Why salvage radiation is bad.

My details should follow....

super max said...

Dewayne said...
Last night after reading this thread I researched and found a great report from a RO out in Oakland (He's written with Demenes) about how the HDR varies from each point in the cathaters to directly hit the cancerous cells while limiting exposure to other organs.

Dewayne, could you post or email me a link for that report? Thanks.

See if you got that email.

I'm a pt3b who before surgery was Pt1c . I went for RP even as a Gleason 9. So far my ADT and SRT have not been that bad and I'm undetectable.... So far. Fingers crossed.
If I knew about the risks involved with SRT beforehand, I may have chosen ART. Oh well, can't look back and am hoping, nay praying, that I don't get mets!
Bob

I had a post interspersed in the thread on confidence, which i posted earlier this morning, It was early and was on my way to the day. On a reread later in the day, Isaw it was totally confusing and did not convey my thought, so deleted. When my posts are written with confidence and clarity they can be confusing enough… I realize. Anyway, thats that

thumbs up on that, purgatory, almost to the letter as written.

One thing I always try to remember in all this is that Doctors are still fallible people. All treatment decisions are, eventually, a judgement call. Based on what they know, and what their gut tells them, they choose a treatment scenario. The surgeon, in real time, decides to cut a little more or a little less; The RO inserting seeds concentrates on one area over another; the RO doing SRT chooses to aim at one location over another. This is why we do our best to find the best available team for our treatment, and make that final gut call about which way to go.

Medicine, in the end, is still an art. No matter how many scientific trappings we put on it, the art of medicine is still real, still viable, still about practicing. And, if I get to that point, I hope I can develop and maintain the attitude that maybe my experience can serve as a teaching moment for someone who comes after me.

Does SRT suck? Of course it does. Is it a true crapshoot? Of course it is. Does that mean it shouldn't be used? Ideally, no one would ever need it, but it doesn't work that way. If it's needed, then it's needed. The message I see here is that it's wise to go in with your eyes open to the odds, and the choice of whether to roll the dice is ultimately each man's alone.

This thread is a little confusing at times. Some seem offended by it; but to me TA titled it appropriately, "When salvage radiation is bad". Not that "it's always bad".

This thread should help countless people, even if it's just in way of them talking to their doctor and getting different opinions. I had not thought of the radiation beam coming down and not having a prostate there to block some of it. Interesting to learn, imo.

Candidly, I have been considering complaining about the title myself. We have seen a steady stream of members on this thread who were alarmed by the title and needed to be reassured that Tall wasn't talking about them, and that for them SRT was a sensible next step -- not bad at all. My choice of title would come from a phrase in one of Tall's first paragraphs: "Salvage Radiation: Not a Walk in the Park."

Purgatory, re: your last couple of posts: WOW.

Re: this entire thread: WOW

Some real food for thought here. As a G9 who was barely able to make a decision for surgery vs RT primary, and who ended up being not contained ( as was probably at least predictable despite the surgeons feeling), I am certainly a candidate to have to deal with all of this in the future.

And if that scoundrel starts rising ( not the little scoundrel I wish would rise, the other one), then I am left to wonder: what to do? As usual, I have many questions for which there seems no clear answer, just like I did before surgery.

Is there anything else that would help at all or even as much as 30%? HT? Is 30% actually the odds that SRT will help, or cure, or is that just for some specific sub-set of patients but others have a significantly higher % chance of it being worth the possible SEs?

Are the potential problems of ART less than the ones discussed here for SRT? I was not offered ART by my guys up at Vandy, which has surprised me seeing how many here get that. What I was told at the 7(8?) month visit was when and if it starts rising and gets above .2, we will discuss the pros and cons of SRT and various options. I guess the various SEs and maybe low % of success is why that bunch is slow to go the SRT or ART route?

My, it is a lot to think about. So what else is new?

PeterDisAbelard. said...
Candidly, I have been considering complaining about the title myself. We have seen a steady stream of members on this thread who were alarmed by the title and needed to be reassured that Tall wasn't talking about them, and that for them SRT was a sensible next step -- not bad at all. My choice of title would come from a phrase in one of Tall's first paragraphs: "Salvage Radiation: Not a Walk in the Park."

