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Posted 10/31/2014 3:07 AM (GMT 0)
I am considering doing Post open RP SRT because my
PSA at 3,4 and 6 months was 0.224, 0.247, 0.29
Both high and rising.

Pathology Report ....
GS 4+4, SemVes clear and 20 Lymph nodes all clear
No Vascular invasion
Surgical margins; free of tumor; Negative margins
Perineural Invasion seen; half left nerve removed.
Prostate size 395cc
Staging pT3aN0Mx

Does this sound local and thus support for SRT ??
Posted 10/31/2014 4:44 AM (GMT 0)
Welcome to HW, sorry you need to be here.

What's your doctor say?

I am not a doctor, just some random guy on the internet, but in your place I'd be starting to talk to ROs and a medical oncology who specializes in PC. Yes, SRT would be very much on my mind.

The question really is - is there still some PC in the prostate bed? because if there is SRT might just do the trick. At G8, though you might also need to consider a round of HT as well.

Hopeful, guys who know this stuff better than me will be along soon.
Hang in there and keep us updated on your progress.
Andrew
Posted 10/31/2014 5:12 AM (GMT 0)
Pablocito,

Welcome. Sorry to have to meet you on this forum, but you've come to a good place. Your PSA results post RP suggest to me that there is a need for further treatment. SRT would be an appropriate next step if there is reason to believe that the PSA is coming from the pelvic region around the removed prostate. However, even with SRT you will likely be put on ADT also, given your post-surgery PSA results. I suggest you consult with both a medical oncologist who specializes in prostate cancer and also with a radiation oncologist before making a decision. If they recommend that you go to Lupron and/or Casodex, you need to ask them if SRT offers any additional benefit beyond ADT. If not, I'd bypass the added risks of SRT and go straight to ADT.

Jim
Posted 10/31/2014 9:51 PM (GMT 0)
Hi Pablo,
SRT seems to be in my future, too, so I am also looking for more information about it. You have two things going against you, your high gleason score and your negative margins, which is initially a great result in the pathology report but turns out to be a major bummer when the cancer recurs, making it likely that the cancer has escaped through the nerve pathways to a distant location and making SRT to the prostate bed probably ineffective. With my clean margins, my Radiation oncologist put it at about a 1/3 chance that the cancer is still local and the SRT will take care of it. Those aren't very good odds, but seems worth the sacrifice on the possibility of a second chance at a "cure." I am planning on looking into the alternative of not doing SRT, waiting for symptoms and mets to appear, then dealing with those as they develop. I'd like to get some idea, with my numbers, what the most likely scenarios and time frames would play out if I were to decide to forgo SRT. Please keep us updated on what you find out and what you decide to do, as I and others will be following closely.
Posted 10/31/2014 10:30 PM (GMT 0)
Phenom,

From reviewing your signature, and assuming its current, I still wouldn't be going to SRT at this point. Not pretending to be your doctor, or even you, but with <3% cancer found in your post surgical biopsy, and with your highest reading just now being over the detectable point, I think you have time on your side, to avoid the chances of RT damage and going through that ordeal, especially when its not known clearly if you even have any remaining cancer in your prostate bed. Just my take.

David
Posted 10/31/2014 11:12 PM (GMT 0)
Thanks, David, I always value your posts, and I certainly appreciate the caution. True, I'm not there yet at the .2 level that seems to be the standard for initiating SRT, but my numbers are getting there, so I'm assuming the next test in Dec. will reach it. Both my urologist and RO view my steady rise and doubling time as evidence that there is, indeed, a recurrence going on. I don't feel any great urgency in initiating the SRT, and none has been urged upon me by the docs, but I also don't see the point in waiting much longer if all it buys me is putting off treatment for a couple months. My plan now is to schedule SRT for Jan/Feb when the weather is the worst here and I'm least active anyway, then see what the Dec. PSA shows. If it's steady or down, I'll postpone treatment, and if it continues to rise I'll go ahead. In the meantime, I'll look into the option of forgoing SRT altogether, living life as if I didn't have cancer, and waiting to deal with it as it presents itself in the future. The odds are that's what I'll be doing anyway, but right now the 1/3 shot does seem worth taking. I haven't had much luck getting information about what's likely to happen should I choose to forgo the SRT, maybe because it's something beyond any realistic prediction. I have picked up some tidbits like a median time to metastasis of 8 years following a recurrence, but not much else. It's probably just too individual a situation to be making any concrete guesses about what might happen in any particular case.
Posted 10/31/2014 11:54 PM (GMT 0)
Pablocito,

