I am one of the least lucky ones among prostate cancer survivors
in that 6 weeks after surgery, my PSA was as high as before surgery
(around 7, with repeated test--I am curious if any one of you are
as unlucky--or worse- than I, but I would guess those who are less
lucky than I are probably no longer around--but maybe their love ones
could mention those).

Since the margin was negative, and the surgeon cut
"way beyond the prostate", including removal of
right seminal vesicle (cancerous--no lymph node removed cancerous,
and negative on bone, pelvic CT scan as well as MRI/prostascint.
He said that it is unlikely that the residual cancer is only
near the prostate bed, so, SRT was no longer mentioned (he would
have suggested a wait of 6+ months before doing SRT even if my
PSA remain zero after surgery anyway).

Since it is now 6 months after surgery, should I still pursue
SRT--just in case most of the cancer is still near the prostate bed ??
I don't think so, but does anyone feel that SRT might still do some
good for me (to compensate for the side effects--cost is not an issue
since I am on HMO).

BTW--I'm on hormone treatment (2 3-month Trelstar shots so far) and
recently PSA is <.1 but would expect hormone treatment to fail in
3/5/8/years ??? .
Posted 4/16/2010 12:15 AM (GMT 0)
For starters, regardless of what you uro is saying, you should meet with one or more good radiation oncologists, particulally one that has dealt a lot with Prostate Cancer. While the % of cure with SRT is not great, many men in your situation, myself included, go through it and hope to be on the winning side of the odds. SRT would be your last curative approach as it it anyway.

Definitely think you need another opinion from a different perspective and doctor at this point.

David in SC
Posted 4/16/2010 12:38 AM (GMT 0)
I would say David said it all.

Unless they can fimd where the cancer is, by MRI's or color doppler, or some other testing technique, shooting the prostate bed with radiation will most likely not do much good, and the side effects can be bad.

Hopeully you can find a major cancer center near you that can give you a solid recommendation based on factual information.

On the other hand, we have many men on here who have gone for many years on HT. One had a PSA over 3000. So don't discount the tremendous strides thay are making with HT.

Good luck, and hopefully some much more knowledgeable guys will be along to help.
Posted 4/16/2010 12:44 AM (GMT 0)
I agree with Purgatory you need to talk with a radiation onc.but they will probably want you to do radiation,good luck !!!!!!!!!!!!!!!!
Deerhunter
Posted 4/16/2010 1:30 AM (GMT 0)
You could try the salvage radiation tool at www.mskcc.org/applications/nomograms/prostate/SalvageRadiationTherapy.aspx to get a rough idea of the odds of success. You will need to input a few more pieces of information than you provided here, like Gleason. I imagine the odds will be stacked pretty high against success, especially given the negative margins.

I agree with the others who say to consult a radiation oncologist. I would also consult a medical oncologist. Goodlife made an important point: if you can get to a major cancer center, that's where I would go. Here are a couple of sources to find one:

National Cancer Institute NCI-Designated Cancer Centers

US News & World Report Best Cancer Hospitals

just my 2 cents. Best of luck to you.
Posted 4/16/2010 2:15 AM (GMT 0)
I think the consults with the radiation and medical oncologists are a good idea. Make sure you know what impact the SRT might have on any other treatment types.

Bill

Posted 4/16/2010 10:14 PM (GMT 0)
Thanks for all the replies--I was hoping that someone with similar experiences as I would comment on this. Based on the 50+ hours on the prostate cancer forums, I would guess that many radiation oncologist would push SRT--but I don't see the point unless someone with similar circumstances have positive results. The chance of residual prostate cancer being ONLY around the prostate bed is minuscule with such a high PSA of 7 (before hormone treatment) .


--------------------
PSA trend
Pre-biopsy (Apr 09) 4.2 (this triggered the July 09 biopsy
4+3=7 Gleason prostate cancer)
Pre-surgery (Oct 09) 6.7
DaVinci surgery 10/9/09 (Gleason 4+3=7; T3c; right seminary
vesicle cancerous; has to remove that AND "way beyond the
prostate" to get negative margin)
6 weeks post surgery 7.0/6.4
10 weeks post surgery 9.2 (doubling time 2+ months)
13 weeks--12/16/09--took Trelstar (Lupron surrogate)
21 weeks PSA (3/3/10) <.1 (testoserone 13)
23 weeks--3/15/10 --took 2nd Trelstar LA shot (plan to go
intermittent in June

