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Is Radiation in my Future?

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Posted 6/14/2010 11:53 PM (GMT 0)
As my stats show, I have had a slowly rising PSA with quite a jump to 0.2 at 25 months post-surgery.

I recently went to my GP, and just got the results of an unscheduled PSA test (27 months) -- still 0.2. Needless to say, I am glad (delighted!) that at least it hasn't gone up further. If it had I would be looking at salvage radiation -- even though with my stats, the chance of a "cure" is only about 30%.

As it is now, I plan on more watching and waiting until my next scheduled PSA test four months away.

If my PSA continues to rise slowly (seems to me the most likely possibility) will radiation still be an option? Is watching and waiting a good policy at this point? I know that none of us are doctors, but I would still be interested to hear the experiences of others who have traveled a similar path.
Posted 6/15/2010 12:10 AM (GMT 0)
Am interested in some of our more scholarly folks.

I am watching all of this as well. I have heard some say that the longer the doubling time, the better the odds are that the PC is still in the prostate bed.

Good luck. Hopefully you have a good oncologist to help you through the next stage.
Posted 6/15/2010 12:10 AM (GMT 0)
Piano,

From your 19 month to you 25 month tests, a period of 6 months, you more than doubled your PSA. Your 27 month test confirmed your 25 month results, so the .2 is probably real. If I were you, just an opinion as you are asking, I would do one more test within 3 months of the last, and if it is still .2. or higher, I would strongly consider SRT in your future, as much as I personally hated doing it for myself.

The odds of SRT working are lower as we know, but even with that said, I think I would still consider doing it in your case. If SRT is going to work, it needs to be done before the PSA gets too high, some already use .2 as a line in the sand, while others might go as much as .5.

What none of us know for sure, is the remaining cancer still in the prostate bed or not. Since SRT would be your last curative means available, I would rather use that card, then to wait to long for it to do any good.

I know it will be a tough decision.

David in SC
Posted 6/15/2010 1:09 AM (GMT 0)
No we are not doctors but we have a great deal of experience talking with so many over the years, Piano. If it were me I would not mess around with grade 4 cells. You already have a high risk case because of the G8. You are looking at WPRT using IMRT if you decide to get it done. i know some guys will tell you to use a more precise method of delivering the radiation, but I don't think anyone can tell you where your relapse is located. Prostate bed likely but where? That stated, with a relapse with grade 4 cells, you would want to ask about including the regional lymph nodes in your treatment.

Wish you were not dealing with it, but you can still do quite well.

Tony
Posted 6/15/2010 4:21 AM (GMT 0)
Sounds a lot like me ... I was .01 for almost 2 years then upgraded to .2 and last check up was .4... Schedule for SRT and in my 4th week now ( half way ) :) my .2 went to .4 in one year.. and my doctors said due to the long progression to .4 Srt is the best solutiong at the time so it is being done  now. Yes the longer the doubling time ( according to my doctor ) the better the chance of curative treatment. So im putting my hopes he is right. He said the longer the doubling time tells them how agressive it is. So the longer the better and .4 is a good time to get it done. Hope you dont go that far but if you do SRT is a  good plant to take. So far it has been a experience for me but not a bad one. I was nervous about it but now that im haf way trough all the bad things that could happen (my imaginatioen stuff) has not happend and I satisfied ill get past the SRT ok... But then i have the next wait after it is done.. and the next psa... I hope all goes well for you and you stay low on the psa....
Posted 6/15/2010 5:05 AM (GMT 0)
I could understand that. Most centers would probably say 0.4 is ok before intervention with salvage therapy. Mine told me that when I elected to have adjuvant radiation instead based on a sour post-op pathology. There probably isn't much data from 0.2 to 0.4 showing the benefits of waiting or not. Because of the Gleason 8 it might be better to error on the side of caution. But still the 27 month PSA didn't go up...

Fun disease...:-(

Tony
Posted 6/15/2010 12:57 PM (GMT 0)
Hey Piano...I am in the same boat as you at this point except for a lower gleason which is very significant at this point as Tony said. My doc wants to wait for further progression and so I follow his advice / experience in this field, but it sure does make my wife nervous waiting, much more so than me.

