Planning for SRT

Hi, Everyone

As I posted last month, I am on the verge of getting kicked out of the zero club (PSA=.092 with about one year PSADT, four years after prostatectomy.)

Today I saw a highly-recommended radiologist and am starting down the path toward SRT.

Even though I am not at the official recurrence point of .2 plus a confirming test result, my steadily increasing PSA indicates that a recurrence is underway, and there is no point in waiting further. At least that what this doctor is telling me, and it's consistent with what Scholz has advised and with my own reading of the trend.

The question now is what kind of adjuvant treatment should go along with the radiation. Both today's radiologist and another I consulted with believe that adjuvant HT increases the odds that SRT will work. Today's radiologist is relatively conservative: he recommends a four month course of basic ADT -- Casodex/Lupron -- to go along with IGRT. A doc I consulted with for a second opinion advises me to be more aggressive: A year's worth of Zytiga plus a month's worth of low-dose Taxotere. This doc says that taxotere has shown itself to be more helpful when used with ADT than sequentially in crpc patients, so why not use it here?

For those of you who have done SRT with adjuvant ADT, what did you decide to go with as the adjuvant treatment, and for how long? Any other factors I should take into consideration in making this decision?

Thanks, and good luck on your journeys.

With a clean pathology report your chances of a successful Srt are reduced. I would venture to say you could do nothing for another 10 years be fore even starting HT if even , then. I am sure you will not take this advice, but offer it anyhow. Its perfection or nothing with most post tx. folks with recurrence., it seems. A year doubling time… hmm, according to JohnT, who's knowledge I respect , it takes 40 double times to kill. I say without any tx, you die with PCA. Personally I don't think you have even crossed the line into recurrence. I support you on your quest in your Pca Journey. But no way will I support the path you seem to be embarking on. I believe I am allowed that latitude on this forum. My reasoning is an edumacated guess, which is all a study is btw. No better, no worse, than my own, but again, that would be an edumacated guess also. Goodluck Proscapt.

In most of the discussion I agree with Purg.

The only disagreement is in using chemo early. My uro would love to do that if my insurance would cover it. I would do it today rather than wait until I am so beaten down that the chemo would kick me into a hole I could not climb out of.

Thanks everyone so far, for your thoughts. I don't mind strong disagreement; one of the most valuable aspects of this community is to have well-informed people who will challenge my thinking.

Tall Allen -- I put my numbers through the SKMCC SRT nomogram, and it says that I have something between a 70 -78% chance of salvage radiation "working" which they define as 6 years without a PSA recurrence. That assumes I do adjuvant HT along with the SRT. Otherwise the probability of success is in the 50% range. I was told that imaging would be very unlikely to show anything at this stage, unless I could get Combidex, and we all know the story there.

Yes, the probability of success is lower because of the lack of positive margins. But it is higher because of the other factors such as low PSA, relatively long time since surgery, slower doubling time. In any case it seems to be better than a coin toss.

Logoslidat - Here's how I do the math on doubling time, perhaps you can help me understand the error in my logic. I don't think the generalization that it takes 40 doublings to kill necessarily holds up. For example, at a 12 month doubling time, after 10 years I would have a thousand-fold increase. (2^10=1024) So if my PSA is roughly 0.1 now, then in ten years, when I'm 68 the PSA would be 100 which is fatal for some. What would be the value in waiting that long to begin treatment? In 15 years, when I would be 73 years old, my PSA would be about 330. Now in my case, the PSA is going up a bit faster than 12 months, depending on how I interpret the data so the situation is a bit less favorable. Other than the PC I'm a pretty healthy guy with no comorbidities to take me out early.

Purg - I understand the disastrous experience you had with SRT. I just might wait for the three consecutive rises post 0.1 as you recommend. I have just had five consecutive rises, so it won't take long. My PSA is not bouncing around at all. It is just monotonously, steadily, grinding upwards. That's why one of the docs I've seen said "it's a slam dunk" that I'm having a recurrence.

I hope Sephie joins this conversation; I would like to learn more about her husband's situation. Right now I am trying to imagine a biological process that would generate a steady stream of increases for two years and then somehow level off. How would that work?

142 - what is your / your urologist's rationale for using chemo early? I'm trying to understand both sides of this argument.

