HealingWell
Search Close Search
☰

Adjuvant RT for pT3 Post RP

Support Forums
>
Prostate Cancer
✚ New Topic ✚ Reply
❬ ❬ Previous Thread |Next Thread ❭ ❭
Posted 4/25/2011 9:35 PM (GMT 0)
I believe the "undectable" PSA value used for the study linked below was .01

 

Does any have any thoughts on this study - Tony, are you out there?

Phase III postoperative adjuvant radiotherapy after radical prostatectomy compared with radical prostatectomy alone in pT3 prostate cancer with postoperative undetectable prostate-specific antigen: ARO 96-02/AUO AP 09/95

 

urology.iupui.edu/papers/prostate/adjxrtprostateARO96-02.pdf

 

This link http://www.phoenix5.org/Basics/PSAundetectable.html indicates undectable thresholds vary by testing method and cancer organizations

 

K2

Posted 4/25/2011 10:18 PM (GMT 0)
The study is perfectly in line with what I was reading early on when I was deciding whether to add radiation.

This is no longer as controversial for post op positive margins and seminal vesicle invasion. If you look at the graph it shows all categories as reaping some benefit but the >G6 stage 3 and 4 guys are seeing much more benefit. I would not recommend ART for a G6 guy regardless of stage. For patients that I personally have met of known here - all of the ART patients that I know that were stage 3b or higher have yet to relapse after ART. But for those that were stage 3b or higher that elected to not have ART most have relapsed and started SRT and/or hormonal therapies.

Additionally, while this study concludes with the recommendation to see if there is an overall survival benefit, there are other studies that say there is. I no longer have any doubt about it. But there's a catch. I was pretty young when I had the treatment and I have to go a long way with possible future morbidities. So far so good. I think the benefits do outweigh the risks. I also added adjuvant hormonal therapy for two years. And that one may have been unnecessary but whatever I did is working.

But I would do it again to get past four years without relapse...I am glad I studied about adjuvant therapies and acted upon my findings.

Tony
Posted 4/26/2011 2:17 AM (GMT 0)
Tony, After re-reading the study, I think it defined "undectable" PSA at 0.1 ng/ml (not 0.01 as I stated earlier) Oddly the study does not define the term "undectable PSA" until page 6.  I'm unfamiliar with the "SWOG trial" used for comparison. Page 6 (pg. 2829) "Our results support an analysis of the SWOG trial. In this randomized trial, part of the patients were treated before the PSA era. When the data of patients with a PSA level of less than 0.2 ng/mL were analyzed (the undetectable range at this time), there was a clearly significant benefit for bNED at 5 years (46% v 77%) and 10 years (28% v 58%). Our undetectable range was at least 0.1 ng/mL and defined progression at an earlier stage (0.4 ng/mL in the SWOG trial). Thus in the German trial, the 5-year results are better than in the SWOG trial." My post RP PSA was 0.2 at 20 days and 0.03 at 34 days - So 0.03 PSA may represent my nadir PSA. I'll have another PSA test in about a month - before I begin ADT. I am pT3a with a single positive apical surgical margin (thought to be focally present but the pathology report did not specify). I have Gleason 3+4, NO, MX, No SVI, Perineural invasion present, Lymphovascular invasion present. I'm not sure about the implications of the perineural and lymphovascular invasion other than they are negative. Neither appear to be routinely used as a prognistic indicatior. Of course I would have liked my last PSA test to be 0.01 ng/ml but there appears to be different opinions on very low PSA numbers above 0.01 ng/ml. Tony when you received ART the trend was probably just beginning to gain acceptance - now all of docs say its the best way to go for me. From what I've read I'd have to agree. I,m praying for resilience against ART side effects. K2
Posted 4/26/2011 2:49 AM (GMT 0)
K2,
There is a very distinct difference between T3a and T3b in the graph and discussion. When I was looking into this originally there was one study from Stanford University that I saw that had a median follow up at 7 years. Just like this study you posted it showed that all T3 guys benefitted in terms of biochemical failure and that T3b saw the biggest benefit. In that study it was done with adjuvant hormonal therapy and that's the way I went. The pro's were obvious and the one con was that the study lacked follow up to see if there was a survival benefit. In time I have seen that in fact there is when applying both adjuvant therapies after RP. My oncologist told me in the past that he has changed his mind from "not knowing" to "understanding" that there is indeed good history with prostate cancer specific survival.

The question is if there is enough information for the T3a guys. There are still many doctors that believe that it's not appropriate to send all pT3a men for radiation after prostatectomy since 75% will be biochemical failure free at five years.

I believe however since pT3b guys have higher risk they should at least consider it and discuss it with their doctors and a radiation oncologist.