12/09 Both the Bone scan and the Prostascint/MRI scans were
negative (the uro says that most of the time, one would
not see cancerous modules in these scans until your PSA is
~40+.
Posted 4/17/2010 6:14 AM (GMT 0)
John, I'd recommend checking with a radiation oncologist - SRT can be aimed at the pelvic region to hit the lymph nodes, not just the prostate bed - and there may be different strategies they can develop in case only the nearby lymph nodes are affected so far. Seems like it's worth a shot, rather than giving up on a cure.
You have my prayers
Jeff
Posted 4/18/2010 1:10 AM (GMT 0)
Hi John! I'm sorry to hear about your difficult PSA result. To answer your question regarding other members that have had similar situations, there is only one that I can recall in the time that I have been here. The thread is under "myman". The author's name is Susan and she writes about her husband's odyssey. She is an amazing woman and was very supportive and caring to me when I first joined the forum. Her husband's PSA came back higher post surgery and they waited to find out where the cancer was before doing treatment. Unfortunately, in their case, the cancer ended up being systemic and radiation was not an option.
They haven't posted in awhile, but last I remember hearing was that he was responding well to HT. Sorry I don't have more people I can recall. Please keep us posted!!
One other thing, for advanced disease, there are no clear cut answers and it can be extremely frustrating. My advice, for what it is worth is to pick a team you are confident with, hope for the best and don't look back. Best wishes.
Posted 4/19/2010 11:34 AM (GMT 0)

JohnK11,

I would doubt the HMO would cover SRT unless the radiologist would ethically say on the insurance form (that he fills out) that the cancer is likely in or near the prostate bed. Otherwise, it becomes a high cost fishing expedition, something insurers generally do not cover. Its too bad that we don't have better scanning techniques. That doesn't mean you shouldn't talk with a radiologist. You must explore all avenues until those avenues either come back with something tangible or rule those avenues out.

Posted 4/19/2010 1:53 PM (GMT 0)
I found an article on the web that support my strong feeling on the futility of SRT for my case (see the *** section). As mentioned by the previous poster, SRT is only suitable if one has a strong indication that ALL THE CANCER is near the proposed irradiated place.
With negative margin and a high PSA after Prostatetectomy, that is almost certainly not true. Fortunately, Hormone treatment is keeping PSA low, and thus hopefully cancer at bay.
Wish me luck. (Again, I would like any comments from people in similar situation or people who know of other posting from people in similar situations -- I will post a similar item on the thread involving Myman--the only one mentioned so far ). Thanks again for comments

----------------------
Management of Asymptomatic Rising PSA After Prostatectomy or Radiation

Therapy By

Robert P. Huben, MD

(from the web page)
Adjuvant Radiation Therapy Following Surgery

A strong argument can be made for administering adjuvant radiation
therapy inselected patients with a rising PSA following surgery. As the authors

pointout, factors such as Gleason score, pathologic stage, and PSA velocity
may beuseful in predicting the likelihood of benefit from adjuvant radiation.

Interestingly, the presence of positive surgical margins does not appear to
be a risk factor, since only 30% to 40% of patients with focally positive
margins progress at 5 years. A case can therefore be made against the
use of adjuvant radiation therapy following radical prostatectomy in the
absence of a rising PSA as an indicator of local recurrence. Also, random biopsy of
the anastomotic area is of limited value in predicting response to adjuvant
radiation therapy, since a significant percentage of patients may
demonstrate a reduction in PSA to an undetectable range following radiation therapy
even in the face of a negative random biopsy.

Most of these criteria, whether considered singly or in combination,
fail to predict response of the individual patient to adjuvant radiation.
Consequently, treatment is often empiric.
******************************
**The clear exception, as the authors state, is the patient in whom PSA
fails
**to fall to an undetectable range following surgery, and for whom adjuvant
**radiation is an exercise in futility.
******************************************
In our experience, PSA will return to an undetectable range in a clear
majority (about 80%) of patients treated with adjuvant radiation following
radical prostatectomy, and the response will be durable in about 60%. Thus,
nearly 50% of patients will derive a sustained benefit from adjuvant
radiation therapy, and this will likely result in cure of their prostate
cancer. It has also been our experience that when one weighs the risks of
treatment vs the benefits, most patients tolerate adjuvant radiation
therapy remarkably well.

