Immediate vs Salvage Radiation After RP

Here's new research from UroToday saying your chances are better with having radiation therapy immediately (adjuvant) as opposed to waiting for your PSA to come back up. Note: "immediate" means after you have healed from RP; 2 or 3 months.

UroToday

A multi-institutional analysis comparing adjuvant and salvage radiation therapy for high-risk prostate cancer patients with undetectable PSA after prostatectomy - Abstract

Monday, 08 November 2010
Department of Radiotherapy and Oncology, University Hospitals Leuven, Leuven Cancer Institute, Leuven, Belgium.

In men with adverse pathology at the time of radical prostatectomy (RP), the most appropriate timing to administer radiotherapy (RT) remains a subject for debate. To determine whether salvage radiotherapy (SRT) upon early prostate-specific antigen (PSA) relapse is equivalent to immediate adjuvant radiotherapy (ART) post RP.

130 patients receiving ART and 89 receiving SRT were identified. All had an undetectable PSA after RP. Homogeneous subgroups were built based on the status (±) of lymphatic invasion (LVI) and surgical margins (SM), to allow a comparison of ART and SRT. Biochemical disease-free survival (bDFS) was calculated from the date of surgery and from the end of RT. The multivariate analysis was performed using the Cox Proportional hazard model.

In the SM-/LVI- and SM+/LVI- groups, SRT was a significant predictor of a decreased bDFS from the date of surgery, while in the SM+/LVI+ group, there was a trend towards significance. From the end of RT, SRT was also a significant predictor of a decreased bDFS in three patient groups: SM-/LVI-, SM+/LVI- and SM+/LVI+. Gleason score >7 showed to be another factor on multivariate analysis associated with decreased bDFS in the SM-/LVI- group, from the date of surgery and end of RT. Preoperative PSA was a significant predictor in the SM-/LVI- group from the date of RP only.

Immediate ART post RP for patients with high risk features in the prostatectomy specimen significantly reduces bDFS after RP compared with early SRT upon PSA relapse.

Written by:
Budiharto T, Perneel C, Haustermans K, Junius S, Tombal B, Scalliet P, Renard L, Lerut E, Vekemans K, Joniau S, Poppel HV.   Are you the author?

Reference: Radiother Oncol. 2010 Oct 13. [Epub ahead of print]
doi: 10.1016/j.radonc.2010.07.008

PubMed Abstract
PMID: 20950879

UroToday.com Prostate Cancer Section




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Gleason score post op pathology all relevant.
Also need to think about quality of life issues, age of patient, side effects. and don't forget to treat the patient not just the cancer.

I will have a look for this study (As it's from Belgium the original may be in French or Dutch, but that should not present a problem for me.)

(My own PSA rose so soon after RP anyway that I never really had a chance to wait and see what might happen, so my SRT less than a year after surgery almost made it feel like it was ART)

Alf

edited addition: I think this is the article:
www.thegreenjournal.com/article/S0167-8140(10)00397-X/fulltext

Julios,
As my doctors have said ~ You are always at your best prior to starting any therapy.

Many centers show the same results with adjuvant radiation versus salvage radiation after prostatectomy. Here are a few that I have:

Mayo Clinic:
www.ncbi.nlm.nih.gov/pubmed/10737490

Baylor University Article:
www.medicalnewstoday.com/articles/43871.php

UCSF Article (Carroll):
esciencenews.com/articles/2010/08/06/surgery.better.radiation.hormone.treatments.some.prostate.cancer.study.shows

Stanford University (WPRT vs. PORT in high risk cases)
www.ncbi.nlm.nih.gov/pubmed/17459606?dopt=Abstract&otool=stanford

I don't think there is any doubt that biochemical failure is delayed by adjuvant radiation. We have even seen prostate cancer specific survival improve in the 5-10 year studies but we do need much more data on it. I chose adjuvant therapies as I already had the data for salvage radiation and HT. I wasn't too thrilled by what I read about salvage radiation being only 44 at the time. It made venturing out beyond to what data we don't have in regards to adjuvant therapies more comprehensible.

Tony

Casey, I'm happy to share. There's a lot of cancer history in my family, but no prostate cancer, at least within three generations. My first PSA and DRE was at age 46. My family practise Dr. noted the left globe was slightly larger than the right. The next was at 49; same doc found left side much larger and abnormal and referred me to a uro. The uro did DRE, observed the same, but concluded it was simply the left seminal vesicle causing the abnormal feeling. No follow-up suggested. Next one was by original doc at age 52, who was quite alarmed when he felt it to be even bigger. Same uro felt it and immediately said most likely cancer. He did a biopsy only then, and confirmed it. So I probably had it for more than 6 years before diagnosis. PSA was normal the entire time (1.7 or so).

