Rising PSA (again) - questions -- UPDATE

Update. I posted back in May that my PSA had risen from 0.03 to 0.05 and the surgeon rescheduled my next test for 3 instead of 6 months. Well, I had the test done last Wednesday and learned Friday that my PSA has risen again to 0.1; so doubled in the last 3 months. He says I have recurrance and should start salvage radiation therapy but said hormone therapy is not indicated. So, I have a consult with the radiation oncologist at my surgeon's urology group in Birmingham, AL (Urology Centers of Alabama) on Sept. 2. The problem is Birmingham is 2 hours away making it necessary to spend weekdays there. That's not such a problem in that I'm retired and they offer free lodging (I also have a travel trailer and a nice state park is about 15 minutes away). But, I'd rather have it done locally at the East AL Medical Center in Opelika, AL if the equipment/personnel are equal. From what I can tell on their websites, both use IMRT/IGRT equipment. My questions to you:
1. What are the questions to ask each center to determine who has the latest/best equipment and experience?
2. While I don't want HT and the surgeon says its not indicated, should I be concerned NOT to have it?
3. Should I ask for bone/abdominal scans or are my numbers too low to pick up?
3. Any other questions that I should ask?

I must say I have had a variety of emotions since Friday; not many of which are pleasant; add to that, my mother has moderate Alzheimers and is driving me nuts. Thank you all for any assistance. This is a great forum.

Post Edited (Edwardo43) : 11/15/2015 1:59:54 PM (GMT-7)

Edwardo - You want the best RO you can get. The equipment used is a secondary consideration as it's really the skill of the RO that matters. The only way to judge is to get appointments in both places and see what each says. Maybe some of the folks in your area could comment on their experience with ROs in that part of the world.

The SRT will get what PC is left in the prostate bed. The side effects aren't bad and most guys tolerate the procedure just fine. At a G7, I wouldn't be too worried about doing HT right now. I don't know all the studies on it, but I doubt you'll be missing much if you don't do that now. You can always start that up later if the SRT fails. You still have a shot at that mythical curable zone provided the PC hasn't escaped the prostate bed.

They'll likely do some MRI or CT work to setup the SRT (the RO will need to map where things are inside your body) and at .1 PSA it's not going to show where the PC is. A bone scan or other imaging at this point isn't worth the time or effort.

It's scary to be told that the surgery did get it all and now you have to do more. This is as much a mental game as it is a physical one. Do take time to keep your mental and emotional health going.

Hang in there and keep us updated on your progress,
Andrew

Edwardo,
Forget the technology and concentrate on the radiologist. It's the Indian and not the arrow that makes the difference. Get the absolute most skillful and experienced radiologist and you will end up with the most favorable results.

First, let me say that I am sorry to hear this disappointing news. I'm glad you are jumping on this as early as possible while you have the best chance of a cure with salvage radiation. Early treatment can make a big difference.

1. What are the questions to ask each center to determine who has the latest/best equipment and experience?

As long as you are getting treated in Birmingham, why not go to the University of Alabama Hospital? There may be other closer places you can go. Here are some questions to ask about salvage radiation:

1. How large a dose do you propose for the prostate bed? (should be near 70 Gy)
2. Do I need concurrent or adjuvant ADT? (see below)
3. How do you decide whether to treat the pelvic lymph nodes? If so, at what dose? (50 Gy) How do you plan to prevent bowel toxicity? How will you account for the separate movement of that area and the prostate bed?
4. What kind of machine do you use? (e.g., Truebeam/RapidArc, Tomotherapy, Vero, etc.)
5. What is the actual treatment time for each treatment? (faster is generally better)
6. What kind of image guidance do you propose? fiducials/Calypso transponders in the prostate bed (best answer)? Using the fixed bones or soft tissue only?
7. How will prostate bed motion be compensated for? Cone beam CT? Moveable bed?
8. What measures do you propose to spare the bladder and rectum? What dose constraints do you set?
9. What side effects can I reasonably expect? How should I deal with them?
10. How will we monitor my progress afterwards, both oncological and quality of life?
11. How many salvage radiation procedures have you done?
12. How has your practice of salvage radiation changed in the last few years?
13. What's the best way for us to communicate if I have a question or issue?


2. While I don't want HT and the surgeon says it's not indicated, should I be concerned NOT to have it?

Yes, you should be concerned not to have it. To be fair to your surgeon, that question is outside of his specialty. Recent evidence has proved that it can indeed affect survival. Please read the following:

Combining ADT and salvage radiation therapy improves outcomes

3. Should I ask for bone/abdominal scans or are my numbers too low to pick up?

Yes, you should have a bone scan and CT to check for gross metastases first. That can change your treatment plan completely. Sophisticated scans like PET scans are not used in your situation because the entire prostate bed must be treated anyway, no matter what they show, so it is a waste to do them.

3. Any other questions that I should ask?

Ask about prognosis, expected side effects of treatment, and measures you can take to prevent or deal with those. Be sure to tell your doctor about any co-morbidities (e.g., diabetes), metal parts you may have (prosthetics, pacemaker), and any supplements you may be taking. Avoid anti-oxidants. Do as much exercise as you can - do not "take it easy."

- Allen

The local cancer clinic (East AL Med. Center) doesn't list their machine but issues this statement which sounds pretty much like the Varian Clinac:

"We have a state-of-the-art linear accelerator (the machine that delivers radiation therapy) with on-board imaging and respiratory gating so our radiation oncologist can precisely target cancer cells while minimizing damage to healthy tissues nearby, and accounting for the motion of the patient’s breathing."

The RO at EAMC has 24 years experience.

Still researching; thanks for all your input.

Respiratory gating isn't very important for prostate cancer - it becomes important for thoracic cancers where breathing affects organ motion. What is more important is the imaging system they use. Any of a variety of linacs (manufactured by companies like Varian, Accuray & Elekta) can do a good job for you, but the imaging system and the precision of the plans they can generate are what's really important.

Tall Allen said...
Respiratory gating isn't very important for prostate cancer - it becomes important for thoracic cancers where breathing affects organ motion. What is more important is the imaging system they use. Any of a variety of linacs (manufactured by companies like Varian, Accuray & Elekta) can do a good job for you, but the imaging system and the precision of the plans they can generate are what's really important.

Which imaging systems are best for my case?

Edwardo: Who was your surgeon at UCA? I used Scott Tully.

Think you'll enjoy meeting Brian Larson. Very patient and willing to spend all the time you need answering questions.

You probably got the flyer that Brian Christine is giving a presentation on the 17th. If you've never heard him, it would be worth the drive. One of the funniest guys I've ever met. Definitely has his act together!

themacs said...
I am going through SRT right now. It sounds like our cases are almost exact. GL 7, 1/2 involved. Rise in PSA about the same. I did not find your e mail address in your profile. Id be glad to talk if you want.

Scott

Hi Scott, thanks for the post; my email is in my profile. Hope things are going well with your treatment.

Edwardo43:

How about an update?

I'm surprised they didn't want you on HT, my RO at MD Anderson won't do ART without starting a patient on Lupron.

If it were me I would also ask about SpaceOAR as part of the prep for radiation.
Jim