Salvage after primary radiation: Personal experiences? (This time w/o the survey)

Thankfully, not yet.

None here either, I'm solid.

Mel,

We tell new members that, while it is true that surgery after radiation isn't generally done, there are possibilities for salvage after failed radiation (more/different radiation, cryo, HIFU, etc., etc.). My question is how often are they done? I don't seem to recall a lot of guys here talking about salvage after their radiation failed so I am beating the bushes a bit.

Jim,

My surgeon took so many nodes that they would have had to target my elbow.

Kidding.

But I don't think my ART plan included any lymph nodes -- just the prostate bed for the full dose and a somewhat wider spread with a bit smaller dose.

PeterDA,
A topic I'd love to know more about. At surgery I had all "possible" nodes removed. 13 in total. So my SRT had nothing to target. My real question would be is all possible... All?

PeterDA, I was also hoping to hear some real life anecdotes but am not totally surprised that we haven't received much. Over the six years I have been here I can only recall one true salvage treatment after failed mono-radiation treatment. That was a salvage surgery that went terribly wrong. Today, even though "salvage surgery" is occasionally practiced, the obvious difficulty would cause most of us to steer clear of that option if and when we needed any salvage treatment (personally I would try HDR Brachy).

I think JackH hit it on the head when he talks about the selection criteria for example, LDR Brachytherapy vs. surgery. Generally LDR brachy as a mono-therapy is only suggested when there is a strong indication of cancer containment within the prostate, e.g. PSA less than 10 or 15, Gleason 3 + 4 or less (or 4 + 3 with few cores and low percentage). This selection will cause failures to be less frequent hence less need for salvage. On the other hand, if a man presents with G 4 + 3, PSA 22, high number of cores and %, nodule near the edge, then the RO is very likely to suggest a combo treatment of brachy + IMRT -- hence less opportunity for salvage treatment from a mono-therapy. On the other hand, surgeons operate all the time with those stats.

Now, my friend Mel took us off in the weeds a bit and I'll just follow him down the path a bit with your permission. Mel said, "The concept of salvage radiation after surgery (should surgery fail) is totally VALID." I agree -- but that's only part of the story and is NOT a reason to choose surgery over radiation because the concept of salvage treatments after radiation is also "totally VALID". Secondly for Mel, I'll try once again to better articulate my debate on the point, "To say that should you need salvage radiation and if it succeeds then you would have JUST needed salvage radiation is specious at best". I would say it's NOT specious IF there is a high chance of salvage radiation needed and the patient knows that at the time of treatment decision.

For example, let's take the above patient who is G 4 + 3, PSA 22, with high cores,high % and a nodule at the edge. The urologist may say to that patient, "I suggest surgery but I want you to know that there is a high probability that you will need follow-up radiation" (BTW, this is not an unusual situation on HW). I would suggest that it is perfectly logical for the patient at that point to say, "Hold on -- if I'm going to need radiation anyway, why not do it first rather than submit myself to the probability of SE's from two separate treatments.

OK..out of the weeds.

Jim

Shaba.Doug, I suggest you learn more about radiation therapy. It is amazingly accurate in its delivery. Nothing hit or miss about it. And where it delivers radiation, it is extremely effective at killing the cancer. That is why it is an excellent choice for initial treatment and salvage treatments.

However, when the cancer is outside the radiation field, the cancer is not killed. Just as when the cancer is outside the surgically removed area the surgery doesn't work. Hopefully this is what you mean by "hit or miss". If so it brings up a very important consideration. Just where is the cancer? When the location is confirmed, radiation in many cases is the best salvage treatment. When it is not known where the cancer is, the radiation oncologist generally does not radiate.

I, personally didn't gamble on my treatment choices and I don't think many men do. We do research, get multiple opinions, and follow a well constructed treatment plan by experts that has the highest probability of being effective for cancer control and limited side effects. That is not hit or miss or a gamble, in my thinking.

Count me as someone that considers the "you can do radiation after surgery, but you can't do surgery after radiation" argument as a false choice.

Admittedly, I was swayed by this and thought, "wow, if I have surgery I get two bites at the apple, not just one." Then I learned that with my high Gleason score there was a higher chance that the cancer had left the mothership. (50% was Dr Lam's estimate.) And that if those cells were on the edge of the prostate are hanging out in the prostate bed that there was a good chance that radiation would kill them, while there was 0% chance that surgery would.

So while I wasn't assured that radiation would work it stood just as good a chance of working as surgery and arguably much better given that 50% likelihood of stragglers outside the gland.

As to the argument that you couldn't do surgery if radiation didn't work, it wasn't like we were going to just throw our hands up and say, "darn, well we gave it our best shot." There would still be other weapons at our disposal, it's just that surgery is not one of them.

