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Does early salvage radiation save lives?

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Posted 1/26/2015 7:06 PM (GMT 0)
It's always a difficult question whether it's worthwhile to undergo salvage radiation after a failed prostatectomy. Salvage radiation carries special risks (see my recent thread "Why salvage radiation is bad."), but if it will save one's life, one might do it anyway. Because of the very long natural history of PC progression to metastasis and death, this has been very difficult to prove. Looking at a surrogate endpoint like biochemical recurrence, we know that earlier treatment improves that outcome, but will it actually increase a man's survival in the long run? A new analysis from UCSF suggests (but doesn't prove) that it will. At the very least, salvage radiation before PSA reaches 1.0 is associated with higher metastasis-free and all-cause survival.

Here's my article about it:
Does early salvage radiation save lives?

- Allen
Posted 1/26/2015 8:31 PM (GMT 0)
I seem to recall seeing that it increased the ADT-free survival -- the time before a man winds up on palliative HT. That's an important endpoint for me given my level of enthusiasm for hormone therapy.
Posted 1/26/2015 8:47 PM (GMT 0)
I've read each of your posts on this subject. I've found them to be exceedingly informative, well thought out and researched, and most importantly meant in the spirit of helpfulness and caring. My husband went into surgery as a T1C after being assured by his urologist that everything would be contained and no positive margins. But I still researched for all the "what ifs" and "just in case." Checked Hans tables, Partin nomograms, MSK nomograms. After surgery with a surgeon that performed 7000+ RRLPs, he was pathologically staged at PT3B with all the bells and whistles that we really, REALLY didn't want. EXE, positive margin, bilateral SVI, LVI. So back to research. More nomogram calculations, more "what ifs" and "just in case" but now with a more serious element - what will be the impact on my husband's body in the near and distant future. The surgeon told us he felt there was a 30% chance of BCR but was adamant about not doing radiation til that point. We interviewed several medical and radiation oncologists, each with their own spin on their recommendations. For 8 months I read every article, scientific research paper, blog, website, etc that I could find in order to help us with the next direction to go in. It was a daily roller coaster ride of confidence and remorse, decisivenes and doubt. All the while keeping a very close eye on his PSA results. Our decision for ART came from the research, professional input and the personal stories of others that are in my husband's stage. Bottom line - we chose what we felt worked the best for my husband. Are there still "what ifs?" You betcha. Do we still go through the "just in case?" Yep. Do we feel we've made the best decision based on the information currently available and keeping in mind future SE's? Most definitely. Would we have done any of this on blind faith? A resounding no. We have been truly fortunate that my husband's surgery and ART SE's have diminished and are now non-existent. Will that hold into the future? Doesn't matter for the life here and now. We're in the process of buying a house. I think that'll kill him before prostate cancer does!
Posted 1/26/2015 9:44 PM (GMT 0)
LWell this is very encouraging and comforting for me.

When I was diagnosed in June 2013, I was pretty much ignorant of treatment options, and did not find HW till well after my treatment regime was underway.

My diagnosis was based on a PSA of 7.1 and a biopsy which said GL 9 (4+5).

Consequently in ignorance, I readily accepted my Uro's recommendation of Surgery followed quickly by Radiation. I had surgery in August, commenced ADT in October and RT in Jan/Feb 2014.

As it happened, post surgery pathology regraded me to GL 7 (4+3 but with tertiary 5's) and stage T3A. First post surgery PSA was .03 and then .07

SE's have been significant (strictures and chronic incontinence) and have left me wondering if I have been overtreated, (though I still regard that as being preferable to being undertreated) and browsing these forums has frequently confirmed that view.

However it would seem that in terms of survival, I may well have inadvertently accepted the right treatment.

Still have to deal with the SE's, and that may take another 12 months and more surgery, but at least I should still then be around long enough to enjoy the "new normal".

Thanks for providing this information.

Chas
Posted 1/26/2015 11:54 PM (GMT 0)
Tall Allen's opinions are subjective as he always promotes radiation treatments. He doesn't have personal experience with surgery or anything that comes with it. Keep this in mind when reading his posts.
Posted 1/27/2015 12:15 AM (GMT 0)
Tdubb...you're welcome to post studies with results that differ from Allen's. If he's cherry picking his data then you should call him on it.

