Results From Mayo

TA:

I know.

I also know my PSA is great on HT, but the vacation part looks like 9-12 months.

I would hope for a longer undetectable PSA (ie: a longer HT vacation).
That is, in fact, a major consideration, part of the QOL thing.
Lots to discuss with Dr. Lam
Mel

Dutasteride will usually also extend the vacation. I do not think the doctor will lower the PSA bar if you take Dutasteride.

George

Wow,
This post was to me one of the most interesting on HW in a long while. Please excuse some rambling here but -Thanks Mel for posting, Tall Allen and also George for detailed responses.

Though my situation is somewhat different, with Advanced PC with four known bone mets, I am interested in learning more about how the whole PC metastatic spread develops. I read a little here and there, but now realize I have a whole lot more to learn. Wish my brain could soak up more info each day, like some of you here.

Clinical trails are numerous. Many brave men and women enter
into those and do not end up with the favorable results they desire, but the information base they help create serves to direct our researchers onward. Many trials do not apply to my particular situation, and I find it pretty difficult to decipher a lot of findings in the various trials.
Thanks always for the "translations" in to simple language Allen, Thanks for the voluminous citations of trials George. Indeed,lots to digest. I do feel sometimes despite the results, the language used to summarize them is somewhat interpretative, and I tend to look for positive statements. Thanks for your particular take and views Mel and others.
I wanted to say I agree or disagree with this or that, but don't feel confident in my info basis yet. Don't want to speak out my my.you know what.
What I do feel confident with is my hope that new and better treatment is just around the corner even if there is no solid evidence that you can point to. I would not say that I am naïve, but would say I am information hungry, and aware that knowledge in King in our plans.
I know that there is "overtreatment " out there, but I do not believe it is rampant, have some modicum of trust in Doctors that have spend a good part of their lives trying to do the best they can for their patients.

As always, I am living and walking by faith and hope.

Wings of Eagles, aka Dan in So Cal

I now read the article by Brandon Bernard: „Approach to oligometastatic prostate cancer“ This is published by the American Society of Clinical Oncology.

I think he describes our discussion quite well:

B. Bernard said...

„However, recent advances in imaging are identifying men with potentially isolated metastases, and mounting evidence suggests that durable control is attainable with treatment modalities targeting oligometastases, either with or without the use of systemic therapy........ there are currently no clear-cut data or validated tools to guide optimal therapy for an individual patient. One school of thought is to consider isolated lesions on imaging as representing the only sites of disease, where local therapy is sufficient. The other viewpoint is that oligometastatic disease is most likely also associated with micrometastatic disease; therefore, concurrent systemic therapy with localized therapy should be considered the optimal treatment......With this uncertainty, there is provider and patient bias toward certain treatments......„

He also mentions that micrometastases may take a long time to grow to visible mets. This could be an argument to radiate just the visible metastases:
„In the setting of postprostatectomy biochemical failure, the median time from PSA recurrence to metastases may be long (8 years in one study)": Natural History of Progression After PSA Elevation Following Radical Prostatectomy Page 125.

George

JNF,

Figure 2 A in the study shows the „Actuarial Likelihood of Metastasis-Free Survival“ after PSA recurrence stratified for Gleason 5-7 and Gleason 8-10. From this figure I read that the Gleason 5-7 group has a median metastases free survival of 10 years and the Gleason 8-10 group of 5 years.

I cited the study results, which are mentioned in the Pound study, just as an indication that it should take a long time from PSA recurrence to the development of distant metastases. This may be 8 years or less, it is still quite a long time.

George

George,
I very much agree that there is a very long time between the appearance of early mets. That argues against treatment of early mets, not for it. It means that in all the studies you cited, absolutely nothing was gained by picking off the early mets with radiation. They continued to appear at their normal slow rate with or without radiation. There is no evidence - none - that this is a useful thing to do.

The studies you cited tell us that with SBRT, the time to the appearance of new mets is 2 years. Now, look at Mel's case, for example, which I think is typical, it took 2 years for his second LN met to show up - nothing would have been gained by zapping his first met.

I recognize that it does make patients feel better to be doing something, even if futile, rather than doing nothing and feeling like a victim. There is value in that. There is value in zapping bone mets that are causing pain or in danger of fracturing. However, if systemic therapies, which we know work well, are delayed to go on a wild goose chase, it puts the patient in jeopardy.

Mel-

Please let us know Dr. Lam's opinion.

Bobby Mac

Mel,

You have thousands of cancer cells in your lymph. It doesn't matter if you eliminate a clump of a few here or there. There are always a lot more that you can't see.

The evidence for early chemo is if it is stage M1 cancer. Yours is N1 M0.

I can understand your fear of radiating the entire area, given your history of IBD. But this is something you should be talking to an RO about. Did you ever talk to Spratt at UMich about all this?

Regarding Avodart, Dr. Lam has had me on Avodart these last 2 HT vacations (not part of my regular HT tx).
This time, with an upcoming scan on 10/6, he had me stop the avodart on 9/15.

I did, and have not resumed it. I will ask him today if I should resume it for the balance of my HT vacation.

Incidentally, my PSA is now at 3.1 as of 10/6. I'm hoping Dr. Lam says I can wait a couple of months before resuming HT (my PSA will be about 7 by then)

Mel

TA:

RE: when to resume HT

I don't recall Dr. Lam mentioning a specific cutoff. I don't think he liked to get into double digits. I'll know more later today.

After my conversation with Dr. Lam, if I am still intent on doing the SBRT, I will have some pointed questions for Dr. King regarding expectations.

Was he your radiation guy?

Mel

Well, folks, thank you all for your input.
I did have my follow-up appointment with Dr. Lam.

I forgot to mention here that my latest PSA at Mayo is 3.1.
My PSADT is 1.45 (from a PSADT calculator, based on my last 3 PSA scores).

Dr. Lam suggested I do another PSA in 2 months. At that time, my PSA will be about 7. That will be the time to get back on HT (he didn't mention an exact trigger point).

He was quite positive about doing SBRT. He does feel I would/could have a longer HT vacation by doing that. He actually brought that up. Needless to say, that fit right in with my proclivity on that issue.

I have been in email contact with Dr. King (he is fantastic about responding to emails). I have to get him the Mayo reports (which I can attach to an email if he is so inclined). I will have to have Mayo send him a disk with my test results.

I think TA had mentioned a mapping (to someone else) about previous radiation. So, I did ask Dr. King if he needs that, as I did have SRT to the prostate bed only.

TA -- I don't have any dates set up right now. I think once Dr. King gets to look over the materials, we will schedule something. Since I will be back on HT probably in mid-December, I will try and schedule late-January to late February.

Mel

two

Mel

TA:

That was my understanding. However, this was based on my initial consultation with him a year ago.

At this point, I am getting the materials to him. He wants to look at the actual disk/pictures before we make any definitive plans. I plan to have a further discussion with him.

Also, I asked him about how much time I would need to be in the area and he indicated 2 weeks. Not sure if that means anything in terms of tx. plans.

I need to talk with him regarding all of this. When I do, I'll report back.

Mel