Trying to decide about SRT 6 months after RRP

I have added some details from my Pathology report that I thought were the key findings, because I now need help deciding about doing SRT.

I recovered very well from my RRP surgery at the end of May 2014 . Dry and ED issues were OK after 2 months. Unfortunately, my post surgical PSA was only undetectable for 6 months and they want me to get one more PSA test and then if its detectable get 33 SRT treatments.

I am 59 and in good health, except I did have a mid grade bladder tumor removed by a TURBT procedure a year before my RRP. I get checked every 3 months and I am fine so far ...

I have read a LOT here, and done some searching too about SRT I know a PSA of .07 is not an emergency, but given I had positive margins and its taken 6 months to reach .07 I think I need to consider further treatment. I am going to ask my RO and surgeon about seeing what my PSA rise is with two more PSA tests, not just one more PSA test as they suggested.

I live in Canada and really like and trust my surgeon, and do not feel the radiation they are suggesting is purely motivated by profits, but, having allowed myself to be rushed into my surgery ( no regrets ) I think I want to consider / study this next step a bit more.

Any comments or questions that will help guide me are welcome.

I wish you all a healthy and happy holiday season.

Thanks Allen,

You have pretty much confirmed what the RO and my surgeon said.

Would you happen to have any idea what the overall "cure rate" is from adjuvant RT ?

That's not the news you wanted but looks like it will be needed.

There are worse things than SRT.

no I won't list them.
Here's hoping it works the way we want it to.
Hang in there.
Andrew

I finished SRT in DEC...my 9 month post RALP PSA was .33 the two before that at 1 month and 3 months were .064 and .074 everything I have read is that they really don't wNt your post RALP PSA to go higher than .20... Sounds like your on the right track..SRT wasn't too bad, just drained me, caused some bowle issues, and burnt butt...back to see my RO on WED hoping for good news.

I have only an "internet education" about prostate cancer, mostly from extensive reading on this website. I am trying to strike a balance between just doing whatever my doctors tell me I should do, and asking questions so I can determine what is best for me. To do this, I need to ask questions about what is being done to me WITHOUT insulting anyone, WITHOUT being a difficult patient or interfering with doctors who are trying to helping me.

Just to satisfy my curiosity, and knowing that past surgeries are not reversible, I ask everyone an extremely hypothetical question ... if we knew in advance I was going to have positive margins and following surgery that I was going to require radiation, would cancer specialists doctors ( and surgical oncologists ) suggest radiation as my first treatment ? It seems that now I am going to have both the risks and side effects of both treatments.

Secondly, if I was to decide I have has enough treatment and don't want radiation, what could I reasonably expect progression wise, given I am 59, in good health, Gleason 7 ( 3+4 ), and a PSA that went for undetectable to 0.08 in 8 months ?

I would really like to ask my doctors both questions, but just wondering what you guys think. I am seeing my surgeon again in ten days so by them I will have the questions worded properly, if I don't get them answered here : - )

Ravine,
Since we're in a very similar place in our numbers and apparent BCR, I will take a shot at your first question. As a radiation oncologist, with nothing to gain as he was strictly a consult and wouldn't have done the treatment, said to me "Why in the world would you do surgery when you might have to do radiation anyway?" And that argument did sway me in that direction until I found out the RO who would have done the treatments also required two years of Lupron hormone treatments in addition. When I got that information, all of a sudden the idea of just mechanically removing the prostate and probably being done with it in a matter of days seemed preferable to two months of radiation and two years of Lupron. Now, apparently, they have started to regard adjuvant hormone treatments for low-intermediate cases like mine as superfluous and do the radiation alone. So, to answer your question, yes, anyone who knew they would require salvage radiation following surgery would certainly have radiation in the first place. And so it is a serious consideration for those whose numbers (high PSA, high Gleason on biopsy) would seem to indicate that the cancer had already spread outside the prostate. What would be the point of removing the prostate under that circumstance? I've heard of "debulking" the cancer with surgery in high-risk cases, but am not up to speed on the pros and cons of that.
As for your second question, I would love to know the answer myself, and will certainly be asking it of my situation if SRT fails and I have another BCR. In other words, what is likely to happen if I do nothing, no hormones, no chemo, and just let it ride. I guess it's a question all incurable cancer patients ask themselves at some point. When does it become better to stop trying to treat and let it take its inevitable course? With prostate cancer, apparently, we would have a good while, at least several years, before it started to take its toll on our QOL, so is that possibly preferable than starting now to degrade that QOL with treatments that will only slow the progression and not stop it. I hope others will weigh in on these questions.