Definitely needs some thinking. I don't understand, maybe because I missed something, and I will go back and read the OP. But isn't the title "why" exactly correct? Is there a group of patients for whom all of those potential problems and low cure rate do not apply? I would guess the low cure rate will not apply if you could know for certain that it was still- a year or 2 after surgery maybe- that it was still hanging out only in the Pros. bed. But if you can not know that? Can you know that with fair certainty?

So if the cure rate is low when looking at all men who have SRT(is it?), and if the # of and risk of serious SEs is much higher % wise for any group who has SRT compared to those who have primary RT or primary surgery that is NOT followed by RT, then it would seem logical to me that- if you thought there was a reasonable chance that you would ever need SRT( or ART?) it would always be best to have the RT to start with. (but I have been in a continuous state of confusion since diagnoses so my logic may be way off)

IF it is the SALVAGE RT that is the problem, when compared to primary RT or whatever, then WHY would I ever choose surgery based on the idea I could always have SRT later? Only reason I can think of is if it was very unlikely I would ever need it.

But as always, it seems for my pea brain clouded by emotion, there are never any clear answers. And there is always more data to consider.

For ex, Primary RT can fail. Most obviously there are the surgery guys who go in with expected contained G6s and get a path report showing quite something different. They did not choose their surgery necessarily thinking "hey, if this doesn't work I'll hit it with some SRT no problem". They did not expect to ever need SRT.

Then there are guys like me, with a Bx G9(5+4) and PSA 10.9 indicating a pretty good chance of some spread. But whose second opinion surgeon's feeling was, based on his DRE, that I had a real good chance of being contained, and if it was he could offer me a cure. So an angel(devil?) on one shoulder was yelling "get the RT first in case it is out of the capsule" and the angel(devil?) on my other shoulder is yelling " a cure IF it is contained and he thinks it may well be". But I must admit, that whatever it was that made me take the hope of the surgical cure of the contained PC, I don't think I realized how much greater were the potential problems of SRT compared to primary RT or surgery alone. If I had, would I have made a different choice? Maybe, quite possibly. So I think it is good to know this in advance. I can assure you know one told me this pre-surgery. And I think they should emphasize it if they are going to say "we can always radiate later, no problem".

BillyBob,

Tall Allen recently posted a thread about SRT where he quoted a study that found, as I recall, that for higher-risk men after RP the best PSA to trigger SRT -- the one that avoided the over-treatment sometimes involved with ART but preserved the benefits of treating early -- was 0.03 ng/ml. So, without putting words on Tall's keyboard, I don't think he was hoping to scare you off from SRT if your PSA starts to head north, even a tiny bit.

And as for that 30 percent success figure, that's complicated. Yes, there are a lot of guys whose salvage radiation "fails" according to the usual endpoint (biochemical failure) but if you follow those failures you find a significant survival benefit for having been treated, especially for the higher-risk cases. Nobody knows why -- the best theory is that even systemic disease has some local component that makes it go faster.

Billy, I think the 0.03 is for high risk RP guys, at least that is what was explained to me. When my first post op PSA came back @ 1.15 I took notice as I was told 0.03 would be the trigger point.

Cheers, Doug

To those concerned, I violated no forum rule. I called no names, made no accusations. Just offered a differing opinion.

As a regular member of a peer to peer forum, our best advice often isn't what is being researched (that has its place of course), but to relate our first hand stories and experiences.

What I have spoke about in this thread, and countless others on the subject, is a real life concern to men, before they (some) jump into salvage radiation therapy. Do you really think I am the only one to be damaged? There are quite a few here.

My concern is definitely about the "if" needed part, and then if it is really needed, the "when" part. What is wrong with that? It was popular here for the longest time (perhaps still), to encourage men not to jump into surgery quickly after dx., I feel its equally important not to jump into SRT quickly, especially when it is so difficult to know where any remaining cancer or recurrence is taking place.

We also have our share of men, who like me, quickly failed SRT as well as their initial surgeries. So I see nothing wrong with giving a clear alarm and warning for those that haven't entered the "waters" yet so to speak.

David