Looking for Guidance

My husband was diagnosed with PCa Gl 9 Dec. 2015. I have been reading this forum, along with several others, ever since, and very much appreciate how helpful you all are. He implemented a radical diet change based on Michael Milken’s and Dr. Snuffy Myers’ books. No red meat, no dairy, lots of fresh vegetables and fruit, pomegranate juice, green tea, etc. Also read Dr. Walsh’s book. He has had 1 hip and 1 knee replacement over the past 3 years. My husband has already put a call into Dr. Snuffy Myers and was told Dr. Myers is no longer taking new patients.

He underwent an open prostatectomy 2/16 at Johns Hopkins. Path report in signature line was encouraging. My husband is about 85% continent at this point and improving weekly.

First post-prostatectomy PSA last week, disappointingly, was .86. We have researched what this probably means and are aware that action needs to be taken asap and he is moving forward. He is scheduled for scans next week with Dr. Joe Busch here in Chattanooga, to see if there is any evidence of metastasis. He will also have another PSA test at that time.

The current proposed plan is to radiate &/or start hormone therapy if there is no evidence of metastasis. Hormone therapy if there is metastasis. He is to meet with his urologist and an oncologist at JH once the scans are read.

Should he be starting hormone therapy immediately after the scans are finished here whether he is having radiation or not, and before he has traveled back to JH, which may take a couple of weeks to arrange? In this case, would it be appropriate to also ask about adding chemo to the ADT? My last question, for now, is if he is eligible for radiation, would you recommend he stay at JH or travel to Dattoli Cancer Center or somewhere else? I haven’t found many comments about radiation for PCa at JH so was hoping to get your collective wisdom. Thank you for being here, though I wish none of us had to be.

Hi Chrisp1. I'm unfamiliar with LVI, so I can't really comment, but the post op path seems to be quite a mixed bag of favorable/unfavorable. It's my hope that the scan shows something still localized though.
Preferably something HT & SRT can nip in the budd.

Wishing you both the best!!!

Thank you, Joe and Newton, for your well-wishes and we hope things go well for both of you in your treatments, as well as everyone else facing this disease.

Tall Allen, thank you so much for the information. We will research local ROs to speak with if the scans indicate NED. Either JH or FL would work as well since our kids live in the DC area and I have family in FL (not close to Sarasota Springs but close enough so my husband could visit them on weekends), but if having the treatment done at home would work as well, I would prefer that as I am still employed full time. I know we have some excellent doctors in Chattanooga but from what our urologist told us there is not really a team approach here and he seemed pleased that we had decided to go to JH for my husband's surgery.

Thank you again and I'm sure I'll be back as things progress.
Chris

They are in the Jupiter and Hobe Sound areas. I haven't really asked any of them about treatment options in the immediate area as we were researching Dattoli Cancer Center as well as options in the DC area and Atlanta. I am now looking into the two major hospitals in our area regarding radiation as both are well-regarded for cancer treatment and at least one has recently added "state- of-the art" radiation equipment, according to their website. Which equipment specifically, and what kind of testing should we be requesting?

Our main concern has been that most of the research I found indicated that with clear margins and a persistent PSA the cancer has most likely metastasized and we have both been a more than a little worried since finding that information - I wasn't considering the possible difference between pt3a and pt3b. The JH surgeon specializes in prostate cancer, especially aggressive prostate cancer, so I'm guessing that's why he took so many lymph nodes. He seemed to be very thorough and is very responsive to any questions we have about the surgery or pathology report.

Thank you again for your help. Chris

I believe Vanderbilt in Nashville has a good rep for RT for PCa, and Dr. Joe Busch, a renowned radiologist for PCa, I believe is still in the Chattanooga area. Dr. Busch's practice may be able to assist you in finding the best treatment facility in the Tennessee area for SRT/aRT. God Bless.

Chris said...
Which equipment specifically, and what kind of testing should we be requesting?

Ask when they got their equipment (last 10 years would be good). It should also be IMRT rather than 3D-CRT, imho. I like VMAT (arc therapy) because it is very fast (faster treatment minimizes the opportunity for prostate bed motion during treatment). I was treated with Truebeam with RapidArc, but there are many brands (e.g., Vero, Elekta Axesse). On the other hand, Tomotherapy is a great choice because it continuously monitors the target position. I think image guidance is very important in adjuvant RT, so that placement of fiducials or Calypso transponders in the prostate bed can help with accuracy. And cone beam CT imaging at the start of each treatment will help increase accuracy and minimize toxicity. But even the fanciest new machine is of lesser importance to RO experience and care in planning.

You should also be looking at a prescription dose of around 70 Gy (at 1.8-2.0 Gy/treatment). How wide they treat can vary based on individual anatomy and assessment of risk. The wider the area they treat, the higher the probability that they get it all, but the higher the toxicity risk. Fortunately, whole pelvic radiation can be avoided because of the very extensive ePLND.

I understand your concern based on PSA that it has already metastasized, and that is certainly possible, but the ePLND and the T3a may suggest that it is still local. Have you looked at a nomogram? The Stephenson nomogram is sometimes used to predict the probability that adjuvant RT will be successful, but it is correct only about 70% of the time. Of course, it does not account for how extensive the ePLND was in your case. Here it is, FWIW:

Stephenson nomogram

- Allen

Chrisp1

Sorry you had disappointing news with pas. I think if Chattanooga does not work out, I would be considering Dattoli.

I went M D Anderson for srt. Quite pleased with everything.
I live in Vhouston otherwise I would have gone t Dattoli.