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Salvage Therapy or Watchful Waiting?

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Posted 3/7/2018 4:53 PM (GMT 0)
This is my first post, I have watched the forum from afar. I have taken great encouragement and learnt a lot without contributing but now is my time to ask. My dilemma ….

Six years after radical prostatectomy (I was 48) my PSA has very slowly reached 0.094. In many respects the surgery was good with full erectile and urinary function. I have recently seen a RT oncologist who suggests 38 sessions of IGRT with Rapidarc equipment. The thinking is that there is a small amount of cancerous tissue in the prostate bed or lymph nodes and that the radiation will give me the cure I am after. With the very low level of PSA I currently have he does not think a scan PET/CT will show anything and thinks that the RT will allow me to see if the pC is local to my pelvis or has spread.

On the other hand i wrote to the surgeon who did the prostatectomy and he describes my PSA as relatively stable at 0.094. And adds that in patients who have erectile recovery it is not unusual to have these very, very low levels. He suggests I wait until my PSA rises to at least 0.3 before I have a PET/CT scan and go from there.

What do you all think …. Let the PSA rise more or get in quickly when outcomes are better?
Is there a question I should be asking my RT oncologist?
Many thanks.


My history is below.

DOB 8/1963
Feb 2012 PSA 6.2 --- Prostatectomy
Biopsy Gleason 3+3 stage pT2cNx one +ve margin - tumour 3% of prostate
PSA: 8/12 0.01, 8/13 0.02, 8/14 0.03, 12/14 0.06, 12/15 0.05, 5/16 0.06, 5/17 0.06 10/17 0.08, 2/18 0.09

Post Edited (Philip B) : 3/7/2018 9:58:16 AM (GMT-7)

Posted 3/7/2018 5:03 PM (GMT 0)
My surgeon also said for me to wait, I forced the issue at 0.20. I wanted to do it earlier but could not catch the Doctor running down the hall. Studies show starting below .2 you can get as much as 4x better results.
Posted 3/7/2018 5:29 PM (GMT 0)
Welcome to HW.

A scan at this PSA isn't going to show anything.

That still not much PSA and you've got a low risk factor.

I am not sure I'd be rushing for more treatment, but there are worse things than SRT.

Hang in there and keep us updated on your progress,
Andrew
Posted 3/7/2018 8:03 PM (GMT 0)
What was your post surgery pathology? I think your sig says you had a positive margin...was the margin a G6?

If your post-surgical pathology was good, I'd considering moving slowly if at all. If it wasn't as good, then perhaps faster.
Posted 3/7/2018 8:34 PM (GMT 0)
Philip, same question about pathology.

We are on similar tracks although my psa has popped with no apparent reason. Doc has ordered path review and decipher and I will meet with him within month.

Interested in your journey. Perhaps order a decipher test to get a sense of the risk of waiting?

My instinct is to go with early SRT considering our ages.
Posted 3/8/2018 2:52 AM (GMT 0)
I would wait as you have a low level and at Gleason 6 your long term outcome is excellent even if you wait until .3. That said I had salvage and it was a breeze - some rectal sx and I worked and went to the gym the whole time. No significant effect on erections - Levitra still works two years later- maybe down 10%. My urologist said that if you go into salvage with ED under control you will do OK.
Posted 3/8/2018 3:24 AM (GMT 0)
Same question what was your pathology Gleason score? And how big was your positive margin, and the Gleason score at the margin? Did you ever get a Decipher test? If not, consider it if your insurance will cover it.

The fairly steady upward trend is still slow, so something is growing but not metastasizing yet.
Posted 3/8/2018 3:57 AM (GMT 0)
Thanks everyone - this is what we do and it is great to have the engagement and support.

My prostate pathology was as follows. Gleason 3+3 bilaterally but mainly in the right about 3% by volume. Circumferential margin positive over 3mm. Perineural invasion Present. Vascular/lymphatic invasion Negative - seminal vesicles negative and extraprostatic extension negative. It will not be possible for me to get the Decipher test.

Treating prostate cancer seems to involve more choices at every stage than any other thing in life!

In short, it seems that my PSA is rising slowly and at some point in the next 12 months I will hit the 0.2 line - even with my pathology I think the sooner I can start SRT the better. Given my age and current good health and no ED I think I am also prepared - no major flaws in my thinking?. I appreciate there are long term SE with IGRT but hopefully minimal - that seems to be what I am hearing?
Side effect and fatigue how bad? Thanks

Philip

-------------------------------
DOB 8/1963
Feb 2012 PSA 6.2 --- Prostatectomy
Biopsy Gleason 3+3 stage pT2cNx one +ve margin - tumour 3% of prostate
PSA: 8/12 0.01, 8/13 0.02, 8/14 0.03, 12/14 0.06, 12/15 0.05, 5/16 0.06, 5/17 0.06 10/17 0.08, 2/18 0.09

Post Edited (Philip B) : 3/7/2018 9:13:13 PM (GMT-7)

Posted 3/8/2018 4:18 AM (GMT 0)
Everyone responses differently. Some get hard with fatigue while others don't get it at all. Exercise during treatment seems to reduce fatigue. Bowel issues are possible. My hemorrhoid went from a little annoying to nearly unbearable. Urgency can be a problem.

Post treatment, I have some ED, urgency can be a problem at times, and I've had radiation proctitis which required treatment a few years after my IMRT. While all of this is manageable, it's best to avoid if possible.

What you do is your choice - just understand the risks you're taking.

Andrew
Posted 3/8/2018 6:02 AM (GMT 0)
There is nothing magic about 0.2 - it's an imaginary and not very useful line in the sand.

With a GS6, the SRT decision is more difficult. It is likely that a bit of GS6 was left behind - but does that mean it needs treatment? Most men with GS6 can live out their lives without needing treatment.
Here are some things to consider:

/pcnrv.blogspot.com/2017/11/myth-gleason-6-never-progresses.html
Posted 3/8/2018 10:10 AM (GMT 0)
I have no idea whether you need treatment or not. However, consider that if you do opt for RT the docs in all likelihood will not use ADT in conjunction.
Posted 3/8/2018 12:53 PM (GMT 0)

Philip B said...
On the other hand i wrote to the surgeon who did the prostatectomy and he describes my PSA as relatively stable at 0.094. And adds that in patients who have erectile recovery it is not unusual to have these very, very low levels.

Have not heard about ED recovery being linked to uPSA scores. If so, wonder what the underlying biological mechanism is for that. Did your doc mention anything else regarding this topic? It would help me to know.

Best wishes in your decision. You are right that there are so many choices -- medical opinions --, and not a lot of definitive research to guide us. Or at least not definitive enough for an individual case. Each guy's docs have different slants on things. Boy, u don't have to read many posts here for that to sink in.

Robert
Posted 3/8/2018 1:53 PM (GMT 0)
Robert - thanks for your support. My surgeon has made this comment since my numbers moved off the 0.02 level and at the time back in 2013 he linked it to the nerve sparing surgery and my very good ED recovery. His comment was that in my circumstances this was quite common but no mechanism was mentioned.

https://www.birminghamprostateclinic.co.uk/our-team/mr-alan-doherty/
Posted 3/8/2018 5:41 PM (GMT 0)
I think he just meant that with nerve sparing, there's more of a danger that small amounts of cancer were left behind.
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