I'm probably coming at this more from a G9 perspective, but it seems that patients should be told something more like this:

1) You can have surgery and hopefully that's all you need and you'll have a 0 PSA for the rest of your life. If a little is left behind or in the prostate bed, then we have radiation as a backup, although that means that you'll have the SEs of both surgery and radiation.

2) You can have radiation and hopefully that's all you need to eventually have no signs of disease. If there is a bit hanging around outside the prostate, there's a chance that the radiation will also kill that, while surgery won't. In the event radiation doesn't work, we may need to do some additional radiation, which probably won't be fun. Surgery is not an effective back-up.

3) If indeed cells have completely flown the coop, neither surgery or radiation will work.

Overly simplified, of course, but wouldn't those be your basic options when being told about your treatment choices?

Michael_T said...
Count me as someone that considers the "you can do radiation after surgery, but you can't do surgery after radiation" argument as a false choice.

Admittedly, I was swayed by this and thought, "wow, if I have surgery I get two bites at the apple, not just one." Then I learned that with my high Gleason score there was a higher chance that the cancer had left the mothership. (50% was Dr Lam's estimate.) And that if those cells were on the edge of the prostate are hanging out in the prostate bed that there was a good chance that radiation would kill them, while there was 0% chance that surgery would.

Very much agree.

Tudpock18 said...
Generally LDR brachy as a mono-therapy is only suggested when there is a strong indication of cancer containment within the prostate, e.g. PSA less than 10 or 15, Gleason 3 + 4 or less (or 4 + 3 with few cores and low percentage).

That was the case with me. 4 + 3 but low PSA.

JNF, that's exactly what I meant. Sorry.

I had a salvage prostatectomy in August of this year. This was 12 years post IMRT at MDA. My PSA had risen over the past few years to 2.0. In June I was advised to have a bone scan, abdominal cat scan and an MRI with endo rectal coil. The bone scan and CAT were all clear. This was all done in Manila (I am based in the Philippines). I sent the results to my oncologist at MDA and then travelled to Houston in July. Based on the Manila tests he advised me to have a biopsy (in Dallas by North Dallas Urology, lab work by Bostwick) which showed a reoccurrence. I am on a business trip at the moment and do not have the results with me but in short I had 3+4 score on multiple samples one side of the prostrate. After a lot of consultations with surgeons and my oncologist I decided to go for the surgery. I am 60 years old and fit, run every day.
The surgery (Da Vinci) was handled by Dr. Claus Roehrborn in Dallas late August, overnight in hospital.
After removal of the catheter I had some problems with bleeding after surgery which led to a second four day stay in hospital. Urine retention which involved two visits to the emergency room. I also picked up two infections in hospital - Providencia and E Coli with the latter being resistant to many antibiotics. Augmentin seems to have done the trick.
My first PSA test one month after surgery showed undetectable. My second PSA test (ten days ago) 0.01.
I am back to running and golfing and full involvement in my business which involves a lot of international travel. I still have a few issues with urine leaks when exercising but during the night and at rest I am dry. It’s slowly coming right.
Going into the surgery I was aware of the risks. Dr. Roerhborn has performed some 1500 prostatectomy’s of which 50 have been salvage.
I will be home at the weekend and will update my profile with the Gleason history and biopsy results.

The point I was hoping to make in this thread is that there is a huge disconnect between theory and practice that becomes visible if you look at what we say here and what we see here.

We get guys coming in who are contemplating surgery. They quote their surgeon as saying "you can do salvage radiation after surgery but you can't do salvage surgery after radiation." We bark at them. We tell them that their surgeon is being misleading. We point out that you certainly can do salvage after radiation, just not usually surgery -- it is typically more radiation or ice balls or something.

We see guys coming to the site who have had a recurrence after surgery. We tell them they should talk to an RO about salvage radiation.

We see similar numbers of guys coming to the site who have had a recurrence after radiation (usually IMRT or some such). We tell them they should talk to an MO about hormones, chemo, and other strategies for fighting a disease that can no longer be cured.

Now I understand that we are not a representative sample here -- that there is selection bias at work where the ROs get the guys the surgeons don't want to treat. But isn't our talk about salvage after radiation just as much of a non sequitur as the surgeon complaining about how difficult it is to do surgery on radiated organs?

Post Edited (PeterDisAbelard.) : 12/30/2014 3:18:56 PM (GMT-7)

John beat me to my reply, but I was going to say essentially the same thing. It's the reason why I chose radiation in the first place--I was given a 50% chance that I would need salvage radiation, so why not start with radiation and go for the wider cure area?

And when the cancer has moved beyond the prostate and near vicinity, the whole concept of the localized treatments doesn't matter anyway.

I'm glad this discussion is taking place here instead of messing up the threads of newly diagnosed folks. (And I realize that I've been a contributor to that messiness...) I always worry that I come across anti-surgery in those discussions--I'd like to think I'm not, but I do get concerned when there are misleading statements from uros and it's exactly what I was told, so it resonates.