BTW, what would be an alternative to failed surgery (which this post is about) to salvage radiation? HT? Chemo?
Posted 1/27/2015 12:30 AM (GMT 0)
Michael, yes and in that order or combo.

Cheers, Doug
Posted 1/27/2015 12:33 AM (GMT 0)
I went through SRT with no side effects at all...I chose a Radiation Oncologist who really knew his stuff and was treated on a up to date LINAC, a Varian RapidArc. These things make a difference..SRT is successful about 50% of the time..In my case it failed. But I still think it was worth the effort...It didn't make things any worse..
Posted 1/27/2015 2:28 AM (GMT 0)

Michael_T said...
Tdubb...you're welcome to post studies with results that differ from Allen's. If he's cherry picking his data then you should call him on it.

BTW, what would be an alternative to failed surgery (which this post is about) to salvage radiation? HT? Chemo?[/quote

I just did..

Posted 1/27/2015 2:35 AM (GMT 0)
It is not a requirement to match someone's accomplishments in research, to point out an arguable point of which there is some evidence. If that were the case we would all have to be equal in accomplishments in order to have a dialogue. Based on posts, TA enjoys this kind of dialog, which is in no way a call out for him to do so. We all have the right to pick and choose what topic we will engage in based on our own personal predilections. Side note….. I bet TA himself, at times, cringes at the veneration he receives. ps radiation is a poison as is chemo. They work but at a price and should be considered with that in mind. cost benefit analysis…any other treatment that could do the same thing?
Posted 1/27/2015 3:08 AM (GMT 0)

logoslidat said...
It is not a requirement to match someone's accomplishments in research, to point out an arguable point of which there is some evidence. If that were the case we would all have to be equal in accomplishments in order to have a dialogue. Based on posts, TA enjoys this kind of dialog, which is in no way a call out for him to do so. We all have the right to pick and choose what topic we will engage in based on our own personal predilections. Side note….. I bet TA himself, at times, cringes at the veneration he receives. ps radiation is a poison as is chemo. They work but at a price and should be considered with that in mind. cost benefit analysis…any other treatment that could do the same thing?

Touché Logo..
Posted 1/27/2015 3:08 AM (GMT 0)

Tdubb said...
Tall Allen's opinions are subjective as he always promotes radiation treatments. He doesn't have personal experience with surgery or anything that comes with it. Keep this in mind when reading his posts.

I don't think he said anything promoting radiation. Did I miss something?
Posted 1/27/2015 3:11 AM (GMT 0)

Dewayne said...

Tdubb said...
Tall Allen's opinions are subjective as he always promotes radiation treatments. He doesn't have personal experience with surgery or anything that comes with it. Keep this in mind when reading his posts.

I don't think he said anything promoting radiation. Did I miss something?


Indeed.. All his other posts..
Posted 1/27/2015 3:40 AM (GMT 0)
TA thanks for the info. It does make me rest a bit easier, for now, that I made the right decision on SRT. My biggest question, obviously, was how does my RO know the cancer is where he is radiating. He admitted he could not say with 100 percent certainty if he was picking the area where the cancer was located. But he said, for me, all signs pointed to cancer in the prostate bed. He sold me on it and it was with a great deal of trust I believed him. So far my PSA is trending in the direction that he was correct and I hope it continues but I guess I won't know for sure for many more months. I was very hesitant about SRT because of the SEs and the horror stories that have been related, but in the end I felt it was the choice I needed to make. And that has been the problem during this whole PC journey. There is no clear cut, safe, guaranteed positive outcome on any treatment.
Posted 1/27/2015 3:53 AM (GMT 0)
Tdubb, merci mon ami… Id put all the whatchamacaliits up but only got a c in french. for that matter I got C's in about every thing. Its fun to be average scool
Posted 1/27/2015 4:55 AM (GMT 0)
tdnjam-

Your positive margins pretty well guarantee that the recurrence is in the prostate bed. It's almost always the site of the first recurrence, especially in the area around the anastomosis. That's the downside of saving the bladder neck and neurovascular bundles - tissue gets left behind, and sometimes there are microscopic bits of cancer in those tissues.

- Allen
Posted 1/27/2015 5:22 AM (GMT 0)

Shaba.Doug said...
Michael, yes and in that order or combo.

Sorry Doug...my question was rhetorical. Meaning that Allen's post pertains to a local recurrence and that SRT is the first line option for that. Totally agree with you when its beyond the prostate bed, which I know that unfortunately know all too well. (Not that you can tell from your cheery posts!)

