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Posted 8/19/2015 3:57 PM (GMT 0)
Salvage Radiation didn't do the trick and now I would like to know if my current treatment is the best thing I could be doing.
I see the Radiation oncologist every February and the Urologist every August ( I go on the 27th)
I also have made trips (2) to NYC Memorial Sloan Kettering as needed currently they would like to see me when my PSA reaches 1.0 for additional treatment options.
Should I be discussing Hormone Treatment, bone scans or anything else with the local Urologist and Radiation Oncologist? I would like to know what to ask the Urologist when we meet next week.
My overall health is good and still in the saddle with the ED drugs. I have never had any symptoms and have only got treatment because of the PSA tests.
Posted 8/19/2015 6:34 PM (GMT 0)
Sorry to hear your PSA is going up. At this point I'd say your done with the RO and it's time to be talking to the Sloan folks.

Sadly, I think there might be HT in your future. The question is when to start. You could start that conversation with your local URO, but Sloan might be better. At this low PSA, I doubt any imagining will find anything useful, but you might want to get a bone scan or MRIs to establish a baseline to compare to later if needed.

I am tempted to say, talk to your URO this month, maybe get a PSA retest in 3 months and plan to get back to Sloan this fall. Sooner if you're concerned. I'd leave the scans up to the Sloan docs. They might have access to better machines than your local URO.

Just some thoughts from a random guy on the internet.
Hang in there and keep us updated,
Andrew
Posted 8/19/2015 7:23 PM (GMT 0)
Did they remove any pelvic lymph nodes during your surgery and/or irradiate them with SRT? It's possible that they can be treated if they haven't been, but that depends on the dose they already received. There is a clinical trial at NIH of a USPIO MRI for detecting LN mets.

It's also possible that there are only a few mets, and they can be spot-treated with SBRT. That would entail identifying them with a PET scan. MSK has some new kinds of PET scans that they are testing in clinical trials. You might want to ask them about it. If you're in the NY area, you might want to talk to Scott Tagawa at NYU who is the leader in developing new detection methods.

Unfortunately, a more likely option is that it is micrometastatic - too small to be detected by any current technology. Many doctors now believe that there may be no survival advantage to beginning hormone therapy earlier rather than waiting for rapid PSADT, detectable mets, or symptoms. All of this can be discussed with a medical oncologist. Howard Scher at MSK is about as good as it gets.

- Allen
Posted 8/19/2015 8:41 PM (GMT 0)
Andrew and Allen,
Thanks for the pointers. We will discuss them next week with the Urologist and schedule an appointment for MSKCC this fall.
Thanks
Posted 8/19/2015 8:57 PM (GMT 0)
I have been a patient at Sloan since the fall of 2011, after my surgery in upstate NY had clearly failed (see history below). Getting to and fro has been a snap on AMTRAK (I live near Albany), time to read and look at the beautiful Hudson River views. I chose to move management of my case to Sloan because I figured this would be a long fight, and I wanted Sloan's expertise and deep bench. My doctor is Dr. Michael Morris -- he is a quality physician who takes time with you. I currently am at what Tall Allen refers to as the micrometastatic stage, three years out from SRT. I cannot imagine being at a better place for this fight. Best wishes to you.

Newspaper Lover
Age 71
11/09 DaVinci surgery upstate NY; nerve bundle taken; clean margins, clean seminal vessels, no incontinence, alas no erections.
06/11 PSA re-emerged.
Gleason 8
Time to recurrence 18 months
Three month doubling time (summer 2011).
PSA rose from .07 on 06/11 to .17 on 11/11.
09/11 hernia surgery to repair hernia resulting from the DaVinci.
10/11 Moved management of my case to Memorial Sloan-Kettering in New York City.
12/11—06/12 SRT plus HT (Lupron, Casodex).
07/12 – 06/14 Five six-month tests returned PSA "undetectable" and testosterone in “normal range”
12/14 PSA .06
01/15 PSA .08.
07/15 PSA .11
07/15 CAT and Bone scans find no evidence of metastatic disease..
Currently receiving no treatment. Next PSA January ’16.
Posted 8/19/2015 9:12 PM (GMT 0)
Been there, Newspaper.

I let the post SRT single micromet grow to PSA 2.9 (two years) which was easily picked up on a C-11 scan. Then Lupron, Casodex and SBRT (Cyberknife). Hoping for an abscopal effect.

