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PSA numbers up over last year, after RP 7 years ago: Advice on what to expect next

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Posted 10/20/2015 8:02 PM (GMT 0)
My boyfriend had a RRP in Oct 2008
age : 50
initial PSA 4.8 in May 08
PSA 7 Oct 2008 (just before surgery)
Gleason 7 ( 3+4)
T3a
Perineural invasion
Davinci at Univ of Chicago/ Dr Kevin Zorn
Chose not to have radiation
only 1 lymph node out of 21 positive

Always had <0.1 psa last 5 yrs

Now last reports LAB shows the 3 decimal point results(ultra-sensitive)
9/2013 PSA .027
4/2014 PSA .065
now that we have a doubling rate in 7 month we are concerned.Having another test this week.

UPDATE: 7/2014 test .067

2/2015 <0.1 ( did not do ultrasensitve)
10/2015 .1 ( did not do ultrasensitve)
10/2015 .110 (second test in month using ultra sensitive)





Test results: 2010-2015
TIMELINE:

8/2010 <.1
3/2011 <.1
10/2012 <.1
9/2013 .027 ultrasensitive
4/2014 .065 ultrasensitive
7/2014 .067 ultrasensitive
2/2015 <.1
10/8/2015 .1
10/16/2015 .110 ultrasensitive

Planning to see a doc. soon
Who should we consult first?
Radiology oncologist?

Much debate on ultra sensitive test, however it did give us a heads up over a year ago.

What should be our next steps?
We live in Orlando area.
If treatment is need we are willing to travel out of state for best care possible and are able to relocate during that time.

PLEASE ADVISE, We are in shock as we just got the last results today.
Any advice on docs in Orlando area or anywhere in USA.

Mike age 58 now, been 7 years since RRP in OCT 2008

thanks guys!

angeusamike57
Posted 10/20/2015 8:25 PM (GMT 0)

angeusamike57 said...
Chose not to have radiation - only 1 lymph node out of 21 positive

When 1 LN is positive, there is often more cancer in the lymph. The detectable and increasing PSA tells you the cancer is active. If you want a crack at curing it, he will have to have salvage radiation. The type of doctor to see is a radiation oncologist. Dattoli (Sarasota), Moffitt (Tampa) & Constantine Mantz (Ft Myers) are all good. He will probably want him to have a bone scan and CT first to check for any detectable metastases.

- Allen
Posted 10/20/2015 8:34 PM (GMT 0)
Thank you, Thats a place to start!!! Any sites or books you could suggest would be great too.
There is a wealth of info on this site, which we are so thankful for. Thank You!!!
Posted 10/20/2015 9:10 PM (GMT 0)
I don't recommend books because they are all out of date by the time they are published. Many people like Patrick Walsh's book "Guide to Surviving Prostate Cancer" last updated in 2012. A lot has been learned since 2012.

As for websites, I like The New Prostate Cancer Infolink. (Full disclosure - I write for it.) It is a good way to keep up with what's the latest in peer-reviewed clinical studies on a variety of PC-related topics. You can put "salvage radiation" or "N1" in the search bar to see what has been written most recently on the subject. You may find the search bar on this site useful too.

- Allen
Posted 10/20/2015 9:14 PM (GMT 0)
angeusemike57

You are in a great place to get world class treatment. The three names Tall Allen gave are all very good options. I would be going to Dattoli if I were as close as you are to him. I would begin the process now. My doctor starts the process when his patients reach .03. He let me go until .06. I was 90 months out from surgery. Started SRT in May. I am at <.006. Going for second reading after SRT next week. Goiod Luck in getting this beast under control.
Posted 10/20/2015 9:26 PM (GMT 0)
Thank you both! Great advice. Will be checking out the http://prostatecancerinfolink.net tonight. Reading all about Dattoli now. Putting in call tomorrow. We are on east coast of Florida just outside Orlando, so a 3 hour drive, which is great he is so close.

What is the process after first call:
Phone consult?
Sand Lake Imaging test?

Thank you so much.
Ive got over 200 post on healingwell bookmarked to read.
The support and info here is wonderful!
Posted 10/21/2015 1:22 AM (GMT 0)
I would advise you see Dattoli; none better!
Bob
Posted 10/21/2015 4:30 AM (GMT 0)
Before you can treat the cancer, first, you must FIND IT....At 0.11 it's going to be very hard to locate using most scanning technology available today..However, there are some new, very sensitive scans available. Sand Lake Imaging, Orlando Fla. might be able to help you..But first see one of the expert R. O.'s available to you and get their thoughts on your situation....
Posted 10/21/2015 4:53 AM (GMT 0)
It is not necessary or even useful to find it first. Prostate cancer has a very characteristic spread pattern. It travels first into the prostate bed and pelvic LNs. Afterwards it can spread to bone and later to visceral tissue. The bone scan provides a quick check that it is still in the locoregional area where it can be successfully treated. Because they know in his case that it is in the pelvic LNs, they will treat the prostate bed and pelvic LNs. They don't really have to do any further imaging at this point because the entire area will be treated. The amounts of cancer are too small to show up even on the most accurate of the experimental PET scans, so it is wise to go ahead and treat the entire area with a curative dose of radiation.