Tony
Posted 4/26/2011 3:17 AM (GMT 0)
Tony,
I'm a PT3a with EPE but with negative margins. At 27 months after RRP my PSA is <.005. My Uro was aggressive and remove a lot of adjoining tissues and the nerve bundles. Do you have any information on whether removing the nerve bundles has any effect on the outcome?
Posted 4/26/2011 3:33 AM (GMT 0)
Hi Ed.
I do not have much. There was a belief at one time that removing them was absolutely necessary in early RP. Luckily Patrick Walsh developed a method to save the nerve bundles and improve QoL. Unfortunately not all men can save keep them. There are many reasons why during the procedure a surgeon has to make the call to take the bundles.

Your case is a good example of a case that most doctors would still discourage adjuvant radiation.

Tony
Posted 4/26/2011 3:36 AM (GMT 0)
Interesting topic since I'm a pT3a person. I'm almost finished with my ART...6 more sessions to go after tonight. My post surgery was a topic brought to a regional tumor board and all agreed that ART was a recommended course; however, when the subject of HT inconjunction with ART, it was not recommended for me. I can see this maybe being the difference between pT3a and pT3b adjuvant strategies.

So far, my side effects have been minimal. A little fatigue along with a little urgency.

I do have a question...however...maybe a topic for another thread - Do most get ultra-PSA tests or standard...I keep seeing numbers to 3 or 4 decimal points from most posts and my post-surgical PSA was <0.1 which I assume that a regular PSA doesn't go any further. Asked my RO today, and he said ultra-PSA was not necessary.
<bobr>
_____________________________________
Age: 54
Routine Physical on 10-20-2010 DRE Normal
PSA 4.3, up from 0.6 5 years prior
PSA 0.6 on 10-25-2005
PSA 0.4 on 7-30-2004
PSA 0.5 on 5-9-2002
Followup with Urologist on 11/10/2010 after elevated PSA; DRE noted slight bump
November 30th, 2010 had prostate biopsy.
December 9th, 2010, Biopsy results 3 of 12 cores positive.
LLB: Gleason's 4+3=7, 11 MM Tumor Length/15MM Core Length (73%)
LLM: Gleason's 4+4=8, 12 MM Tumor Length/15MM Core Length (75%)
LM: 0.1 MM Tumor Length (1%)0.1 MM Tumor Length
Urologist recommended robotic removal using da Vinci method.
RALP Surgery 12/27/2010 Released: 12/30/2010
Thunderbird Banner Hospital, Glendale, AZ
Post-Surgery Pathology: GS 4+5=9
Pathologic Staging: pT3a, N0, MX; location: Left Side; Volume: 10%
Margins: Left posterior inked margin focally involved
Extraprostatic Extension: Observed
Seminal vesicles: Not observed
Lymphatic/Vascular Invasion: Not observed
Catheter: Removed 15-days after surgery
Post-OP Followup on 1/11/2011; Catheter/Staples removed
Adjuvant IMRT 8 Weeks Post-OP.
No exercise for 4 Weeks Post-OP.
Radiation Oncologist Initial Consultation on 1/18/2011
Calypso Procedure on 2/17/2011; PSA <0.1; Bone Scan Clear
341 Testosterone
CT Simulation on 2/24/2011.
Calypso ART in progress - 40 treatments ending 3/3/2011
Posted 4/26/2011 3:56 AM (GMT 0)
Bob,
The kicker for you would be the Gleason 9. I think it's a good plan.

The ultra PSA tests are not necessary for good after treatment care. Since most men will wait until the doubling time is determined the standard PSA has been shown to be effective. It's debatable, however, so to each their own.

Tony
Posted 4/26/2011 4:48 AM (GMT 0)
Yup Tony,
You got that right my friend. I really asked the HT question to several docs and none even hinted at HT. In any event, I feel comfortable with my course of action. Right now, I'm looking forward to finishing ART and taking a 'PC-war' vacation.
Posted 4/26/2011 4:48 AM (GMT 0)

Tony,

 

The graph (figure 4) found at the blue link below shows the greatest benefit of ART is T3a/b with T3c being somewhat less so. It treats T3a/b as a group without differentiating.

 

Journal Of Clinical Oncology - 20 June 2009 (Volume 27  Number 18)

Phase III Postoperative Adjuvant Radiotherapy After Radical Prostatectomy Compared With Radical

Prostatectomy Alone in pT3 Prostate Cancer With Postoperative Undetectable Prostate-Specific Antigen:ARO 96-02/AUO AP 09/95

http://urology.iupui.edu/papers/prostate/adjxrtprostateARO96-02.pdf

 

Journal Of Clinical Oncology Editorial - 20 June 2009 (Volume 27  Number 18)

http://jco.ascopubs.org/content/27/18/2898.full.pdf

Since ART is the path I'm currently on any contra information is very useful.

