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Adjuvant vs Salvage with Positive Surgical Margin and .02 PSA

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Posted 4/23/2013 7:22 PM (GMT 0)
Cohorts:

Just got my first post surgery PSA today.

It's a .02

And of course I already have conflicting advice from oncologists.

One suggests I need adjuvant treatment as soon as my incontinence is a little better managed (currently I'm still getting up several times in the night and find occasional underwear spotting, but otherwise not so bad).

The other says wait and see, with regular PSA tests.

Any thoughts out there?
Posted 4/23/2013 8:22 PM (GMT 0)
With your stats, I would wait and see. Do a subsequent PSA in 1-3 months.

Radiation is a major step. Great if you can avoid it.

Anyway, maybe get a 3rd opinion from a top-notch medical oncologist.

Mel

Posted 4/23/2013 8:27 PM (GMT 0)
first of all is it for sure .02 or or .2. If it is .02,and without getting my "dander" up,no, nope uh,uh, no way Jose……..
Posted 4/23/2013 8:59 PM (GMT 0)
Logo:

It's definitely .02.
Posted 4/23/2013 8:59 PM (GMT 0)
Compiler:

Why a medical oncologist, as opposed to a radiation oncologist?

What's the difference?
Posted 4/23/2013 9:04 PM (GMT 0)
Aachen,

At this point the two options are not mutually exclusive. The doctor who wants to do adjuvant radiation thinks you need to wait a while to heal. The other doctor wants to wait a while and then re-test. I think the cut-off for 'adjuvant' vs 'salvage' is six months. You could, in theory, wait three months, test again, and still be in time for 'adjuvant' radiation if you PSA doesn't behave.

Just a thought. Recent studies have shown that sooner works a bit better than later if radiation can't be avoided. But if it can be safely avoided, that's better yet.
Posted 4/23/2013 9:09 PM (GMT 0)
Peter:

Valid points.

I'm seeing conflicting data out there about efficacy.

Seems to me that the salvage radiation folks in the studies may have had salvage well after their PSAs started to rise, and wouldn't that mean their results would be worse?

In other words, if I still caught it before it rose above .2 and that happened to be two or five years from now would that be as good as doing it now?

I have a hard time determining my stats for a rising PSA as is. Both Jonathan Epstein at Johns Hopkins and two radiation oncologists have now told me they think it's greater than 50 percent chance it will rise. Primarily because my one surgical margin is sortof massive.
Posted 4/23/2013 9:30 PM (GMT 0)
AAchen -
- welcome to the zero club - PSA <0.10 - you are currently undetectable - so why do they want to zap you so soon?

-often it is only after 2 or three readings of post-op PSA of 0.20 that radiation is discussed as an active treatment -

- with gleason 6 - I would slow down and take your time - don't let anyone pressure you -

-it is your time to heal - emotionally, physically, etc...

sympathetic hugs,
Bronson
Posted 4/23/2013 9:35 PM (GMT 0)
Try to relax since your pathology is rather good. If it is indeed 0.02 at one month post-surgery, it still could go down further. We don't know what date in March you had your procedure, so it could be rather early to base future treatment on one test at this time. Most doctors have the first PSA test at 3 to 6 months! If you got a number such as 0.02, then you had the Ultrasensitive PSA test done. Most guys use the regular test and that reports to the nearest tenth (0.0). Some say that there could be "noise" in the Ultrasensitive test and this could be showing up in this single test and causing you worry. Next, many believe that Gleason 6 does not become metastatic disease and Gleason 6 at the margin may not be a major factor at all. I am no doctor, but your stats are really not bad at all. I would get another test in a few weeks. Get another Ultrasensitve test and then you could compare. I know of no one on this forum that "pulled the trigger" on secondary treatment with such a number as 0.02. My doctor was super conservative and said that I would need 2 tests of greater than 0.1 before it was considered a recurrance. Most fellows here would consider 0.02 as super and celebrate! If some prostate tissue was left behind to preserve your nerves, this could also be producing some PSA and it is indeed showing up in the sensitve test.

It would be good if you provided your PSA at the time of diagnoses and the final number stage that you were given, such as whether it was 2 or 3.

Good Luck,
Bill K. from NJ

Age 58 when diagnosed, 60 now
PSA 3.3, 1/12 positive, 30% of single core PCa, Gleason 3+4, DRE Negative.
Surgery 7/19/2011, Downgraded to Gleason 3+3, 10% involvment. Contained
No urinary problems at all. Full ED for 1 year, now at 21 months no ED.
Post surgury PSA <0.01, <0.02, <0.015
Posted 4/23/2013 9:43 PM (GMT 0)
Aachen,

Since your doctors are in agreement that it is too early to do anything now you should take that as an opportunity to spend a few months gathering more information. You can see what your PSA does ... and you can also see what your head does.