Curse this darn internet and its inability to convey nuances!
Posted 1/27/2015 1:28 PM (GMT 0)
Sort of thought it was a strange question from you Michael! LOL Had to get an oblique answer in to point out SRT is not the best for all! It's been shoved at me since day one and I flatly refuse but that's me. People need to do what they are comfortable with, for reasons they are comfortable with. Human nature plays a big part in this disease (decision wise, at least)' some people lead, some people follow blindly.

Cheers, Doug
Posted 1/27/2015 3:02 PM (GMT 0)
Thought that I would add my few bits as this is of great interest to me.
First, the size of the sample of the new study is a bit small as are most. When you divide the sample into subgroups by the various other criteria, the subgroups are very small. This seems to always happen when I try to find results relevant to my case.
Second, I would say that not only is there a potential selection bias because the treatments are not assigned in some random fashion because this is not a clinical trial but it could be worse than that. Take my case for example. My first post surgery PSA was < 0.1 . After that I asked for the more sensitive test and it came back as 0.08. So I would not be a person that could possibly get adjuvant radiation at an "early stage" such as PSA of 0.03. This may mean that I am more likely to get a recurrence regardless of what I do. This is similarly true of people who have post surgery PSA of 0.1 etc. So the good results in the adjuvant and early salvage groups could just be due to this kind of selection bias and nothing to do with treatment. As I did have radiation post surgery I certainly hope not but so far no study that I have seen has been very convincing that this is not actually what is happening.
Posted 1/27/2015 3:07 PM (GMT 0)
Doug, given the distant mets it's surprising to me that SRT would be recommended. I can understand your sensitivity to the subject. And I very much agree with your human nature comment.
Posted 1/27/2015 3:16 PM (GMT 0)
Michael, they were shoving it before the scans! I did some math using my pre and post PSA's along with Path report and decided it wasn't local. Not very scientific, but turned out to be correct, I got some perverse pleasure from that! LOL. They could not show me it was local.

Cheers, Doug
Posted 1/27/2015 4:16 PM (GMT 0)
I went the early SRT route based upon the advice I received at the time, almost 5 years ago now. I was recommended by my uro/surgeon, two radiation oncologists and 3 medical oncologists that I spoke to. I did surprise me, however, since my research concluded, they all agreed, that the chance of success was 50% at best. The rationale was that if you have a 50% chance at a cure, why would you not take it. I agree that it's a crap-shoot with BCR, but if you don't go early the opportunity for a cure my well pass you by. My PSA was .5 just prior to SRT. Still have my fingers crossed and hope that I don't end up will bladder or some other cancer from the radiation. One thing at a time I suppose.
Posted 1/27/2015 8:31 PM (GMT 0)
BB,
It appears your numbers are good now. Are you on Avodart now to keep them low? BTW, I think the last date in your signature should probably 10/14.
Posted 1/27/2015 9:19 PM (GMT 0)

Tall Allen said...
tdnjam-

Your positive margins pretty well guarantee that the recurrence is in the prostate bed. It's almost always the site of the first recurrence, especially in the area around the anastomosis. That's the downside of saving the bladder neck and neurovascular bundles - tissue gets left behind, and sometimes there are microscopic bits of cancer in those tissues.

- Allen

THIS is exactly what my surgeon told me yesterday.

He said they used to do a wide cut during surgery and leave almost every patient 100% impotent and 100% incontinent. If anyone wants the surgeon to "get it all at any cost " tell them to do the wide cut they used to do .... You will reduce the probably of needing salvage radiation, but you WILL be incontinent and need diapers.

<<<<< crickets chirping >>>>>
Posted 1/27/2015 9:19 PM (GMT 0)
Being a gl9 stage pt3bN0M0, I had no choice but to go for RT when I had bcr. But I had very different recommendations from my Johns Hopkins surgeon and from the head rad onco at Johns Hopkins. My surgeon felt I should do nothing unless I had mets which I should attack with spot RT. The rad onco recommended ADT and SRT. Since I had positive margin at the base, my local Uro and rad onco felt that's where the remaining PCa resided. The gradual bcr which went from .1 to .2 to .3 also made them feel that RT could get the rest. Not sure why but hope they're right. So far so good as PSA has been undetectable.
Bob
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