Keep us posted if you decide to pull the trigger and how you came to the final decision for others like me.
Posted 6/15/2010 4:05 PM (GMT 0)
Here's what Dr Strum has to say:

Lou Antonelli ||

> Then in 2006 when ultra sensitive equipment was introduced readings
>were as follows:
>
>Jun 06 .04
>Sep 06 .06
>Dec 06 .05
>Mar 07 .06
>Jun 07 .06
>Jan 08 .08
>Apr 08 .10
> Jul 08 .11
> Oct 08 .13
> Jan 09 .13
> May 09 .14

<Stephen Strum, MD> These kinds of numbers strongly suggest LOCAL recurrence and the PC TOOLS II program at the PCRI website can be used to determine PSAV (PSA velocity) post RP and then the nomogram for LOCAL versus Distant recurrence. Most likely, the above, if not changed a lot, reflects local recurrence. This can be further evaluated with DRE (digital rectal exam) and with 3T MRI of the prostate. Unfortunately, Combidex no longer exists to rule out nodal metastases and the use of CT & bone scan in this context is worthless, and a waste of healthcare dollars.

|| Dean & Lou Antonelli ||

> Oct 09 .19
> Jan 10 .22
> May 10 .27
>
>PSADT Since Jan 09 14 months
>PSADT Since Apr 08 18 months
>
>
>Since Jun of 06 till May of 09 psa increases were very small
>
>But the last three readings show an acceleration and the prospect of
>radiation and/or ADT is now being reintroduced. I have so far twice
>declined. I have tacitly agreed to go ahead at psa .4 or .5.

<Stephen Strum, MD>
You made the mistake of so many patients focusing on WHAT TO DO rather than to determine STATUS (what is happening at a biological
level) which then leads to a rational STRATEGY. If you are seeing a
serial increase in PSA, then go ahead and treat this situation now before the PC population mutates further. Do your investigations now because any treatment will alter the value of further testing such as MRI or labs.

|| Dean & Lou Antonelli ||

> From my amateur research, I learn that men at the lower risk of
>progression do so much better with RT and/or ADT than those with a
>higher risk of progression. So much so that it brings into question
>whether the treatment was of any net benefit. Herein lies my dilemma in
>determining when or whether to treat.

<Stephen Strum, MD> I am not clear as to your thinking expressed above. RT efficacy depends on WHERE THE PC IS since Radiation PORTS of treatment can only kill cells within that field. ADT efficacy depends on the sensitivity of the PC population to the drugs used and how complete the androgen deprivation (AD) approach is. This varies a lot with the treating physician and his or her knowledge of the endocrinology and intracrinology of PC.

JohnT
Posted 6/15/2010 10:17 PM (GMT 0)
I agree with and understand the assessments in the cases of Dean & Antonelli with the severe caution that neither are Piano. Missing data for these patients include PSA at detection, Gleason Grade at surgery and stage of their disease at surgery. Some are arguing that MRI-s is providing usable data to determine if SRT will be beneficial. I don't know how true that is. Recent MRI-s techniques are very new and there is no study data worth considering about using it this way that I know of.

Strum's point about there not being a test to confirm lymphatic invasion is correct but that is precisely why Stanford and Harvard studied radiating the regional lymph nodes in addition to the prostate bed. We do know that it is very rare for prostate cancer to relapse outside the regional lymphatic system as proven by the success rates evidenced in the Stanford Harvard studies.

Maybe Piano's PSA will go down with the next test? Maybe it will go up again. In which case it's already been climbing serially upwards. At this point in the above case Strum recommended intervention before the disease mutates further...

Tony
Posted 6/16/2010 11:08 PM (GMT 0)
Thank you to everybody who has replied.

I will continue with with my plan to wait for the next PSA test, now less than 4 months away. I am expecting a further rise, and if .25 or beyond, then yes, I will go with SRT, even though the nomograms show only a 30% to 40% chance of a cure. (Also depends on what the docs say.) If there is only a small rise, then probably I will continue watching. My uro thought that some benign prostate tissue left behind might have been responsible for the earlier rise, so there is still a chance that that my PSA will stabilize at around its current levels. (Clutching at straws!)

Even if my PSA gets to 0.4 before SRT gets started, that still doesn't make the PCa untreatable. The Sloan-Kettering Salvage Radiation Therapy nomogram:
www.mskcc.org/applications/nomograms/Prostate/SalvageRadiationTherapy.aspx
shows that with my numbers and a 6-month doubling time there is a 35% chance of a "cure" with a PSA of 0.2 and a 30% with a PSA of 0.4. That is trading off a 15% worsening of my chances compared with a chance (5%? -- a guess) that I won't need SRT at all. Is a 5% chance of no SRT at all better than a 15% worse outcome if I do go with delayed SRT? I'm not really a gambler, but right now, I'll run with those odds.

And if I also opted for neoadjuvant hormones, the nomogram shows a "cure" rate better than 50%, so that is something I will also have to consider, again depending on the docs.

Another factor in my case is that I am otherwise in good health so have a reasonable expectation, without PCa, of living another 15 years, which would take me to age 80.

How well will I tolerate SRT and hormones? I have no way of knowing, but I should expect at least a small impact on my quality of life. How does a reduced QOL compare with a longer life? Would I trade off a year of life for better quality? Probably.

