Conflicting advice

I've been getting conflicting advice from doctors on whether I should get radiation treatment soon, or wait until a possible rise in PSA. I'd like to read the most relevant medical literature on the question of waiting, or not.

Background: I had RRP in September. The pathology showed a G7 (3+4), seminal vesicle involvement, a 9mm positive surgical margin (mid-posterior), and ECE. Not good, I realize.

My first post-surgical PSA was <.008, and the second was .01. Since the surgery I've had some complications with urination and have had a catheter in quite bit, so radiation now is out of the question. But a doctor I saw today said he would advise that when the urinary issues are resolved, he would advise that I begin radiation. Other doctors have said there is little or no harm in waiting until, or if, PSA rises, before initiating RT.

My question is this: what are the best studies out there that bear on this question? I'd like to read them myself before I reach a decision.

One I've read is: "Usefulness of ultra-sensitive prostate-specific antigen following radical prostatectomy," by NOBUKI FURUBAYASHI et al, which contends that if PSA reaches a nadir of <.008, then the chances of recurrence are low, even in the presence of adverse findings such as positive margins. But it is based on only 200-300 cases.

What else is there? What are the best, most definitive studies on the question of waiting or not?

Many thanks to you all!!

FC

^^ one more vote to start hormone therapy ^^

Thanks for the responses. I've been looking at the studies that TA cites. In particular there are two randomized, controlled studies of wait-and-see vs adjuvant radiation therapy, and both find benefit in beginning RT prior to BCR. The weakness I see in them is that they both use the threshold of .2 PSA as the trigger to initiate RT in the wait-and-see group. I would not wait that long, and if I adopt wait-and-see I would wait only until PSA reaches .03, as TA suggests. I wonder if there are studies underway to investigate the merits of adjuvant RT vs. waiting until .03.

Any thoughts on specific triggers for starting ADT? I was hoping to wait until a PSA rise, so I'm interested that some of you think I should start now.

fiddlecanoe,
like Tall Allen says nothing in this world of PCa is black and white.
I do like to play with numbers though.
The two results you have, being ultrasensitve can have a small margin of error, perhaps 10%. This could mean that your <.008 may actually be .009 if an error was one way while your .01, if the error was the other way, could also actually be .009. So there may not have been a change in PSA at all. That is why it is best to see additional tests before making a major decision.
On the other hand if the results were dead on the money, this doubling time calculator:

www.doubling-time.com/compute-PSA-doubling-time.php

suggests, if something was going on, your PSA could possibly hit .03 about mid February. If your PSA at that time was in the region of <.008 to .01 I would be doing the

I did say I like to play with numbers

That's even better. Not knowing the actual dates I used a minimum time period (end of Oct to start Dec) as a rough calculation. It is really important to use the same assay by the same lab for the comparisons to be valid. Enjoy Prague.

Tall Allen may be right that ADT would keep the cancer from spreading while you're waiting for your urinary tract to heal. I am curious whether this is a hunch or a phenomenon that has been studied and proved. In the runup to my first appointment to discuss SRT with an RO in November, I tried to figure this out and didn't get too far. When I met with the RO, he did not recommend ADT even though it would take 6 weeks before I could start SRT (this could have been pushed out to 8 weeks to accommodate standard lead time between ADT and SRT).

In recommending against ADT, my RO cited then unpublished results from a phase III study with 800 patients, half of whom got two years of hormone therapy with their SRT and half of whom did not. The patients had PSAs of 0.2 to 4.0; the study began before the arrival of ultrasensitive PSA tests. The results showed that the addition of two years of anti-androgen therapy improved overall survival at 10 years by about 4 percent from 89% to 93%. But the benefits were not evenly distributed throughout the patient population. Those who actually benefited were patients with higher PSAs, patients with Gleason scores 8-10, and patients with positive surgical margins. Your PSA is still quite low and your Gleason score is a low 7 (3+4 rather than 4+3) but you do have positive surgical margins so my RO might recommend ADT to you even if he thought the probable benefits were outweighed by the risk of side effects for me. I didn't have ECE, SVI, or positive margins. As TA suggests, lots to discuss with your RO.

fiddlecanoe,

I'm also 3+4, so I tend to look at the world through that lens, but, unlike your pathology report, mine didn't show seminal vesicle involvement, positive surgical margins, and ECE.

The American Society for Radiation Oncology (ASTRO) and the American Urological Association (AUA) have published guidelines that suggest you may be a candidate for adjuvant radiotherapy, i.e., that you should go ahead with RT without waiting for a rise in PSA to 0.03 or some other trigger:

"Guideline Statement 2. Patients with adverse pathologic findings including seminal vesicle invasion, positive surgical margins, and extraprostatic extension should be informed that adjuvant radiotherapy, compared to radical prostatectomy only, reduces the risk of biochemical (PSA) recurrence, local recurrence, and clinical progression of cancer. They should also be informed that the impact of adjuvant radiotherapy on subsequent metastases and overall survival is less clear; one of two randomized controlled trials that addressed these outcomes indicated a benefit but the other trial did not demonstrate a benefit. However, the other trial was not powered to test the benefit regarding metastases and overall survival. (Clinical Principle)

"Guideline Statement 3. Physicians should offer adjuvant radiotherapy to patients with adverse pathologic findings at prostatectomy including seminal vesicle invasion, positive surgical margins, or extraprostatic extension because of demonstrated reductions in biochemical recurrence, local recurrence, and clinical progression. (Standard; Evidence Strength: Grade A)"

Grade A evidence strength means that the guideline statement is very well supported. If you want to see the documentation, it's here.

I had a mental block on thinking of spread as an issue in the context of your Gleason 3+4 and PSA of 0.01 (at UCSF, your PSA would still read <0.015 and you'd be sitting pretty). But, if adjuvant radiation is appropriate, and you need time for your urinary tract to heal, the suggestion of getting started with ADT may be a good one both to prevent spread while you heal and to enhance the effectiveness of the radiation. The latter may be more important than the former. As always, the benefits and risks of each therapy have to be weighed.

I'm not sure how this fits in with your plan to spend four months in Czech. Perhaps it doesn't.

If I'm pointing you in the wrong direction, hopefully Tall Allen will come to the rescue.

Tomson