Skip whole pelvic SRT and just deal with (oligo) mets using focal therapies?

Had my annual visit with uro Fri. Interesting thoughts from him on future treatment approach, if needed.

You can see my general history in signature. Basically, had 2012 RALP, went five years uPSA undetectable. Then, in early 2017, saw uPSA mid .020s and rising very, very slowly to .040 area now. So doubling time is multi-years, at least for now.

He said I could just come back in a year and scripted me a standard PSA for that visit.

He said mine could just be an indolent case that will never need more treatment before something else gets me (age 70 now).

BUT, and this was most surprising...

Said if my PSA does start heading up, he recommends just waiting for it to hit .4 or .5. Said the field is moving away from the "scattergun" SRT approach after BCR, because there is no way to know where to aim for sure -- the scans aren't really reliable enough until .4 or .5. Then, I could have focal therapies as needed to deal with known mets. Like surgical removal of a hot lymph node(s). Or spot radiation of a rib. And so on. Plus ADT if needed to suppress micromets.

He thinks the scans will improve over the coming years, and this approach avoids potential side-effects from early whole pelvic SRT radiation, when there is no good target for sure.

Sure wasn't expecting this approach. Guys on here treated at major institutions seem to be advised to go for adjunct or early salvage SRT, I guess with the idea of "hit it hard with everything". I was planning to go for SRT at some place like MDA if I got uPSA trend going above .1 and heading for .2, but now I will start researching uro's advice. He does attend all the AUA and ASCO conferences, etc., and was trained at City of Hope. So I guess I will give his recommendations some thought. Sure wasn't expecting that, though.

On the other hand, I did have one margin+, confirmed by Epstein to be 3+3=6. So I think my prostate bed would be a likely source of a real recurrence, if my uPSA does head up. So whole pelvic might be a last cure chance for me, right?

Any thoughts or data welcome.

Robert

You seem to be at really low numbers which is good and your pathology was good except for the positive margin. There is a gross statistical advantage to ART and early SRT but there is also the possibility of over-treating when there is no real problem or the problem is elsewhere and having the radiation side effect potential for the heck of it.

The odds of recurrence for your G6 situation are pretty low so hard to rationalize doing much at 0.03-0.04. I would think that at 0.10, you will have to be giving it some hard thought. Plenty of time to see a RO and anyone else you want to get more opinions. The low level PSA could be coming from a small amount of benign tissue left behind that is just enough to show up in the ultra sensitive testing or could be something else, no way to know now. The same statistics indicate that waiting until 0.50 is not the best idea either so you will have to weigh all the opinions and factors while asking lots of questions to get comfortable with your decision at some point. That’s all I can think of on Sunday evening.

A Radiation Oncologist's job is to eliminate cancer. End of story.

I've been to two. Both with different opinions.

the only thing they *all* agree on is, .2

I met someone receiving SRT at the same time as me that was G6, PSA of 0.5, and had positive margins. The RO explained that someone with his pathology had a low chance of becoming metastatic (due to G6), and with positive margins he likely had continued growth at that spot. That person was seen as low risk.

At the same time, the RO/MO team would recommend treatment at much lower PSA levels (e.g. 0.05) for someone with an adverse or high-risk pathology.

Cary1963 said...
I met someone receiving SRT at the same time as me that was G6, PSA of 0.5, and had positive margins. The RO explained that someone with his pathology had a low chance of becoming metastatic (due to G6), and with positive margins he likely had continued growth at that spot. That person was seen as low risk.

At the same time, the RO/MO team would recommend treatment at much lower PSA levels (e.g. 0.05) for someone with an adverse or high-risk pathology.

then why was he receiving SRT? to increase his chances of permanent SEs?

Interesting...I'm also in a similar situation.

Surgery, then immediate PSA return up to 0.54 within four months. 39 SRT sessions, for a total of 70.2 Gy, to my prostate caviety. A one inch tumor had been identified via PET scan on my cavity wall. For the last year and a half, since SRT, a slow and constant rise 0.116. Next uPSA test in January. Hoping it will level off.

RO is a minimalist which, for the time being, I agree with.

Good luck to you!