Again, thanks everyone.

proscapt,

It sounds like hormone pre-treatment might make a big difference. Unfortunately, that nomogram doesn't give any guidance on how long to continue it afterwards. I agree that imaging isn't likely to show anything until PSA reaches 2, and it could be disastrous to wait that long.

According to Dr. King's analysis, one increases the risk of SRT failure by an average of 2.6% for every .1 increase in PSA. So if your odds of recurrence-free survival after SRT is 70% now, it will go down to about 60% if you wait for your PSA to rise to .5. You would also lose 2% for each Gy of radiation below 70 Gy.

The timing of salvage radiotherapy after radical prostatectomy: a systematic review.

- Allen

The poster's hat trick of treatment were all initiated concurrently as a result of a rise of .02 to.05 in in one subsequent psa test. City of Hope LAX!!!!!!!! Does anyone else sense a disturbance of the Force there, or just business as usual in a disturbing paradigm?

proscapt,

Maybe I can help by sharing my story. I had open RP in Sep., 2007. In April, 2010, my usually normal .04 PSA test came back .06. I scheduled a RO consult at the next result of .08. He developed a plan for 39 sessions of SRT, total 67 grays, beginning when my PSA climb met the standard two readings above .20. I spent from then (July, 2010) to now dreading each test, preparing myself for the 'next' one to be up and crossing the action required line. At the same time, I , along with my Uro, decided that we would take a wait and see, "it could be benign tissue instead" approach. It's worked so far, as my climb had been slow, erratic and sorta difficult to know exactly what is going on. It was erratic enough from one test to the next that I wasn't in any hurry to go ahead with the SRT until it finally crossed the .20 marker in 02/2013. You can see that over time, it has steadily increased though. At the time I talked with the RO, he didn't mention any HT or ADT in his plan. I am a little more educated about the process now and will be discussing this part of it with him, in my anticipated appointment after my next PSA result in March. Here's my test results during this period:
04/10= .06
07/10= .08
12/10= .09
05/11= .08
09/11= .14
02/12= .15
07/12= .13
11/12= .16
02/13= .21
06/13= .22
11/13= .25
03/14=? waiting

I fully expect to be approaching .30, somewhere above the .25- but even that could be lower this time. In any case, if it is above .25, we will be starting SRT after this. Someone studying these results can recognize that I got at least 4 years of non-SRT life out of it before having to act. That's 4 years that I have extended the normal life that I live now, as far as radiation damage risks, incontinece and bowel problems, etc. That's also 4 years that I haven't had to use my next best preventative of keeping the cancer at bay.

As we know, these numbers can be read several ways, depending on the result you are expecting.. I could look at it seeing that I have had a steady rise- over time- that it is slow, not aggressive, and that maybe it isn't anything to worry about in the short term. I have shared these with a few people knowledgeable in the details of living with advanced pCa and some say that they wouldn't worry about it until it hit 2.0 or even 4.0. That it might take years for that and that will be years that avoid the risks of SRT and firing another of my limited bullets in the "living to die of something else" gun. Others have seen this and shuddered, asking why I am delaying treatment and being so risky with my cancer reoccurance.

I have charted my course by choosing a more studied approach, watching carefully what is happening, being guided by the experts I have been paying to provide their expertise, and taking a calculated risk that I have slow growing, non-aggressive cancer and that it can be controlled in a planned and timely manner.

All that said, when I look at your stats, and remembering that we all are different and yours will not be like mine, from my perspective I would say that you don't have enough data yet to make a decision. Your doctors and their plans will be there waiting, and can be started with just a phone call, but I would think you need some more test results before doing anything. I would want at least one more upward result. Depending on how accelerated that one was, I'd decide if I wanted one more, and so on. Unless you start getting results like .04, .09, .18, .24, .30 or even worse= .04, .09, .21. ,80. 1.5, etc. then , as in my case, I wouldn't rush into advanced treatment.

I'm not telling you what to do, of course, I am just sharing my reasoning that I use for my particular situation. My risk aversion impulse is different from yours, and different from the above mentioned bunch of people I mentioned. All I can say is, from my perspective, you don't have enough data points to make any decision that is so major as SRT with or without HT. It's you and your doctors decision and all I can offer is my experience with mine.

proscapt said...
I have just had five consecutive rises, so it won't take long. My PSA is not bouncing around at all. It is just monotonously, steadily, grinding upwards. That's why one of the docs I've seen said "it's a slam dunk" that I'm having a recurrence.

