HealingWell
Search Close Search
☰

Adjuvant radiation for Gleason 6 / 7 positive margins - see Harvard Dr. D'Amico before you decide

Support Forums
>
Prostate Cancer
✚ New Topic ✚ Reply
❬ ❬ Previous Thread |Next Thread ❭ ❭
Posted 9/18/2013 10:57 AM (GMT 0)
I was getting conflicting advice about my need for adjuvant radiation after I ended up with a positive margin after surgery.

My margin is huge - 1.2 cm.

Several radiation oncologists insisted on treating me right away.

But my surgeon referred me to Dr. D'Amico, at Dana Farber Institute in Boston (a Harvard affiliate).

Dr. D'Amico is sortof the king of risk stratification for guys in my circumstance.

His study is here http://www.ncbi.nlm.nih.gov/pubmed/20553253

Sorry, try as I might I can't find a full text version online.

Basically his studies show that for guys with Gleason 6 or even 7 (3 plus 4) and even a huge positive margin, with undetectable PSA absent other negative factors, that he strongly recommends against adjuvant radiation.

Why?

Because contrary to the generic stats you see about positive margins and cancer return rate, the actual return rate (measured by rising PSA) for guys with Gleason 6 or 7 and a positive margin is around 18 percent.

That means you have an 82 percent chance of no return.

If it does return as long as you catch it very early the salvage radiation has a 99 percent cure rate.

Adjuvant radiation in this instance provides NO additional benefit.

And apparently it's quite easy to monitor the PSA rise. Because guys with Gleason 6 or 7 and undetectable PSA have a very slow PSA rise rate. So once it becomes detectable it still takes 12 months or so to double.

And it's that slow doubling speed that makes the difference.

I'm no doctor.

And I strongly encourage others to weigh in here.

But his argument was very persuasive.

Especially since he's in the business of giving radiation.

He could have made $150,000 off of me by telling me to go ahead right away.

But he didn't.
Posted 9/18/2013 12:46 PM (GMT 0)
I had my surgery in June, 2011. My post-op pathology down-graded my gleason score to 6, but I also had a focal positive margin. Extra-prostatic extension was indeterminate.
The only time my PSA was truly undetectable was six weeks after surgery. Since that time, I've been watching a slowly increasing PSA. At 24 months since my surgery, my PSA tested at .06 and seems that it might be stabilizing, or at least slowing down. My PSA history since surgery can be seen here:

This Friday, I go to my Uro to have my blood drawn for my next PSA test. I am very interested to see where I am at this go round. My Uro keeps telling me that SRT will be required at some point, but I keep hoping that he's wrong.
Posted 9/18/2013 2:44 PM (GMT 0)
Thanks for this information. I have been told repeatedly by various doctors that the information coming out of Sloan, Harvard and Duke is ahead of the curve so I have been paying particular attention to the various positions from these hospitals/schools (as well as others). There are so many manifestations & variations of this disease that it seems like a very bizarre puzzle that each individual and his MDs must solve. I am praying my guys are great with puzzles... :-)

 

Posted 9/18/2013 2:59 PM (GMT 0)
Hard to imagine there's anyone in the US better qualified to advise on this than D'Amico. Did he say at what point he would recommend starting SRT?
Posted 9/18/2013 3:13 PM (GMT 0)
Medved:

Yes, he said he'd start monitoring for possible treatment at .1.

My only unclear point now is his thoughts on Gleason 6 vs Gleason 7 and the idea that Gleason 6 metastasizing is very rare.

And I don't want to put words in his mouth.

I can only say what he told me for MY situation.

That's why if at all possible I recommend anyone that can see him in person.

Also, for what it's worth, his staff is great. Extremely friendly, very professional, etc.

What really weirds me out, though, is that I had previously spoken with three radiation oncologists, including two with Johns Hopkins, and none of them mentioned D'Amico or the idea of Gleason 6/7 being less of a risk.

They all trumpeted the new ASTRO and AU Joint Guidelines as saying adjuvant had to be done. They failed to point out that those guidelines don't really differentiate between different Gleason levels. At least not to this degree.
Posted 9/18/2013 4:02 PM (GMT 0)
3+4=7..........The need for radiation might depend on whether the cancer in the positive margin was Gleason 3 or Gleason 4 cancer cells.....

Does your pathology report reveal what type of cancer cells were found in the positive margin?
Posted 9/18/2013 4:11 PM (GMT 0)
At the margin was Gleason 6 only. As read multiple times, including once by Epstein at Johns Hopkins.
Posted 9/18/2013 4:46 PM (GMT 0)
"And, even if the surgical margins are positive, this does not necessarily mean that the cancer is left behind. How can this be? "There are several different explanations why, when the margins are positive, the tumor may still be cure," says Epstein. "One is that literally you cut across the last few tumor cells" -- that what appears to be remaining cancer is actually a cross-section of the perimeter of the tumor. "And even though it looks like it's a positive margin, there's really nothing left in the patient."

Another explanation is that the act of surgery itself finishes the job, killing any remaining cells. No cut or injury to tissue happens in a vacuum; the area around the cut is affected, too. (Think of lightning striking a tree; the tree dies, but so does a ring of grass around it). "When the surgeon cuts across tissue the blood supply is cut off, there's dead tissue, and that can kill off the last few tumor cells that might have been left behind," Epstein says. "

The above was from Walsh at J.H. back in 1997.....

I wouldn't do anything unless your PSA rises......Especially with G6 cells at the margin.....
✚ New Topic ✚ Reply