New Study: Adjuvant Radiation Saves Lives vs. Salvage

This was a major retrospective study among post-prostatectomy patients with adverse pathology at 10 top institutions. It's about the best any retrospective study can do when prospective randomized clinical trials are not available. They found that in men with adverse pathology, adjuvant radiation led to less biochemical failure, less incidence of metastases, and better overall survival compared to salvage radiation. They defined salvage radiation (SRT) as radiation given when the PSA was in the 0.1-0.5 range. They couldn't address with this dataset what I would call "early salvage" (ultrasensitive PSA under 0.1).

/pcnrv.blogspot.com/2018/01/new-study-adjuvant-radiation-saves.html

Read the caveats at the end carefully.

Thanks Allen for posting this. Reniforces my belief that ART is what we persisters need.

Still waiting four days after second post-surgery persistent psa to hear from the surgeon.

And after thinking some more, my plan now is to accept the cost of an apartment in the City and try to get Dr. Zelefsky to do the ART. Hoping that I can get an appointment with him soon — based on the two post-surgery readings my PSADT is 10 months, meaning it would hit 0.2 in October, by when I would hope to have finished ART. For now if I don’t hear from the surgeon tomorrow I will contact Dr. Zelefsky directly.

Rob,

if you have positive margins, the recurrence is mostly located in the prostate bed and the radiation of the prostate bed will treat that. In case of negative margins chances are that there are affected lymph nodes and radiating just the prostate bed will not help much.

George

Saipan said...
How is the tipping point for losing the advantage determined to be at 56%? Practically speaking, how does one use this information as a patient having to decide when to pull the trigger on RT? (I hope those questions make sense.)

It's a very good question. It's explained in the full text. They did what is called a "sensitivity analysis" where they looked at only the records of those patients who received ART, but might have been cured by their surgery alone. Patients with GS 6 were only a small fraction of these patients, and GS 8-10 patients were highly likely to progress. That leaves GS 7s as the equivocal group. they were 57% of all patients in the study and they typically break about 2/3 GS 3+4 and about 1/3 GS 4+3. They looked at their nomogram-predicted cure rates vs the actual results. They found that ART would only lose its advantage if 56% were overtreated, but the nomogram-predicted overtreatment rate was only 46%. So on the whole, ART outcomes exceeded SRT even considering overtreatment. The whole does not necessarily predict for the individual, however, and each patient must look at his individual characteristics.

Roblee-

While a positive margin is a risk for recurrence, it is also prognostic that SRT will work. That's because you have a really good clue that the cancer is still local. If they can't find a large enough tumor, the cancer might be micrometastatic and/or systemic.

Sorry, that should be “good” conversation.

This study fit my situation after my RALP. My first psa returned as <.05, but my urologist kept insisting on me seeing a RO. I didn't need to see a RO as my PSA party was just beginning. Heck, it's undetectable and I'm almost convinced I've been cured. He kept mentioning data out there to support ART with my adverse pathology report. After some convincing, I reluctantly agreed to see a RO and it was that moment I saw relief in my urologist's eyes. He genuinely cared about me as a patient, person, father to an eleven year old, and a husband to my wife. However, I was still going to put up a fight with the RO since my PSA is undetectable, but in the end I did find myself fully committed to ART. The hardest part of the ART journey was not knowing if I was being overtreated, what side affects will I have, and the daily committment till treatment is over. Looking back, I still don't have all the answers, but pray I have beaten this disease so one day I can grow old and possibly walk my daughter down the isle. I am by no means advocating any type of treatment for anyone. This was my journey and the decisions came very difficult to make just as you guys will experience. What ever you guys decide about ART, god bless & best of luck.

When I had my surgery in February of 2007, I had a bad enough post op pathology and went searching out the next steps. My PSA at the time of surgery was 20, by post op pathology was bilateral seminal vesicle invasion stage pT3b. My Gleason was 4+3=7. Positive margins as well.

After reviewing a possible clinical trial and also reading information out of Harvard and Stanford that guys like me were doing better with adjuvant therapies. My PSA did drop out to >0.1 from the surgery alone but at age 44 I wasn't thrilled with the nomograms and tables on recurrence. So we started ADT for two years and I started IMRT radiation all within 4 months of treatment.

I lucked out and never had a rise in PSA. I go in for my 11th year tests in a couple weeks. I haven't had a PSA test in two years but they've stayed good for me. After all these years I function well and live a cancer free life.

I will never know if the adjuvant therapies helped me. I suspect they did. To date I do not feel there are any side effects worth mentioning. I still have low T levels (below 250 ng/dl) but I get along fine.

I was one of the first to go this rout and I didn't know anyone here at HW at the time in 2006/07 that went that rout prior to me doing so. But I know a few that followed my path and they all seemed to do well.

TA,
I’ve seen very few cases who chose surgery on this board that were stage T2c and no adverse path who have not had BCR - most had BCR after than 2 years and in some more than 5 years and a few after 7 years. So my assumption is BCR is going to happen eventually to me and what you shared shows it’s better to go with ART now than to eventually wait for Salvage , shouldn’t a patient be given the option to get ARt done. I am ok to deal with SEs related to ART than deal with BCR.

Roger that Saipan. The only consolation if it is one is that we know we have recurrence now, rather than seeing a rising psa after the post-RT nadir, which may mean that we’ll get adjuvant rather than salvage second treatments. Still sucks.
“i can get it all,” said the surgeon, and then, “I got it all,” without saying in either case that there might be cancer lurking somewhere. In my case the tumor was on one side only, no multicentricity, and the fat adjacent on that side was also benign. Hope that doesn’t mean it’s migrated so that RT would be useless, but it appears there’s no way to know at psa level of 0.11.

ddyss said...
I’ve seen very few cases who chose surgery on this board that were stage T2c and no adverse path who have not had BCR - most had BCR after than 2 years and in some more than 5 years and a few after 7 years.

That's a big problem with boards like this. Many of us come here because there is a problem, and the ones who have no problem don't come here. So we get a very slanted pictures of the real probability of progression. In the new AJCC staging system that went into effect starting this month, there is no such thing as pathological stage T2c. One has cancer either confined to prostate (pT2) or not. They got rid of the subcategories because statistics showed that it really didn't matter if it was on one side or both sides, only that it was contained.

To understand your real statistical probability of a recurrence, you'll want to look at a nomogram based on the experience of thousands of men. The best one I know is the MSK nomogram (you will notice that it doesn't even ask for the stage T2 subcategories - they are irrelevant to prognosis):

/www.mskcc.org/nomograms/prostate/post_op

I think you'll see that your probability of recurrence is very low. Out there in the real world, most men with your diagnosis never need any additional treatment. It's certainly safe for you to just monitor uPSA occasionally.

Thanks ddyss, for your kind words.
And Tall Allen also — for the depth of your understanding of prostate cancer and those who have it.

Great to hear, Saipan. You had posted something earlier about knowing when you would find the right RO for you and how important that is. As many people have counselled me, now relax and go for it!