In the Briganti study, the median PSA was .2, and the median dose was 66.6 Gy, so you are right there. Some are pushing the dose up to 70 Gy now, but with your GS 3+4, I can see why that might not be needed, and nor would adjuvant hormone therapy. I think the Calypso system is excellent and should really mitigate any potential side effects.

How are you doing at the halfway point? I hope you're getting plenty of exercise.

- Allen

Ravine,

Unfortunately you will not feeling find simple answers to your questions. There are so many variables in this equation that it is nearly impossible to calculate the answer.

Stephenson, who is currently at the Cleveland Clinic, and was one of the original authors of the nomograms, has done some work on when is the best time to commence SRT. He found a clear correlation to successful treatment based on lower PSA at beginnng of SRT. I am sure you can google his paper.

As a Gleason 9, I set .05 as a decision point for SRT before I had surgery. I was less than zero for about 18 months, and then it slowly started to class to close to climb over the next 18 months. I commenced IGMRT at a .06. My rationale was that since SRT is radiating the Prostate bed, the sooner I started radiation., the better chance I had of getting the PC cells before they migrated elsewhere.

The only other option in SRT would be full pelvic, which would also target all the lymph nodes. You should consider going to Minnesota and getting an acetate scan, to see if you have any lymph nodes involved. You could have a single lymph node that is causing the low PSA.

I am satisfied right now that the SRT was successful. It initially dropped to a .02, and then rose to a .08, and now is slowly dropping. Last PSA was a .05. I am hopeful that next PSA in 3 months will drop to .03 or .04.

Good luck to you. I wish I could give you better guarantees of a successful treatment plan, but just don't think it is possible.

Goodlife

Shabadoug. I would say it is because it is because they are hoping for a "cure". cure is parenthetical , as the many threads{studies have been no help,to my knowledge in that regard} on the subject of cure shows that a cure with pca is questionable and defies definition. they are willing to take that risk and as I can not argue against hope I wish them well. Im not sure what the odds are of any study being correct,in the sense of meeting the end point for which they hope The odds of SRT bandied about here and there is 30% or so as you know. Positive margins increase that %.
Of course the elephant in the room is with that low a psa would the radiated ever have reached a point of a feared endpoint. I have kicked the elephant a few times but possibly the elephant,like cancer cells are in hibernation. We simply do not know. ,so we do what we can. My question re studies and the skewing effect of low psa participants is the elephant. I just want the low psa guys to be aware of that, as another risk factor, but may be " crying in the wilderness " It points out the possible negative effects of hope. which , I surmise is one of the genesis{plural} of " Hope is a good breakfast but a lousy dinner" quote.

Well, got my second post RP PSA test in January and PSA increased to 0.08 in a month from .07 the month earlier. I am getting it tested again Friday and if its increasing I am going to proceed with radiation to both my lymph nodes and prostate bed, hoping it's local disease and I get "cured".

My biggest concern is that I am over treating my G7 PCa .... I know surgeons love to operate and ROs like to radiate and I lack the confidence to go against their advise and refuse further treatment.

My surgeon, the RO and my brother-in-law uro-oncologist all say there is no need to rush but I don't see much point in waiting for my PSA to rise to 0.1 or 0.2 Just hope they get it this time and I don't get too many side effects from the radiation.

Maybe I will get real lucky on Friday and my PSA will drop or become undetectable ... otherwise I will be another SRT patient this March ....

Thanks to everyone here for helping me get this far.

I wish you all excellent results for whatever treatment choices you make.

I faced all these issues and went for SRTand ADT after I had BCR post op as indicated in my signature. I was told that my pos margin at base was helpful in terms of targeting the SRT and my docs believe I " won't die from PCa" . Hope they're right! Lol
My next PSA is in one week. Hope it stays undetectable. All of this is a crapshoot IMHO. But namograms give some guidance on average outcomes. But we all think we're not " average" right?
Bob

In The Shop, I agree, the real issue is if the PC is still in the prostate bed. If it is not the radiation won't help
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Allan, no I have not had the CT scan yet. My RO said radiating the lymph nodes is controversial and does have small extra risk of side effects - but said because the risk is small I should do the lymph nodes as part of an aggressive pursuit of a cure. He said the nodes are the second most likely reason for BCR ... and since it can't be done safely after SRT ( too risky ) he thought it should be done with the SRT.