There are no easy answers here, and as with much to do with PCa, it is an individual choice. As a compromise, I will perhaps see an oncologist, so that if my next PSA shows a significant rise, the wheels will already be in motion.

Thanks again for your interest and inputs, and I will update this thread when there is anything new to report.
Posted 6/18/2010 9:31 AM (GMT 0)
Piano,

Sorry to read about your PSA creeping up. Same thing happened to me and I found it quite depressing at the time. I was a lower Gleason 3+3 post op pathology, but with 2 focal "point" margins... which the doc said would probably not be a problem. Well after 32 months, I found my PSA had risen to 0.13... I decided that since factors suggested local BCR, I wanted to jump on it right away... 32 treatments of IMRT x 2 gys = 64 gys.
My body took the radiation with minimal side effects which have since passed. My first post SRT test results after 3 months were 0.02! The doctor was very happy and confident. I feel very fortunate and strongly fell that I have beaten the beast back to a good "zero" this time. I was never really positive after the surgery as strange as that may seem... Like a little nagging voice in the back of my mind... That little voice is gone now... :-)

Anyway, there has been lots of good words spoken here and a lot of information... The SRT treatment involve both physical and mental consierations.... For my personality, I jumped on it quick... at 0.13... but did wait a couple of months for my depression to abate before starting the SRT. Jeesh... 7 weeks of treatments seemed too tough to grasp... especially since we had moved and were 220 miles from the hospital. Lucky that I am retired. I stayed at a friends house that was only 30 miles from the hospital and after the 1st treatment, they flew by and it was over... I took my treatments around 5-6pm... Made it a reverse commute. Ended up having a great relaxing stay at my friends with plenty of sleep... and became a live in "grandpa" to their 3 y/o... Spoiled her rotten... but that environment really kept my spirits up along with the required rest you need during the treatments. Also helped with the time away from my dear wife and home. I did drive back home for a weekend in the middle of the treatments.

Anyway, get your plan together and think about all the phases and logistics of the treatments if you end up going that way. With a good plan and a body that hopefully takes the radiation well, the SRT treatments can be tolerated quite well. And the results can be good.

God Bless,

pasayten
Posted 6/18/2010 11:42 PM (GMT 0)
Pasayten, thank you for the encouragement. It's always a good sign if the PSA drops after treatment -- it means you got zapped in the right places :-)

I am something of a procrastinator, so am not jumping into treatment as quickly as you. Also, I don't suffer from depression, and don't lose any sleep over my situation. With my higher Gleason there is a higher chance that SRT will be ineffective anyway -- the PCa may have already spread.

Without PCa, I have another 15 years to live. With PCa in the worst case, it might be about 5. So PCa could possibly shorten my life by 10 years -- not really so bad (if you say it quickly!). So I will live life as if I have only 5 years left, and if it turns out to be longer, that will be a little bonus :-)
Posted 10/25/2010 10:26 AM (GMT 0)
Four months have elapsed and I had blood drawn again last week. I visit the uro tomorrow to find the results of the latest PSA test, and discuss future action. Of course I hope for a reduction -- it does happen -- see Pattersson's current www.healingwell.com/community/default.aspx?f=35&m=1936979, but fully expect another rise, hopefully only a small one...

Post Edited (Piano) : 10/25/2010 4:29:15 AM (GMT-6)

Posted 10/25/2010 12:26 PM (GMT 0)
I've got my fingers crossed for you.  You have a great attitude, a ton of common sense, and a lot of courage.  Speaking as someone who has not yet had a PSA test post-surgery, I hope I can emulate your approach if my results are less than hoped for.

Posted 10/25/2010 12:34 PM (GMT 0)
Piano will be waiting to see if your playing on the Black or the White Keys....Sure hope your playing in C Major not B flat minor.

Cajun jeff
Posted 10/25/2010 10:15 PM (GMT 0)
Let us know the result. Hope it's a decrease

Mel

Posted 10/25/2010 10:38 PM (GMT 0)
Been there done that and here we go again :
couple sources :
My Current therapist Finding a rising PSA after Proton Radiation ( medical Oncology )

Mark Scholz, M.D., one of the nation’s leading prostate cancer specialists, Prostate Oncology Specialist

http://www.prostateoncology.com/

Round two 17months after DV Surgery
James M. Slater, M.D. Proton Treatment and Research Center

http://www.protons.com/

Round One :
City of Hope CA, Prostatectomies using the da Vinci Surgical System.

Best of luck !
Posted 10/25/2010 11:28 PM (GMT 0)
Piano

My case presents similar to your, (wow, didn't that sound just like those researchers?). My first PSA after RP was 0.54 at 2 mo, and 0.44 at 3 mo. My uro, radiation oncologist and medical oncologist all recommended I get adjuvant RT together with 6 months ADT without delay. They consider it "curative" at this point, but admit it's most likely just a matter of time before it's really just treatment. Studies I've read say there is overall survival benefit from doing the RT sooner rather than later, so I'm following their orders.