 

I am a bit concerned about QoL post radiation. I was continent on the third day after my catheter was pulled so I'm hoping that will remain - but the bowel issues sound unpleasant.

 

I'm still trying to get a foot hold on the POST RP T3 ART literature and appricate your input. It sounds like an age old debate but I think the ART folks are currently getting most of the attention with the post 5-year outlook showing the most improvement.

 

K2

 
Posted 4/26/2011 5:06 AM (GMT 0)
K2,
You are correct. But there is another factor to include. First let me explain that this study uses the AJCC1997 cancer staging manual. In 2002 they changed the staging system to lump all the previous stage T3a and T3b into one group as T3a. T3c was re-classed to T3b.

The survival improvement is much higher in the T3b guys. Additionally the adjuvant hormonal therapy helps:

prostatecancerinfolink.net/2011/02/06/limited-value-of-immediate-adjuvant-adt-in-men-with-pt3b-prostate-cancer/

K2 I did very well with adjuvant therapies. At least thus far.

@brampy,
I am currently on a PC-war vacation. No therapy and steady PSA tests. LOL...Of course not sure how much a vacation I am on working as an UsTOO chapter leader and site moderator, among a few other things...:-)

Tony
Posted 4/26/2011 6:42 AM (GMT 0)
Tony,

That's very interesting about the re-classification of T3 stages. The article you cited pertained specifically to T3b folks exclusively but did illustrate a notable upside to ADT for T3b.

My Rad Onc cited the NCCN guidelines (linked below, which I'm sure you've seen) which advocates ART (or observation) if adverse pathological features are present i.e., positive marigns, SVI, extracapsular extension, detectable PSA. The adjuvant therapy recommended is the same for T3a thru T4 (to include G-scores 8-10 and PSA > 20 - I assume preop). Basically, everyone considered high risk is recommended to undergo ART.

Reading Walsh's book he only recommends RP for "some men" with T3a (defined on page 241 para 3). 

On page 374 he has a table to determine if you're at high risk for early PSA recurrence. You add the weighted factors, if the total is higher than 2.84 your risk for developing an elevated PSA level within 3 years is 50%. I was 2.57 but these are just assertions - he doesn't show the science/experience it's based on. He uses three pathological factors and four Gleason scores. Interestingly 3 + 4 is weighted quite a bit better than 4 + 3. Most of what I've read lumps all G-7's together. His book was published in 2001 and revised in 2007 but it seems dated - especially for "locally advanced" prostate cancer.

BTW, What do you think of the NCCN?

Page 9

http://www.indianacancer.org/resources/files/NCCN_2010_Prostate.pdf

K2

Posted 4/26/2011 8:08 AM (GMT 0)
Tony, as you know I am a T3a, and failed SRT, my doctor I notice has scheduled me for an "ultrasensitive" PSA test in August, would that be because my PSA has gone from 0.5 to 0.7? normally I just have the normal PSA test.

Regards Mal.
Posted 4/26/2011 10:00 AM (GMT 0)
I don't quite match the trial group:

I note that all those in the trial had had open surgery and not robot, and that they had all had their (pelvic) lymph glands removed too. (I had da vinci surgery and they did not remove any lymph glands.)

Finding out after surgery that I was T3b told me I was going likely to need RT at some stage, and actually had it about 38 weeks after surgery (I began my SRT a year ago today as it happens after my PSA jumped from 0.1 to 0.4).

I have had now been "less than 0.1" three times in a row, so feel fairly content at present.

Alf
Posted 4/26/2011 2:35 PM (GMT 0)
K2,

Back in the first part of 2010 there was a study (I'm sorry, don't have the link, but it was posted here) in which Walsh participated, and agreed that ART was much more valuable than was earlier believed. It was not a real reversal of opinion, but he did open the gates a bit. Because the numbers were very real for me (I was just starting adjuvant IGRT, and fell dead center into the "positive results" group) it got my attention.

I remember it well, because there were still people telling me I started RT too early.

I am still getting single decimal PSA tests from the uro, but my GP is doing ultrasensitive (2 decimals). I have had very different opinions on which is needed

Posted 4/27/2011 5:41 AM (GMT 0)
Tony, et al.,

I was looking at the Han table calculator for (my stats) non-organ confined disease, G 3+4 and PSA 0-4. The numbers were 

Probability of Biochemical Recurrence
(detectable PSA level) at
3 years after surgery: 8% (3-21)
5 years after surgery: 15% (5-33) 
7 years after surgery: 19% (7-45) 
10 years after surgery: 24% (9-54) 

It's hard to believe the numbers are that good. Just for curiosity I changed the G-score to 4+3 the stats drop a lot! - approx. half

Probability of Biochemical Recurrence
(detectable PSA level) at
3 years after surgery: 19% (7-44)
5 years after surgery: 29% (11-62) 
7 years after surgery: 40% (16-76) 
10 years after surgery: 48% (21-84)