The advantage of waiting until the PSA goes up to treat your positive margins is that it gives you more time before you have to put up with the side effects of radiation (which, candidly, I haven't found that bad, but maybe I was lucky.) But if you are an incurable worrier and you know you will use that extra time making yourself miserable worrying that the cancer might come back, then why not do the radiation sooner since you are going to me miserable either way? It's a bit like a second chance at Active Surveillance. You have a couple of months to figure that out.
Posted 4/23/2013 9:43 PM (GMT 0)
Z06:

Sorry about that.

Pre surgery was 5.34

Surgery March 6.

Prior to surgery one guy read my biopsy as Gleason 6.

Johns Hopkins re-read it as Gleason 7 (3+4).

After surgery they reversed. My surgeon's pathologist (Virginia Hospital Center) diagnosed me Gleason 7 (3+4). Johns Hopkins diagnosed me Gleason 3+3 with tertiary 4s. I actually spoke with Dr. Epstein at Hopkins after he read me. He said it was only the tiniest bit of tertiary 4, and none of that was in the positive margin area.

I've updated my stats accordingly.
Posted 4/23/2013 9:52 PM (GMT 0)
Peter:

Thank you.

I'm in the unfortunate position of second-guessing my original decision to have surgery, and then second guessing my choice of doctors.

I know, my head tells me that's stupid.

But I can't seem to help it.

I actually had a surgeon call me at home when I was weighing surgery vs radiation and tell me every day I waited was one more day that I was more likely to get metastasized cancer.

Of course, this was from the same profession that knew I had strong family history of prostate cancer but still waiting more than two years after my initial 3.99 PSA reading to order a biopsy (and that was after I insisted on it).

Feeling now like I was pressured into a decision then, and feeling the same way again post surgery.

Sortof feeling overwhelmed.
Posted 4/23/2013 10:13 PM (GMT 0)
Aachen,

I think you meant to say that you PSA was 5.34 pre surgery in you sig (not post surgery).

Making decisions sucks. Sorry you are stuck there in the middle again.

Probably the only advantage to getting my Gleason 9 post-op pathology report was that I no longer had a lot of decisions to make. Before I had my surgery all the doctors I talked to told me different things and none of them would tell me for sure what I ought to do. But once I came back a GS9 with positive margins they were suddenly all in agreement. Surgeon, medical oncologist, radiation oncologist, all on exactly the same page -- adjuvan IMRT with neoadjuvant HT. I was the only one who needed any convincing but at least I didn't have a lot of decisions.
Posted 4/23/2013 10:18 PM (GMT 0)
Peter:

Thanks. You are right. Fixed now.

Much appreciated.
Posted 4/24/2013 2:25 AM (GMT 0)
Surgeon called you at home to tell you to decide? Geez that had to have been murder.

I think a lot of us all second guess our treatment choices.
Posted 4/24/2013 4:23 AM (GMT 0)
There are never any absolute certainties, but it sounds to me like you should have nothing to worry about, especially with what is considered to be an undetectable PSA reading.

The thing the experts say about Gleason grade 6's is that they cannot survive outside of the prostate. Gleason grade 4's and higher ARE equipped for survival out of the gland, but not a G3 grade (which, of course, is a Gleason 6 score).

In fact, Johns Hopkins did a study a few years ago that included 17,000 Gleason 6 patients. And, out all those patients with a true G6, the number of metastatic incidents was ABSOLUTE ZERO. So that is good news for you.

In addition, Mayo Clinic recently released another study that says (as I referred to up on top) that a Gleason 6 cancer cell will die if it escapes the prostate environment because it needs the nourishment it receives within the prostate to survive.

So, all in all, you should have great hope that you have been cured.

I hope & pray that this is true! :)

Chuck

Resident of Highland, Indiana just outside of Chicago, IL.
July 2011 local PSA lab reading 6.41 (from 4.1 in 2009). Mayo Clinic PSA Sept. 2011 was 5.7.
Local urologist DRE revealed significant BPH, but no lumps.
PCa Dx Aug. 2011 at age of 61.
Biopsy revealed adenocarcinoma in 3 of 20 cores (one 5%, two 20%). T2C.
Gleason score 3+3=6.
CT of abdomen, bone scan both negative.
DaVinci prostatectomy 11/1/11 at Mayo Clinic (Rochester, MN), nerve sparing, age 62.
My surgeon was Dr. Matthew Tollefson, who I highly recommend.
Final pathology shows tumor confined to prostate.
5 lymph nodes, seminal vesicles, extraprostatic soft tissue all negative.
1.0 x 0.6 x 0.6 cm mass involving right posterior inferior,
right posterior apex & left mid posterior prostate.
Right posterior apex margin involved by tumor over a 0.2 cm length, doctor says this is insignificant.
Prostate 98.3 grams, tumor 2 grams. Prostate size 5.0 x 4.7 x 4.5 cm.
Abdominal drain removed the morning after surgery.
Catheter out in 7 days. No incontinence, occasional minor dripping.
Post-op exams 2/13/12, 9/10/12, PSA <0.1. PSA tests now annual.
Semi-firm erections now happening 14 months post-op & slowly getting a bit stronger.
Posted 4/24/2013 4:30 AM (GMT 0)
In a case of two equal values, such as 3+3 or 4+4, my surgeon says there is no such thing as tertiary. That "tertiary" value, in his scheme, becomes the second value.