>>and not just shooting the patients last curative hope into the air<<

i guess i don't understand this.  you'll either need RT or you won't.  the danger is "overtreatment", not wasting a curative bullet.  in my case i opted for combination treatment because there was a 60% chance that my PC was out of the capsule. 

ed

julios, thanks for sharing your history.  I don't have references at my fingertips, and of course the aggressive/indolent PCs are not thoroughly understood yet, but I recall reading retrospective info about low PSA/high Gleason combinations being infrequent, yet higher frequency among younger guys (like you) than older guys.  This is possibly counter-intuitive...

I recall from a post you made last month (a reply in a Piano thread) that your 2-month & 3-month post-RP PSAs were high right out of the gate, and you are now 4-months post-RP.  What are your RT and/or HT plans?  [I apologize if you have already discussed them in another thread.]

Add this article to the list of studies indicating favorable statistics from preemptive ART from The Journal Urology (2009) (sorry I can't find a full text link at this time):

Adjuvant Radiotherapy for Pathological T3N0M0 Prostate Cancer
Significantly Reduces Risk of Metastases and Improves Survival:
Long-Term Followup of a Randomized Clinical Trial
Ian M. Thompson,*,† Catherine M. Tangen, Jorge Paradelo, M. Scott Lucia,
Gary Miller,‡ Dean Troyer, Edward Messing, Jeffrey Forman, Joseph Chin,
Gregory Swanson, Edith Canby-Hagino and E. David Crawford
From the University of Texas Health Science Center at San Antonio (IMT, DT, GS) and Wilford Hall Medical Center (ECH), San Antonio, Texas, The Fred Hutchinson Cancer Research Center, Seattle, Washington (CMT), The Kansas City Community Clinical Oncology Program, Kansas City, Missouri (JP), The University of Colorado Health Science Center, Denver, Colorado (MSL, GM, EDC), The James P. Wilmot Cancer Center, University of Rochester School of Medicine, Rochester, New York (EM), Wayne State University School of Medicine, Detroit, Michigan (JF), and the University of Western Ontario, Department of Surgical Oncology, London, Ontario (JC)

Purpose: Extraprostatic disease will be manifest in a third of men after radical
prostatectomy. We present the long-term followup of a randomized clinical trial
of radiotherapy to reduce the risk of subsequent metastatic disease and death.
Materials and Methods: A total of 431 men with pT3N0M0 prostate cancer were
randomized to 60 to 64 Gy adjuvant radiotherapy or observation. The primary
study end point was metastasis-free survival.

Results: Of 425 eligible men 211 were randomized to observation and 214 to
adjuvant radiation. Of those men under observation 70 ultimately received radiotherapy.
Metastasis-free survival was significantly greater with radiotherapy
(93 of 214 events on the radiotherapy arm vs 114 of 211 events on observation;
HR 0.71; 95% CI 0.54, 0.94; p 5 0.016). Survival improved significantly with
adjuvant radiation (88 deaths of 214 on the radiotherapy arm vs 110 deaths of
211 on observation; HR 0.72; 95% CI 0.55, 0.96; p 5 0.023).
Conclusions: Adjuvant radiotherapy after radical prostatectomy for a man with
pT3N0M0 prostate cancer significantly reduces the risk of metastasis and increases
survival.

Casey

As for my RT/HT plans: I began ADT with a Shot of Lupron 3.5 months post RP. Two months later I begin RT using about 68 Gy to three involved pelvic lymph nodes and about 62 Gy to the tumor that remains in the prostate bed. The hope is that the ADT will shrink the lymph node tumors allowing a smaller RT dose. The exact Gy will be determined after the 2 months of ADT. A PET scan will clearly delineate the status of the tumors, in my case.

I think I have a pretty good medical team. I live in Santa Barbara. The medical oncologist also does research at UCLA. The radiation oncologist graduated from Havard, and interned at Dana Farber.

As I recal, your disease is similar to mine. What is the difference in your condition, and what are your plans?

Sam,

This is a confusing topic.  For as many searches as you do on the topic, you find as many opinions.

Nomograms are a statistical statement.  The studies are an observation of the sample at hand.  Stats say that heads or tales is a 50/50, however when you do it 100 times, it may be 30/70, or 70/30, or it may land on the edge once.

It is true , PT3NOMO is not the best diagnosis statistically, but you will find many guys here who are beating the odds.  The why is the tricky part.  Every trial may come up with a different conclusion based on what they are studying.

For me, it has become a personal choice of when I want to pull the radiation trigger.  So far, I figure I have potentially extended my longevity by a couple of years by waiting, if I can expect 10 yearspost radiation, which may be an entirely bogus belief and number.  With .01 PSA, I just am going to wait.

Oh, and welcome to the forum.

Goodlife