So, the crux is what will ART add? How good are the Han tables? 
I wish I knew. The NCCN seems on board with ART for T3a. Studies indicate  starting RT with low PSA is best (< 0.05 being optimum ?). But am 
I chasing a few percentage points? Can T3a be cured? some lit. says yes and a lot says no.

http://urology.jhu.edu/prostate/hanTables.php

K2
Posted 4/27/2011 6:47 AM (GMT 0)
@Mal,
Your case is a very unusual case I've come to learn. You have a PSA of 0.5 after surgery and after adding radiation your PSA went up. But whatever, your cancer isn't in any hurry ~ it's been three years to get to 0.7! Hopefully you are still spending a great deal of time with the lawn bowls...

@Alf,
Two thumbs up. Stay well.

@K2,
Yea. Try entering my numbers. I just didn't like the tables at the time using multiple sources ~ they didn't go to even ten years in their projections. I had 40 years that I was interested in living. The MSK nomograms only went to 7 years at the time. LOL, today they go to 10 years and I am even more convinced that it was logical in my case to go with the adjuvant therapies.

Tony

Post Edited (TC-LasVegas) : 4/27/2011 12:50:19 AM (GMT-6)

Posted 4/27/2011 2:49 PM (GMT 0)
Tony,

Although they're stated inversely Han & MSK are close (Han is a bit better) in my case. My urologist stated he thought of my chances were ~50% of having undetectable PSA post RP...clearly he's using other prognostic tools. At 34 days I was 0.03 and he thought that might be due to my focally positive apical margin. But 0.02 worth of PSA 34 days after RP could be several things.

All of this comes back to the question benefits of ART for T3a folks. Some evidence indicates ART at very low PSA is better than SRT begun with slightly elevated PSA. How much better? Debatable.

I'll be getting ART every day at 5pm after work - the rad onc said he expects I'll do well due to my age (50) and condition but I might feel a bit tired and of course there's the bodily functions issues :(

Mostly, I'm basing my ART on the recommendation of my docs, the NCCN and a few studies. The rad onc did say the largest benefits for me were expected in the long term (cure?) but that he said that was 50/50. It all seems a bit murky as far as clear evidence of efficacy. Given my relative young age even 10 years is definitely not near long enough. ART will improve my chances even though there's no way to really know by how much.

K2

Han Table calculator
Progression-Free Probability After Surgery
2 Year 94%
5 Year 87%
7 Year 84%
10 Year 80%

MSK calculator
Probability of Biochemical Recurrence
(detectable PSA level) at
3 years after surgery: 8% (3-21)
5 years after surgery: 15% (5-33) 
7 years after surgery: 19% (7-45) 
10 years after surgery: 24% (9-54) ? cry
Posted 8/2/2011 8:34 PM (GMT 0)
Just got my ultra-PSA results - <0.03

3 months post ART. I trust these are good numbers? - Anyone give me a high-sign since I've taken a break from the PC War.

_____________________________________
Age: 54
Routine Physical on 10-20-2010 DRE Normal
PSA 4.3, up from 0.6 5 years prior
PSA 0.6 on 10-25-2005
PSA 0.4 on 7-30-2004
PSA 0.5 on 5-9-2002
Followup with Urologist on 11/10/2010 after elevated PSA; DRE noted slight bump
November 30th, 2010 had prostate biopsy.
December 9th, 2010, Biopsy results 3 of 12 cores positive.
LLB: Gleason's 4+3=7, 11 MM Tumor Length/15MM Core Length (73%)
LLM: Gleason's 4+4=8, 12 MM Tumor Length/15MM Core Length (75%)
LM: 0.1 MM Tumor Length (1%)0.1 MM Tumor Length
Urologist recommended robotic removal using da Vinci method.
RALP Surgery 12/27/2010 Released: 12/30/2010
Thunderbird Banner Hospital, Glendale, AZ
Post-Surgery Pathology: GS 4+5=9
Pathologic Staging: pT3a, N0, MX; location: Left Side; Volume: 10%
Margins: Left posterior inked margin focally involved
Extraprostatic Extension: Observed
Seminal vesicles: Not observed
Lymphatic/Vascular Invasion: Not observed
Catheter: Removed 15-days after surgery
Post-OP Followup on 1/11/2011; Catheter/Staples removed
Adjuvant IMRT 8 Weeks Post-OP.
No exercise for 4 Weeks Post-OP.
Radiation Oncologist Initial Consultation on 1/18/2011
Calypso Procedure on 2/17/2011; PSA <0.1; Bone Scan Clear
341 Testosterone
CT Simulation on 2/24/2011.
Calypso ART in progress - 40 treatments ending 5/3/2011
✚ New Topic ✚ Reply