They can't know for sure if it's a local recurrence or a distant recurrence. The imaging studies they can do, like bone scans or PET scans, aren't very good at showing mets when PSA is as low as yours. I've seen cases where they have used an mpMRI to detect recurrence sites in the prostate bed, and any suspicious site can be biopsied. Most often, they just give you IMRT to the prostate bed because that's the place the cancer typically travels to first, and your pelvic lymph nodes were clear. Several recent studies have demonstrated a benefit to early adjuvant radiation over waiting.

- Allen
Posted 11/1/2014 4:30 PM (GMT 0)
Pablo
A .2 reading and a .3 three months later is generally considered a signal for SRT, and ADT before ,during and after SRT has proven in studies to be very helpful for high risk cases like yours (and mine). I did not wait, but the decision is yours.
Bob
Posted 11/1/2014 9:08 PM (GMT 0)
Going through SRT now my PSA was a little higher than yours 13 of 35 treatments down...just a little tired so far...hope that ths works! Good luck to you
Posted 11/2/2014 12:17 AM (GMT 0)
This probably won't help but shows we are all different. My PSA was/is 1.15 @ 3 mos, 2.29@ 6mos and 2.81 @ 7 mos. I do want to do SRT as I feel it's travelled out side the bed. Your PSA is much lower and your path report close to mine, maybe in your case it is in the bed. Who knows? Tall Allen, as usual, seems to be bang on. Best of luck in your decision making!
Cheers, Doug
Posted 11/2/2014 4:35 AM (GMT 0)
Doug
You say ....
"I do want to do SRT as I feel it's travelled out side the bed."

If you feel the PCa is outside the Prostate/Pelvic bed then
doing SRT will ........
not get any PCa that is already systemic,
not be a cure and will probably,
not increase your survival time.

Why then would you want to do SRT ?

Post Edited (pablocito) : 11/1/2014 11:01:13 PM (GMT-6)

Posted 11/2/2014 12:08 PM (GMT 0)
Oops!! I missed the the NOT! I certainly do not want the SRT for the reasons you stated plus possible ramifications down the road.

Cheers, Doug
Posted 11/2/2014 4:17 PM (GMT 0)
since there is a high risk of your cancer being systemic and not local it would make sense to get a C11 PET scan to confirm a local reoccurrence before subjecting yourself to a procedure that wouldn't work and would cause more harm. SRT is only effective on local cancers.
Posted 11/2/2014 9:47 PM (GMT 0)
John;
Thanks for your excellent suggestion
It is my understanding that C11PET scans are not sensitive enough to
pick up mets until PSA is above 1 or 2.
I am at 0.29 right now so I have to use probabilities, nomograms,
and common sense to estimate the possible success of SRT.
I know of no other more sensitive tests.

A friend who has hospital experience suggested to me to ask
for a laprodectomy; going in to the pelvic bed thru a hole like with RLP
to look for cancer. I do not know if that is viable but will
be asking some surgeons soon.
Posted 11/3/2014 5:07 AM (GMT 0)
Go to the MSKCC nomogram for salvage Radiation and plug your numbers in and see what it predicts for six year recurrence-free survival. I think you will conclude that srt is worth it, and that adding ADT to SRT is worth it in your case.

No one can say for sure if it is local. At your PSA you are only just beginning to get in the range of of where the best imaging can detect a recurrence and the best imaging is not done everywhere. Look up the "Roach Formula" for estimating whether the cancer is likely to be present in your lymph nodes at this stage and based on that you might do better having your lymph nodes radiated as well depending on whether you have ever been a smoker and on your age and general health. It is all relevant.

http://www.redjournal.org/article/S0360-3016%2808%2903298-7/abstract .

Most evidence suggests that if you are going to get SRT the earlier you get it done (in terms of lower PSA) the better the likelihood of cure. So if you are thinking you want it, do it now.
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