Thanks to all for responses. Wanted to mention that I have my first endocrinologist appt. mid-Jan. This is mainly to discuss my ongoing low free-T/low DHT/high estradiol, whether I was on or off TRT. Maybe she can give me something like Clomid or Arimidex to slow my aromatase process, so I can keep more of the T I produce naturally, though it is on the lower part of the total T range. She may also know something about my uPSA trend and give advice. My uro was good on helping me with TRT (androgel, then later T-cyp injections), but he never seemed interested in monitoring anything but total T. I think there may be other ways to crack the egg. Will post again after that meeting.


F8: yes, I will definitely get other medical opinions before biting off on any other strategy.

Mumbo: yeah, .5 seems a little high to be waiting—I think the uro meant that with my slow doubling time, the nuclear scans will have improved enough before I get to that level that I can do something before the horses get out of the corral, yet wait long enough that we know what we are aiming at.

island time: thanks for the perspective, since your case is so similar to mine.

mattam: yep, avoiding ADT is a key goal for me; also, agree that cells escaping is a real concern.

Cary1963: yes, so glad I got my 2nd opinion from Epstein, including the 3+3 ruling on the one + margin, since my original path did not state gleason at the margin.

garyi: didn’t understand this—did they say you were organ confined, THEN they found a 1” at apex that they had missed; or were they telling you it grew in that apex area after the prostate was out; I have read that the prostate wall at apex is kinda undefined…

.....

Busby2 and all others: following is some information I have run across after starting to research this a bit..

(1) https://www.cancernetwork.com/prostate-cancer/metastasis-directed-therapy-prostate-cancer-why-when-and-how

I think this “Metastasis Directed Therapy” is what my uro was talking about, though he didn’t use that phrase. In the above link, the authors make the points that SABR (stereotactic ablative radiotherapy) is well tolerated, may avoid ADT, and is (surprise) potentially curative.


(2) In the following from American Cancer Society

https://www.cancer.org/cancer/prostate-cancer/treating/recurrence.html#references

“Sometimes it might not be clear exactly where the remaining cancer is in the body. If the only sign of cancer recurrence is a rising PSA level (as opposed to the cancer being seen on imaging tests), another option for some men might be active surveillance instead of active treatment. Prostate cancer often grows slowly, so even if it does come back, it might not cause problems for many years, at which time further treatment could then be considered.

Factors such as how quickly the PSA is going up and the original Gleason score of the cancer can help predict how soon the cancer might show up in distant parts of the body and cause problems. If the PSA is going up very quickly, some doctors might recommend that you start treatment even before the cancer can be seen on tests or causes symptoms.

Observation might be a more appealing option to certain groups of men, such as those who are older and in whom the PSA level is rising slowly. Still, not all men might be comfortable with this approach.“


(3) This article talks around about these topics – I need to wade through this again

https://ascopubs.org/doi/full/10.1200/edbk_239041


Robert

I am in the same boat but younger with lower uPSA for now.

My post was

Any advice, opinion or insight would be greatly appreciated

Questions regarding the when(s), how and where(s) of SRT as my uPSA levels have started to rise post-op RP after 2 years.

A big issue is finding the right health insurance plan in case I need treatment in the coming year which is the issue for guys under 65 and medicare. This means I need to know a few options going forward and if the health insurance plan covers them. Hoping for no treatment in the coming year.

A friend of mine just got treated at Stanford with ADT then SRT with a post-op RP uPSA level of 0.05 after 4 years. Blind shotgun prostate bed and lymph node radiation since nothing showed on MRI imaging.

Is blind shotgun radiation preferred over waiting for higher PSA levels, positive imaging locations and targeted radiation?

My uPSA was first detectable at 17 months (with b vitamin supplements being used).