This is just my opinion based on my own experience, not medical advice. But I, like some others here, would be of a mind to wait until hitting a PSA of two or greater. Even though your PSA is climbing steadily upward, for reasons unknown, when mine hit 0.1 it stayed there for three years before it began moving again - and then at a much faster rate, doubling to 0.4 in ten months. So I'm not sure we can all project reliably ahead, especially based on the low measurements of ultra-sensitive PSA tests.

As for HRT. My RO recommended using Casodex only, which I did for three months beginning a couple of weeks before my first SRT treatment. He acknowledged that this is not a standard approach, though it is more common in Europe than in the U.S. His reasoning was that the Casodex-only treatment had fewer side effects than Lupron or Casodex plus Lupron, and nonetheless seems to improve the effectiveness of SRT only.

My results thus far, nearly four years since completion of SRT are literally perfect. My current PSA is 0.00 as of a week ago. I know I am a sample of 1, so you can't draw conclusions from my experience only. Maybe I've just been lucky.

FWIW the I've used the same nomogram linked above. Based on my numbers and pathology, which include seminal vesicle involvement and an enlarged lymph node that turned up on an x-ray at the time of my SRT, I have about a 38 % chance of being recurrence free at 6 years, if my Cassodex-only treatment counts as HT within the nomogram's underlying logic. If the Cassodex-only treatment doesn't count, then my recurrence-free expectation is something like 13%. But at four years and counting, I've so far done well better than my own, or for the matter my RO's expectations.
Jim

Thanks everyone for your feedback

142 - your argument makes sense to me. One can put up with a lot if there's a reasonable hope that it will hold off the cancer for a while.

Tall Allen - King's meta-analysis is very helpful. Thanks for that.

Logo - I still can't get my head around the idea of "40 doublings" being a magic number particularly when you consider that the rule of thumb does not seem to take account of whether we're starting at .01, .1, or 1. each order of magnitude difference in the starting point is equivalent to about 3.5 doublings. Maybe John T. can weigh in here??

HD-Rider - Thanks for sharing the details of your example. With your slow doubling and gleason 6 even I wouldn't be moving to SRT at this point. Also from your chart I think your PSA might be leveling off. I bet if you went to one of the online nomograms and calculated the doubling time for the first half of your data vs. the doubling time for the second half of your data they would be very different. i would be inclined to do nothing for now, or do the avodart approach that Myers recommends to many patients.

james C: thanks, I appreciate your perspective. Your doubling time is clearly slower than 12 months and your G6 status is reassuring. You make a good point about giving it a bit more time.

Peter - I see what you mean. I hope it's worked well for you.

Bohemon - I'm glad the SRT + Casodex worked for you. it would be great to pull a four year string of zeros. Congratulations, you are beating the odds. You meant waiting until 0.2, didn't you, not waiting until 2? waiting until 2 really hurts the probabilities based on the King study.

Again, thanks everyone, and good luck.

David

I would change my lifestyle before pulling the SRT trigger.  In fact, this is exactly how I am fighting a post RP rise in PSA.  Dr. Katz, well known Uro has written a book about diet and PCa.  I have completely eliminated red meat and diary from my diet and increased vitamin D consumption.  Like you, I have had very small rise in PSA over the last 3 years but I'm still in the safe zone but don't know for how long.  I've been on the diet for 2 months and have lost 13 lbs.  cholesterol dropped from 235 to 119 and my last blood pressure (a week ago) was 104/64.  I will be having another ultra sensitive PSA test and will post the results.  My PSA has risen very slow over 3 years .01, .021, .025, .028.  I know that's not high but represents a trend.  I want to get this under control before facing alternative treatments.  December was my last PSA at .028.  Dr. Katz recommends a biopsy for post RP patients with a PSA rise.  He indicated in the book that some prostate tissue is usually present where the bladder tube was cut.  That is where he does the needle biopsy to see if cancer is present.  If negative he puts his patients on Avodart and the PSA seems to drop.  In any case it is a healthy diet and can't hurt.  My 2 cents, believe me you will lose some weight by eliminating the red meat.  Best of luck.