- Allen
Posted 10/21/2015 1:36 PM (GMT 0)
Interesting take Allen has re: not necessary to find it first. Not sure that Dr Dattoli would agree because the dosimetry for each patient targets the precise location of the PCa and surrounding area. He certainly would want to know if it were in any organs or bones. But since you had a lymph node involved at pathology it might be enough to conclude that's where the PCa resides. At any rate, Dr Dattoli calls you spending about an hour on the phone which is amazing. Then his office schedules a face to face consult in Sarasota where he gives you his recommendation. However he will have come to a conclusion as to what's needed based on docs you send him re: previous treatments and scans, but he may send you to Sand lake Imaging in Orlando for pet ct and MRI scans.
My situation was like yours but Gleason 9 and my surgery failed right away due to the severity of my PCa which had penetrated the capsule at the base and invaded my SVs but not my nodes based on ten dissected at RP. But as it turns out later as per MRI with contrast at Sand Lake, it did eventually travel into two of my iliac nodes.
As Allen says this disease travels silently and microscopically and can reappear many years after treatment. I had IMRT to the prostate bed over a year ago when PSA reached 0.3 but not the lymph nodes which was in retrospect a mistake. PSA climbed again to 1.22 after I was off ADT , so now I'm having the pelvic nodes done via Dattoli's DART process along with ADT3 and metformin.
Good luck.
Bob
Posted 10/21/2015 3:28 PM (GMT 0)
Thank you all. Just talked to Megan at offices of Dattoli, and will be sending paperwork to him today and waiting for his call. So the process begins.
Posted 10/21/2015 5:41 PM (GMT 0)
Bob,

The term ROs use for adding more radiation to an identified lesion is called "Simultaneous Integrated Boost" therapy. It may make sense when the radiation delivery system is not all the precise because it would enable the RO to deliver a higher dose where they've identified a lesion but a lower dose elsewhere, thus avoiding toxicity to organs at risk. But one can see the problem with SIB -- is the lower dose delivered elsewhere enough to kill the microscopic cancer cells hiding there? Prostate cancer is almost always multifocal. So concerns about toxicity may unwittingly allow some cancer to escape full annihilation. Fortunately, current IGRT/IMRT systems have been able to reduce toxicity considerably, enabling a higher dose everywhere in the pelvic bed. Current pelvic bed doses are now running at about 50 Gy. You can see in the following how this has been done with very low toxicity:

Quality of Life Outcomes in Patients With Prostate Cancer Treated With Nodal Irradiation

GI and GU Toxicity in the Pelvic Nodal Treatment of High-Risk Prostate Cancer

If the entire pelvic lymphatics can be irradiated to a higher and curative dose, why would anyone bother with a SIB?

- Allen
Posted 10/21/2015 6:22 PM (GMT 0)
I highly recommend Dr. Dattoli.

Like you, my PSA started rising after surgery. When it hit .028, my urologist recommend radiation therapy. I was originally diagnosed as PT2cN0M0, Gleason 6.

Dr. Dattoli is a PCa specialist. I had CT and bone scans that found no cancer. Within 10 minutes, Dr. Dattoli identified a suspicious site at my anastamosis (where my urethra was stitched back together. using Color Flow Doppler Ultrasound - think TV news weather radar except it measures the flow rate of blood to cancer cells.) I was able to view what he was viewing. He said he would target that site for treatment as well as the prostate bed and lymph nodes.

His equipment is state-of-the art in all aspects. He goes above and beyond expectations by providing free classes on nutrition and exercise and DVDs you can check out as well as a 3 ring binder that contains very useful information such as supplement and diet recommendations.

He has a published track record of over 80% success rate of treating higher risk patients over a 16 year period. I'm not aware of any other doctor that has that.

My side effects were minimal: a little fatigue, irritation of my rectum and an occasional, urgent need to urinate and defecate (not to the point of using pads.)

Be sure to make a list of your questions when he calls you.

You should not attempt to commute. Dr. Dattoli has to reschedule patients to allow for down time on his 2 treatment machines. His staff can provide a list of lodging available, or you could do what I did and find a room to rent on Craigslist.

Best of luck to you!
Posted 10/21/2015 6:25 PM (GMT 0)
A correction to my last post; my PSA hit.048 when my Urologist recommended I see an RO. Sorry for my mistake.
Posted 10/21/2015 8:58 PM (GMT 0)
Angeus and domino
I agree with domino. Treatment is very comprehensive and beyond the so called "normal protocol ". For one thing, he gives higher doses but over more sessions. And he insists on triple androgen blockade plus metformin. But for a shorter period:13 months. My local RO wouldn't dream of risking giving me more radiation after the 68.2 gy to the prostate bed.
There are lots of types of accommodations in Sarasota. I rented a nice two bedroom two bath condo for $1800 a month. Vacation rentals by owner (VRBO) is a good place to look. If you want to stay on the beach you'll pay much more. The high season is Jan-April. Now is low season.
Bob
Posted 10/22/2015 12:37 AM (GMT 0)

Domino95 said...
I highly recommend Dr. Dattoli.