==========================================

Age 63 in 2015
12/02 PSA 2.9 age 51
9/03 BX/DX, Gleason 6, 4 of 12 cores
9/03 Brachytherapy
5/08 PSA nadir 1.1
12/08 PSA 1.8
2/09 BX/DX, Gleason 8, 1 of 12 cores
6/09 Hyperthermic Radiation, Hormone (short term), IMRT (10 fractions) spring 2009
10/09 PSA nadir < 0.1 10/09 through 01/12
4/12 PSA 0.2
3/14 PSA 2.9
5/14 C11 Acetate PT/CT, found 2.0 cm lymph node
5/14 Lupron/Casodex (9 months)
8/14 nadir <0.01
2/15 SBRT to node, at UCSD
3/15 PSA 0.02,T=0
6/15 PSA<0.015,T=105 (yippee!)
Posted 8/19/2015 10:45 PM (GMT 0)
Cicero, excuse the ignorance, but what is SBRT and what is abscopal? I thought SRT was the final bullet. This is hopeful.
Posted 8/20/2015 12:03 AM (GMT 0)
As you can see by signature, hubby also had SRT fail. We consulted with medical oncologist here in Tampa at Moffitt. His thinking was get a baseline bone scan when PSA reaches minimum 1.0 but he would not begin any hormone therapy til PSA gets between 8-10. We then decided to get a second opinion from medical oncologist at Sloan Kettering. Couldn't get in with Scher but had consult with Dr. Slovin who was wonderful. Her thinking was also baseline bone scan at 1, then therapy at PSA of 8-10. However, she avoids chemical castration for as long as possible and would start hubby on Casodex. Fortunately for us, she has shared patients with our medical oncologist in Tampa so we will be able to have any type of therapy done here at home and then occasional appointments with her as necessary. We went into the consult with her thinking it was the end of the world, but she pulled us back from the edge and gave us a good sense of hope.

Age 58 at surgery
Sep 2013 PSA 3.7, clinical stage T1c, 3+4
RRP 10/31/2013, path stage pT3bN0Mx
SVI bilaterally (direct, not distal), LVI, pos margin at apex (3+3), EXE at base
4+3 w/ tertiary 5 (65% 4, 35% 3, 5% 5), tumor involved 15% of gland
12/2013 PSA 0.02; 2/2014 PSA 0.03; 3/14 PSA 0.02; 4/2014 PSA 0.02; 6/2014 PSA .03
MRI/bone scan negative
7/01/14 to 8/27/14 - 40 sessions adjuvant radiation
11/26/2014 PSA three months after radiation: .03 (same as before radiation)
2/25/2015 PSA six months after radiation: .05
5/21/2015 PSA nine months after radiation: .17
7/21/2015 PSA eleven months after radiation: .41
Posted 8/20/2015 7:52 PM (GMT 0)
Cicero, excuse the ignorance, but what is SBRT and what is abscopal? I thought SRT was the final bullet. This is hopeful.

SBRT is Stereotactic Beam Radiation Therapy. They can "shape" the beam to the radiated area shape. The C-11 scan I received was able to indicate place and shape. Abscopal is where the radiation induces the immune system to recognize the cancer as an intruder so it can kill it. This is the holy grail.

However, as I understand it, the abscopal kick in is only 35% of the time in this scenario, and this is a wildly uncertain estimate.
Posted 8/20/2015 8:44 PM (GMT 0)
Where did you see that 35% figure for prostate cancer? My understanding is that it is always part of the post-RT cancer killing. Otherwise there would be no cures from adjuvant HT.

SBRT, while highly conformal to the shape of the target (like 3D-CRT or IMRT), also utilizes fewer more intense treatments to kill the cancer, typically 5 treatments for the prostate and 3-5 for mets.

- Allen
Posted 8/21/2015 3:25 AM (GMT 0)
The smartest thing I have done so far was to drop my Urologist as my "lead" doctor and placed that responsibility with a Medical Oncologist. This is the specialist that should be in charge of any ADT drugs or any cancer treatments involving drugs. Radiation Oncologists are typically not involved at this point unless a treatable tumor can be located and you have not already received your maximum radiation dose...

Hormone Therapy (as it's called) has serious side-effects. Some oncologists will agree with their patients and put off starting it as long as possible, preserving quality of life as long as possible..Since I had already been on HT for 2 years as part of my RT, my Oncologist recommended I go back on it immediately in order to keep my cancer contained for as long as possible. He does not believe in HT "vacations" or intermittent HT, at least in high-risk, G-9 patients like me...His feelings are "You let that beast out, it can be impossible to get him chained up again".....Understand, every patient is different and different patients get different treatments...
Posted 8/21/2015 11:33 AM (GMT 0)
Thanks to all!
You have provided good advise.
Newspaper Lover- we also live outside of Albany (12186) My insurance (Empire Plan) pays for travel and logging for trips to Cancer Centers of Excellence, and we have taken the train ride twice. So it is really a no brainier. My treatments were at St. Peter's.
Again Thanks to All!
Posted 8/31/2015 6:20 PM (GMT 0)
Met with my urologist he suggested to maintain current course PSA's every 6 months, with alternating visits between urologist and radiation oncologist. He said I maxed my limit of radiation to the prostate area.
Posted 8/31/2015 6:55 PM (GMT 0)
JEKNY I can't see why you would even need to talk to the RO unless you need radiation again at a different location. My RO and URO both said Lupron was next but they have no hi-tech scanning ability at the hospital. That's why people look to C-11 Choline or Acetate scans. There's even a 68GA psma scan out. Don't let the doctors or clinics limit your chance for a cure because they don't have the tools to detect where your cancer might be.
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