My interpretation would be that you should move ahead as if you were a 3+4.

Posted 4/24/2013 5:00 AM (GMT 0)
I'll agree with most of the others...with a 0.02 I wouldn't be in a hurry to do anything.....with the ultra sensitive test you will see activity in plenty of time to take action....just be sure to do your PSA tests frequently and be sure it is the ultra sensitive and have your plan ready. Radiation can carry some nasty side effects....at this stage weigh the risk vs reward.
Posted 4/24/2013 6:01 AM (GMT 0)
I agree with 142 about it being a 3 +4, but a very very soft GL7. but disagree you should jump on the post op radiation band wagon. He did say the margin was a 3, right. My opinion is wait till you get a bcr As defined by the American Cancer society and that includes the 3 successive rises after it hits .2. Did Epstien and the other give you any thing to back up the 50/50 odds. That usually what people say when they don't know, but don't want to be wrong. Know what I mean jelly bean. If I had to guess, I'd say they feel pretty good about your long term prognosis, but want to seal the deal, and figure at your age you can handle the S/E. Its not an outrageous position, actually from there point of view. So Deal or no Deal?? Im shouting out No Deal to ya.
Posted 4/24/2013 11:14 AM (GMT 0)
Highlander:

First I've heard of the Gleason 6 and the unlikeliness of spread beyond the prostate.

That would indeed be good news for me.

If you have any links to studies I'd really love to see them.
Posted 4/24/2013 11:27 AM (GMT 0)
If this helps, here is a short version of mine...
G7 (4+3) going into surgery... Hoping that would change to (3+4).
After surgery G9(5+4)... <5% involvement single tumor. Totally encircled.
Clear margins, nodes, sv... Etc etc...
So "our" plan was to wait... And start the srt process below 0.08-0.1
1st PSA <0.04, 2nd <0.04 then bang next one was over 0.2. So being a G9 is very unpredictable...

My point I guess, is that I was very comfortable with our plan. No real regrets. So what ever you decide with your doctor now try to be comfortable with it. I wouldn't jump into anything based on term 'salvage' or 'adjuvant'. Maybe get your next PSA and see where it is. Either way, you'll probably wait that long anyway for recovery time. Talk with your Dr so he knows how you feel. Maybe talk with a rad onc and have that first step out of the way.
All the best with your decision.
Posted 4/24/2013 11:55 AM (GMT 0)
TooYoung:

Thank you.

I've talked to two radiation oncologists, and they had different advice.

One said do adjuvant as soon as urinary symptoms are ok. He said this even before knowing my .02 PSA.

The other said wait and see.
Posted 4/24/2013 12:23 PM (GMT 0)
Logo:

Epstein said my case was weird. Only one positive margin, but it was huge. Apparently that's pretty rare.

Graded me a pT2x because of that.

He said a positive margin due to intraprostatic incision is associated with an increased risk of recurrence comparable to focal extra-prostatic extension with a positive margin.

He recommended immediate radiation. But referred me to radiation oncologists for their opinion.
Posted 4/24/2013 1:17 PM (GMT 0)
Aachen,

It looks like your first PSA was done barely 6 weeks after your surgery. My first PSA at 3 months post surgery was .07. I didn't have a positive margin, but I would wait for the next PSA test to see where your number goes. I had a very large G7 tumor (60%) and my PSA is now <.01.  I remember HW members asking why I didn't have ART with my numbers and my first PSA of .07, my URO never suggested that I needed the post surgery treatments.

Any ART until you completely heal could have long term effects on your continence. 

Terry

Posted 4/24/2013 1:23 PM (GMT 0)
I tend to agree with 142 that a GS6(3+3) with a tertiary 4 sounds like a GS7(3+4). Your Gleason score wound up where mine started. I moved from a GS7(3+4) to a GS9(4+5) between biopsy and post-op so for me adjuvant RT (with neoadjuvant HT) was considered a no-brainer by all my doctors. Your situation is different (with a small percentage of Gleason type 4 cells and with the cell type seen at the margin being mostly type 3) but on the other hand, my experience with radiation was that it was not that bad. My side effects were minor (mostly aggravated hemorrhoids) and if you did decide to pull the trigger on radiation I would expect you to do fine too.
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