Like you, my PSA started rising after surgery. When it hit .028, my urologist recommend radiation therapy. I was originally diagnosed as PT2cN0M0, Gleason 6.

Dr. Dattoli is a PCa specialist. I had CT and bone scans that found no cancer. Within 10 minutes, Dr. Dattoli identified a suspicious site at my anastamosis (where my urethra was stitched back together. using Color Flow Doppler Ultrasound - think TV news weather radar except it measures the flow rate of blood to cancer cells.) I was able to view what he was viewing. He said he would target that site for treatment as well as the prostate bed and lymph nodes.

His equipment is state-of-the art in all aspects. He goes above and beyond expectations by providing free classes on nutrition and exercise and DVDs you can check out as well as a 3 ring binder that contains very useful information such as supplement and diet recommendations.

He has a published track record of over 80% success rate of treating higher risk patients over a 16 year period. I'm not aware of any other doctor that has that.

My side effects were minimal: a little fatigue, irritation of my rectum and an occasional, urgent need to urinate and defecate (not to the point of using pads.)

Be sure to make a list of your questions when he calls you.

You should not attempt to commute. Dr. Dattoli has to reschedule patients to allow for down time on his 2 treatment machines. His staff can provide a list of lodging available, or you could do what I did and find a room to rent on Craigslist.

Best of luck to you!



Thank you Domino, for your detailed experience at Dattoli . If you could email me I have a few specific questions re: Dattoli Thanks! angela
Posted 10/22/2015 12:42 AM (GMT 0)

Break60 said...
Angeus and domino
I agree with domino. Treatment is very comprehensive and beyond the so called "normal protocol ". For one thing, he gives higher doses but over more sessions. And he insists on triple androgen blockade plus metformin. But for a shorter period:13 months. My local RO wouldn't dream of risking giving me more radiation after the 68.2 gy to the prostate bed.
There are lots of types of accommodations in Sarasota. I rented a nice two bedroom two bath condo for $1800 a month. Vacation rentals by owner (VRBO) is a good place to look. If you want to stay on the beach you'll pay much more. The high season is Jan-April. Now is low season.
Bob


Bob, Thanks so much. We most likely will be in high-season rentals for treatment. Is what it is. Just sent his documents in today, and was told doc will call within 1-2 weeks. The Dattoli Center being only 3 hours from home still is a blessing. Thank you!
Posted 10/22/2015 12:48 AM (GMT 0)

Tall Allen said...
I don't recommend books because they are all out of date by the time they are published. Many people like Patrick Walsh's book "Guide to Surviving Prostate Cancer" last updated in 2012. A lot has been learned since 2012.

As for websites, I like The New Prostate Cancer Infolink. (Full disclosure - I write for it.) It is a good way to keep up with what's the latest in peer-reviewed clinical studies on a variety of PC-related topics. You can put "salvage radiation" or "N1" in the search bar to see what has been written most recently on the subject. You may find the search bar on this site useful too.

- Allen

Allen, So much to read! We are particularly interested on length of ADT, and short-term (6 months) vs longer term ADT. Been reading the link you sent above. I would be interested in any surveys done comparing the length of ADT treatment in Gleason 7's vs higher Gleason scores. So much to learn. Thanks you for all your advice/comments! Angela
Posted 10/22/2015 2:17 AM (GMT 0)
That's discussed in the following:

Combining ADT and salvage radiation therapy improves outcomes

The detail of GETUG-AFU 16 that would break down results by Gleason score has not yet been published. We don't yet have the results of other clinical trials that would tell us the optimal timing for various recurrent risk groups (RTOG0534 and RADICALS).

To some extent, use of ADT is probably substitutable for radiation dose. More important is the dose of radiation used. It is not always immediately obvious. The nominal dose, expressed in Gray (Gy), is different from the Biologically Effective Dose (BED, also expressed in Gy), and depends on the treatment schedule. For example, all of the following salvage doses to the prostate bed are biologically equivalent in their cancer control power (treatments are called "fractions.") even though the nominal dose ranges from 81 Gy to 44 Gy.:

54 fractions of 1.5 Gy/fraction
=41 fractions of 1.8 Gy/fraction
=35 fractions of 2.0 Gy/fraction
=25 fractions of 2.5 Gy/fraction
=18 fractions of 3.0 Gy/fraction
=11 fractions of 4.0 Gy/fraction

The standard of care is 35-41 fractions of 1.8- 2.0 Gy, although ROs have used the other treatment schedules experimentally. Someone in my support group recently completed his salvage radiation under a clinical trial at USC in 15 fractions and has so far had no side effects of treatment. As I said, the standard of care for the pelvic LNs is around 25 fractions of 2.0 Gy, although that is much less proven.

- Allen
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