Patients With Persistent Disease After Adjuvant Radiation
As Waxman et al mention, additional or salvage local therapies for
biopsy-proven persistence of prostate cancer following radiation therapy
are associated with frequent and serious complications. Candidates for salvage
prostatectomy should be very carefully selected and be made fully aware of
the probability and nature of these complications. For example, rectal
injury will require a diverting colostomy to reduce the risk of a rectourethral
fistula. Cryosurgery appears to be an attractive option in this clinical
situation, but further experience with this technique is needed before its
niche is established.

Given the limited options, hormonal ablation is the usual treatment choice
for patients in whom radiation therapy failed. Once again, the rate of
climb of the serum PSA is the usual indicator to initiate hormonal therapy. At
what PSA value should treatment start? At our institution, we generally
recommend that hormone therapy be initiated, without further clinical staging,
when the PSA is in the 10- to 12-ng/mL range. At this level, there is little
doubt of treatment failure and it is unlikely that symptoms of disease progression
have developed that may distress the patient.
Posted 4/19/2010 2:14 PM (GMT 0)
John,

You started out this thread by asking for advice, but right from the start, it sounds to me that you have your mind made up 100% against any type of salvage radiation treatment. If that is the case, then so be it, its your choice anyway, and your body, and your cancer.

Some doctors would feel that taking the HT now, without the SRT, since you have had reccurance after surgery, is just "masking" your situation, and the longer that you choose not to have SRT, the less likely it would help you.

Understand again, it is your last curative chance, doesn't matter if those chances are 10% or 30%, it is something to hope upon. You are talking to a guy that abosutely , positiviely did not want to have radiation, either as a primary or secondary treatment, no matter what. From the day of my PC dx, I felt that way and let my dr know.

But after my surgery ,and all the complications I have endured, when I did have recurrance, as much as I hated the idea (based on a terrible experience 10 years ago with radiation treatments for other cancer), my logic told me, that at age 57, that SRT was my only chance of possibly stopping the cancer.

I knew it was a long shot for me too, with know PSA velocity issues both pre-surgery and post. Just recently, on my second reading post-SRT, I got what I thought I would never see, a zero, a .04 reading. Know I know that might not always stay that way, but it has given me hope, and yes, for me, radiation for a hellish experience even this time, but if it got the cancer, then its worth the pain.

There's never any point in asking for advice, if your mind really isn't open for suggestion. I wish you luck either way, but make sure you aren't painting yourself into a corner. More than one guy here, myseslf included, has had to reverse their thinking along a troublesome PC journey path.

David in SC
Posted 4/19/2010 6:36 PM (GMT 0)
While I feel that SRT in my situation is not going to help, I will reconsider if there is anyone in similar situation (i.e., PSA DID NOT DROP after prostatectomy) that has been helped by SRT --hence the post. If my post-surgery PSA were .1 or .2, I would have opted for SRT in a shot--but I was not so lucky. Hormone treatment is not a cure, I know, but cure in my case is almost certainly not going to happen (with a PSA doubling rate of 2+ months, in addition). I feel like Napolean retreating from Moscow.
Posted 4/19/2010 6:56 PM (GMT 0)
understood, but even if the SRT managed to knock out most of the remaining PC, then it would give non-curative treatments like HT a better chance to work, fighting against a much lower Post Surgical PSA number, and may buy you even more time.

I see very little reason, with your stats and situation, not to try it, will it get 100% of remaning cancer? Probably highly unlikely. But it could, in theory ,still knock a big chunk of what is left. I don't see where you have much to lose in doing it, assuming that money and insurance isn't an issue for you.

but you got my support no matter what you do. that is how is works here at HW.

david in sc
Posted 4/19/2010 8:46 PM (GMT 0)
John, Purgatory has a point in that radiation may give you a fighting chance at beating this. However, I also understand your reluctance to undergo radiation (and its side effects) if your chances for a "cure" are minimal.

Hopefully you'll hear from Zufus who is a wealth of information for our more advanced PCa brothers and frequently mentions many different protocols for the advanced stages of this disease.

In the meantime, I would try to meet or speak with as many PCa experts as possible to get a better understand of what your options are and what you are most comfortable with. Please don't give up.
Posted 4/19/2010 8:47 PM (GMT 0)
John, have taken the liberty of cutting and pasting Zufus' email address from his profile...get in touch with him please.

E-Mail Address : [email protected]
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