These b vitamin supplements were subsequently eliminated with uPSA being detected again at 26 months post-op RP

I am 60 years old

Ultrasensitive PSA test results - 17 months clean post op RP until positive at 22 months

Radical Prostatectomy 11/19/2015 with Gleason 3+4 at age 56

uPSA test result history

12/20/19 12/13/19 12/6/19 12/4/19 7/15/19
0.010 0.012 0.011 0.011 <0.006

4/3/19 11/29/18 11/16/18 9/21/18 7/16/18 4/30/18
0.008 0.007 0.009 0.007 0.007 <0.006

2/24/18 1/8/18 11/14/17 10/11/17 9/16/17 9/15/17
<0.006 0.008 <0.006 <0.006 0.009 0.010

6/5/17 3/3/17 12/1/16 8/29/16 5/4/16 1/14/15
<0.006 <0.015 <0.015 <0.015 <0.015 <0.02


my medical history is as follows

Genomic Health Decipher test score 0.22 below-average risk, 0 to 1 scale

Genomic Health Decipher test predicts metastasis risk and longevity for 5, 7 and 10 years out.

11/19/2015 Radical Prostatectomy UCSF Dr Peter Carroll da Vinci robotic surgery

Synoptic Comment for Prostate Tumors
- Type of tumor: Small acinar adenocarcinoma.
- location of tumor: Single tumor. Left posterolateral midgland and base (1.2 cc; slides B10-12).
- Estimated volume of tumor: 1.2 cc.
- Gleason score: 3+4=7; primary pattern 3, secondary pattern 4.
- Estimated volume > Gleason pattern 3: 10%.
- Involvement of capsule: Tumor invades capsule: left posterior midgland (slides B10, B11).
- Extraprostatic extension: None.
- Margin status for tumor: No tumor at ink, but tumor into capsule is less than 0.1 mm from ink; slide B11.
- Margin status for benign prostate glands: No benign glands present at inked excision margins.
- High-grade prostatic intraepithelial neoplasia (HGPIN): Present, extensive.
- Tumor involvement of seminal vesicle: No tumor.
- Perineural infiltration: Present.
- Lymphovascular invasion: None.
- Lymph node status: Negative; total number of nodes examined: 1.
- AJCC/UICC stage: pT2aN0.

Johns Hopkins (Epstein) pathology 10/13/2015
Gleason Score: 3+4=7
Left Base
2 cores (60% + 20%) (30% Gleason pattern 4)

Kaiser pathology, 9/1/2015
STAGE: T1c
Gleason Score: 3+4=7
NUMBER CORES INVOLVED/TOTAL NUMBER CORES: 2 / 14
TOTAL CARCINOMA LENGTH: 10 mm
PSA 3.2 6/10/2014
PSA 4.8 6/8/2015
PSA 4.4 8/10/2015 (free PSA 7%)
PSA 5.0 9/28/2015 (free PSA 8%)

A) PROSTATE, RIGHT APEX, NEEDLE BIOPSY
-- ATYPICAL SMALL ACINAR PROLIFERATION
-- TOTAL SPECIMEN LENGTH, 44 MM

B) PROSTATE, RIGHT MID, NEEDLE BIOPSY
-- FOCAL HIGH GRADE PROSTATIC INTRAEPITHELIAL
NEOPLASIA
-- TOTAL SPECIMEN LENGTH, 30 MM

C) PROSTATE, RIGHT BASE, NEEDLE BIOPSY
-- FOCAL HIGH GRADE PROSTATIC INTRAEPITHELIAL NEOPLASIA
-- TOTAL SPECIMEN LENGTH, 23 MM

D) PROSTATE, LEFT APEX, NEEDLE BIOPSY
-- BENIGN PROSTATIC GLANDS AND STROMA, 43 MM

E) PROSTATE, LEFT MID, NEEDLE BIOPSY
-- BENIGN PROSTATIC GLANDS AND STROMA, 22 MM

F) PROSTATE, LEFT BASE
ADENOCARCINOMA, GLEASON GRADE 3+4 = 7
ADENOCARCINOMA INVOLVES 2 OF 2 CORES AND 10 MM OF 30 MM

The first involved core from the left base contains 3 mm of Gleason grade 3+3=6 adenocarcinoma and the adenocarcinoma is located 6 mm from the presumed peripheral edge (see note).
The total core length is 17 mm.

The second involved core from the left base contains 7 mm of adenocarcinoma. Greater than 6 mm of the adenocarcinoma is Gleason grade 3 and less than 1 mm is Gleason grade 4. The Gleason grade 4
adenocarcinoma is located approximately 2 mm from the presumed peripheral edge (see note).
The total core length is 13 mm.

NO PERINEURAL INVASION IDENTIFIED