Your condition is more positive than mine. Best wishes to you.
Posted 10/27/2010 10:26 AM (GMT 0)
To all who posted here, thank you for the continuing support.

My PSA is now 0.3 up from 0.2 four months ago -- higher than I hoped for but it could have been worse.

But what an anti-climax! Instead of my uro, I saw a registrar (junior doctor) who made it clear that she knew less about PCa than I did with her opening comment that a PSA of 0.3 is really quite good and nothing to worry about!

My uro had previously indicated that he thought radiation might not help in my case -- I think because of negative margins, Gleason 8 and slowish PSA increase. So I would really have liked to discuss this in greater detail. The registrar went off to see the uro with the 0.3 figure, and the decision was come back in 6 months. My suggestion that I see an oncologist, or move to 3-monthly PSA tests (from 6- monthly) fell on deaf ears.

All too casual for my liking -- I can see a window of opportunity slipping by. I have today gone to my GP who will send a letter to my uro for a written answer to the radiation question. Let's see what happens...
Posted 10/27/2010 12:41 PM (GMT 0)
Just my opinion...time to visit the medical oncologist. Gleason 8 - negative margins - I agree all too cavalier from your uro's perspective in my way of thinking.

Best of luck to you
Posted 10/27/2010 12:46 PM (GMT 0)
Piano:

I'll even go a bit further: Your current medical management borders on malpractice.

PLEASE try and get a second opinion from an oncologist. Is there a major cancer center near you where you can do a consultation?

THIS IS IMPORTANT!!

Mel

Posted 10/27/2010 1:16 PM (GMT 0)
 

Piano,

I am also a G8 who had good pathology and experienced recurrance at around 9 months I went right to an oncologist, do not waste time with your uro doc, anyone with an 8 which is an aggressive cancer should be under the care of a good oncologist.  I did SRT and it did not work for me however, your recurrance was a lot later then mine which is a very good sign that it could be local.  Get the opinion of experts and get far away from your uro doc who does not take a recurrance of 0.3 seriously.

Good luck, as a side note I did not experience any side affects from the IMRT.

Jerry1

Posted 10/27/2010 1:49 PM (GMT 0)
Piano-
Your original choice of title: "Is Radiation in my Future?", has, to my non-professional mind, been overtaken by circumstances.
Radiation should now be in your present or your immediate future; I think it could be sensible to start it before the end of 2010.

Not helpful for you to have had a junior doctor who "didn't read the notes before opening their mouth"
I now only have the one uro, but he has hundreds of patients and I know that he cannot be expected to remember everything about all of them - it's a miracle he remembers anything about any of them. (He usually does two da vincis in the morning and sees about a dozen out-patients every afternoon.)
I am therefore always very glad that when I enter the room there is that pause for a few seconds before he says anything to me while he opens my file and looks at a couple of things in the notes that are going to help remind him who I am and what my history is. (I guess I am lucky that being in Holland I stand out a bit from the rest by not being Dutch)

My PSA went from 0.1 to 0.4 so quickly that we had no trouble deciding then and there that we had to go for SRT (And the appointment with the RT department was made on the phone for me before the uro even saw his next patient)

It's a pity that most PSA results above 0.2 don't come back with more than one decimal point.
You might have had a better idea about whether or not you were rising or staying stable if they had.
Imagine that with your 25 month test it had said say 0.18 instead of 0.2 and then at 27 months you'd had say 0.24 instead of 0.2. That could have given a more accurate picture.
Even with your 0.3 it could help to know if it was really 0.26 or 0.34.

Your membership of the old Zero club has been suspended, so I'd be surprised if you do not now find your self joining the RT club so as to try and get your zero club membership restored.

Good luck with all the decision-making etc

Alf
Posted 10/27/2010 3:14 PM (GMT 0)
Here's a new research article on benefit of RT + HT over RT alone. If it asks you to login and you aren't registered with UroToday, you can register for free.
Posted 10/27/2010 6:27 PM (GMT 0)
Piano said... Is Radiation in my Future? Piano,   You now have what the American Urological Association terms "biochemical recurrence" (BCR).  I would say that salvage radiation (SRT) is likely to be in your future.  Your signature says i) organ confined, ii) negative margins.  These favorable pathology indicators, plus the late PSA relapse (2-years), are good indicators that your recurrence is "local", which means SRT has a good probability of success.   I plotted your five detectable data points, with an exponential best-fit line.  (Cancer cell growth is exponential.)  See IMAGE.     VIEW IMAGE     edit:   typo Post Edited (Casey59) : 10/27/2010 1:38:48 PM (GMT-6)
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