SRT May be On The Horizon

To give some background... undetenctable for 2 years after RALP, then .02, .033, .033, .046, .06.
Positive margins on frozen section (during the surgery) so surgeon did further resection to obtain negative final margins.
My uro/Surgeon, Dr Tewari, told me last month, at PSA .06, that based on my pathology, combined with a low risk Decipher score of 37%. i should do nothing until and unless PSA gets to .2. At that time we would do imaging. (he mentioned Auxumin) If it showed nothing, he would even wait until .4 or .5 before taking action (not sure i would do that). He said he has seen many men go to .06, .08 even .1,or more, and not go any further. He said if there was a treatment with little potential for bad side effects, he would say treat, but SRT can have difficult SE's.

I went to see Zelefsky, RO at MSKCC in July when i was at .033. He stated that my negative margins are questionable, and he doesnt believe in waiting until PSA reaches some magic number. He said to continue following up with Tewari, and come back and see him if/when i see a clear trend. (which i think i have).

So i sent my last two PSA results to him, and today, i spoke with his Secretary, who discussed it with him (or his fellow, not sure). She told me that they said they want me to come in to discuss SRT (and to retest before i see him).

So here i am. I am really not wanting to treat, and especially nervous about overtreating, but i am afraid if i wait until .2 it might be too late for a cure. At age 67, i think i'm too young to just let it go.

I tend to have stomach problems anyway (like since surgery, when i have to go, i REALLY have to go) and im sure SRT will make it worse. Among other things.

No right answer, i realize, i guess its a question of how much risk i'm willing to take and WHAT risks i'm willing to take.

Anyway, comments welcome.

Treat at .06? With low risk genomics? and pretty good pathology, with (3+4)? really?

I think those factors give you pretty good assurance that it hasn't yet spread. You know what the data tell us. Let me ask you the question -- what indicator would make you comfortable that SRT is right for you? What would make you uncomfortable?

yes, you should decide to treat or not treat. I think that's a great course of action.

I'll have more helpful advice as the day progresses.

and there are worse things than sitting under a radiation beam, but sadly it won't give you x-ray vision or make you glow in the dark.

sigh, I was hoping for at least one ...

Andrew

Prat said...
First, regarding what the data tells us - this just confuses me even more because the data tells us, that >.03 indicates BCR is pretty much a foregone conclusion IN THE SETTING OF ADVERSE PATHOLOGY. But i don't really know, in view of my positive intra-operative margins, if my pathology is adverse or not.

There have been two studies dealing with two different situations. The Kang study dealt with the situation of adverse pathology:

/pcnrv.blogspot.com/2017/07/how-soon-after-surgery-should-salvage.html

The Koulikov study dealt with the situation of rising uPSA irrespective of pathology. They found that when uPSA was above 0.03 and was steadily rising, it usually predicted biochemical recurrence. They defined "steadily rising" as either two subsequent increases in PSA, and/or PSA velocity of 0.05 ng/ml/yr or greater.

/pcnrv.blogspot.com/2016/08/low-detectable-psa-after-prostatectomy.html

I agree that your pathology was not adverse, but you still fall into the risk group defined by the second study. As we've discussed before, the Koulikov study predicts biochemical recurrence within 7 years in 63% of patients who fall into your risk category. That means that 37% will get lucky. How lucky do you feel?

Did you ever find out what the Gleason score was on the frozen section with the positive margin?

Tall Allen said...


Did you ever find out what the Gleason score was on the frozen section with the positive margin?

As i mentioned in my second post in this thread, i am waiting to hear back from pathologist, but i did revisit the original pathology report and it looks like 2 frozen sections with positive margin, one at the posterior was a g6, the other at the apex was G7(3+4). If i am reading it correctly.

Re the data, yes, based on the second study, i have a 65% chance of TRUE BCR. How lucky do i feel, you ask? What a way to make a decision.

Thus, my confusion remains.

@Tall Allen....In your blog post on the Koulikov study, you state, near the very bottom, ....

There is an open controversy as to whether salvage radiation therapy, even if given after biochemical recurrence (a confirmed PSA ≥ 0.2 ng/ml), translates to a survival benefit. Fewer than a third of patients with a post-prostatectomy biochemical recurrence experienced systemic progression,


So i interpret this to mean, with an unstable psa, i have a 63% chance of getting to BCR, defined at .2. And even if i do, i have a 66% chance of never experiencing systemic progression.
Is this not a really good argument for not doing SRT?, unless i am misinterpreting it?

Also, in the study, unstable PSA is defined as a PSA >.03, followed by 2 consecutive rises. So if i consider .033 to be the same as .03, then my first PSA greater than .03 is .046, and i've had only one rise subsequently. Correct? And i dont have a rise of .05 in one year, i've gone from .02 to .06 in 15 months.
So if i am to follow the study, i need one more rise before pulling the trigger. If i am so inclined.

I want to be careful not to refrain from taking action (or taking action) based on what i WANT TO believe.

Post Edited (Pratoman) : 5/4/2018 1:00:13 PM (GMT-6)

Prato, I would agree about overtreatment but also think my 66% chance of no BCR for ten years seems like a good bet (of course I’m ten years older with worse pathology).

Maybe see if it levels off where it is or goes above .1? Wonder what Zelefsky would think about that. So many of the long-term studies predate ultrasensitive psa assays, which makes interpreting more of a challenge. For example isn’t “persistent” psa when the lowest measure was .1 different from “persistent” psa when the lowest measure is .01?

Prato, a thought on MSKCC: my question to RO was, “how about doing nothing?” His response was “doing nothing is always an option, but in YOUR case I wouldn’t recommend it.” My takeaway was that he is reflective rather than reflexive.

If there is a .63 probability of progressing to .2 PSA, and then a .34 probability of experiencing systemic progression, that leaves you with a .2 probability of systemic progression. To me, that seems like a high enough number that I would be willing to do a lot to avoid systemic progression, which I gather is very unpleasant. Unfortunately, even if you subject yourself to SRT, it does not reduce the .2 probability to zero. In may case, with worse pathology than you, the RO thought there was between a .2 and .5 probability of completely eliminating the cancer. So maybe the SRT would reduce the probability of systemic progression from .2 to .1. Of course there is a large error term associated with all of these estimates. This kind of analysis may not be very helpful.

Progressing, you make a good point about so many studies predating uPSA.

I’ll have a long list of questions when I meet with Dr Z on June 19th.

TA thnks for the additional comments, I wasn’t really sure about counting the PSA rises.
I read the additional blog study you posted about, I wouldn’t consider myself having adjuvant, after 3vyears, but it makes the point that sooner is better.
I’m obviously gonna make my own decision here, so don’t worry about appearing to convince me.at the end of the day it’s all me.
And my wife, i guess. She says wait , listen to Tewari. But she’s an ostrich, likes to put her head in the sand. Besides, she doesn’t read studies.

Do you think, if I decided to wait till .1 plus one more rise beyond that, it would elevate my risk? I’ll ask Zelefsky, but curious for your take. That last study seems to indicate that it would, saying that men who waited till a range of .1-.5 had a worse outcome.

Never dismiss a women's savvy if it opposes your own...An ostrich?...I think not...I could make a very convincing argument that it is you that is the ostrich...I would title it...Neuroses In The Sand......I know...I know...tough...

Pratoman said...
.... and much to think about.

...in Florida.





(You know I love ya bro)