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Adjunctive vs salvage RT for high risk PCa

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Posted 6/28/2021 6:26 PM (GMT 0)
New research indicate that men with positive pelvic lymph nodes or a prostatectomy Gleason score of 8 to 10 with disease extending beyond the prostate may benefit most from adjuvant radiation therapy

https://www.cancernetwork.com/view/adjuvant-radiation-therapy-may-yield-a-significant-reduction-in-all-cause-mortality-in-high-risk-prostate-cancer-vs-salvage

Thought? Comments?
My hubby already states he does not want to do RT because of additional SE. BUT...when it's curing or prolonging life, isn't it worth it?

Sorry guys,
I do not know how to make this a clickable link.
Posted 6/28/2021 6:53 PM (GMT 0)
This is the news story that Bweaver cites.

This is the study that the story discusses:

Adjuvant Versus Early Salvage Radiation Therapy for Men at High Risk for Recurrence Following Radical Prostatectomy for Prostate Cancer and the Risk of Death

Anthony D'Amico is a co-author. He and and others have been advocating for a few years now that: high Gleason/high risk men who have (1) even on adverse finding in their post-RP path report or (2) have persistent PSA after surgery should be advised that they need adjuvant therapy to complete their primary treatment.

The dverse findings D'Amico has cited in his studies are :

Lymph node invasion
Positive surgical margin(s) or bladder neck invasion
Seminal vesicle invasion
Extraprostatic extension.

Results of three recent studies designed to look at adjuvant vs early salvage therapy appear to have concluded that early salvage works just as well as adjuvant; however, this is for low- and intermediate-risk men. The big advantage to early salvage for these risk groups is that will cut down on the many men for whom adjuvant therapy would be overtreatment.

From the Full Text of this recent paper:

"Relevance

"Three randomized trials and an associated meta-analysis found no difference in progression-free survival when comparing adjuvant with early sRT, which can cause many physicians to not offer adjuvant radiation therapy, irrespective of the pathologic findings at RP. We provide evidence to support that adjuvant compared with early sRT may lower the risk of death in men with adverse pathology at RP."

Unfortunately, many fewer men high-risk men who, by the above criteria would benefit from it are getting actually getting it. Previously D'Amico stated the advisability of adjuvant therapy for Gleason 9-10 men with at least one adverse findings. In this paper he and his co-authors extend it to Gleason 8.

Djin
Posted 6/28/2021 7:01 PM (GMT 0)
I started with radiation--not surgery--so I was never in the shoes of a high-risk person that failed surgery. But I'd certainly do SRT if faced that situation and I'd assume most guys would since the alternative isn't great. But clearly, it's a very personal decision and it would also likely involve ADT, which many guys would prefer to avoid. (ADT is not fun, but it's doable.)

I see your husband had a positive margin, but I didn't see anything about a positive lymph node. If that's the case is your game plan to wait and see what his first PSA says?
Posted 6/28/2021 7:13 PM (GMT 0)
BWeaver, I would note that your husband is not in the group discussed in the study. He is G7 (4+3); the study was with G8-10 men.

You should update your signature to include his post-op PSA results. They are most important now! Your husband should be getting an ultrasensitive PSA test, BTW.

Opinions may vary among docs regarding adjuvant vs very early salvage therapy in your husband's case. If he doesn't opt for adjuvant, then you'll probably be paying very close attention to his PSA numbers and rate of climb, if any, to decide on a RT "trigger point." The path exam found that his PCa was 75% pattern 4 with significant SM+/EPE+.

You might also consider and ask his docs about a Decipher test on his RP tissue to determine the 5-year risk of mets. If this were me, and it came back high-risk, I'd opt for adjuvant RT if I were otherwise on the fence.

IMO, it would be prudent to meet with an RO now for an opinion as to adjuvant vs very early salvage, and, if the latter, at what are the deciding criteria? Having a treatment plan ready is would be prudent and may contribute to peace of mind.

Djin
Posted 6/28/2021 7:46 PM (GMT 0)
Michael T-thankfully no positive lymph nodes
Djin-I think I've updated the signature now 🤞 if it doesn't show, his post op PSA 0.06 at 26 days post op (very early test for some reason)
He was originally dx as G8, so my eye still catches on articles related to that. Very thankful he was down graded in his post op path.
Thank you for posting the clickable link and summary!
Posted 6/28/2021 7:56 PM (GMT 0)
Signature update worked, thanks!

Yes, I now remember that early PSA score now. I realized your hubby wants this to be over, but at any consult, the docs will be looking at what they feel give him these best chances for a great future. My layman's guess is that if his PSA remains basically the same, you'll be hearing more consult votes for adjuvant after a healing period than for waiting and doing very early salvage.

You have time to watch and see what happens in the next few months. I would think that if his PSA is actually 0.06, it may start to rise fairly soon.

All the best,

Djin
Posted 6/28/2021 8:14 PM (GMT 0)
BW - Been there, done that, since I was 4+3 (tert 5) with margin and EPE after surgery. The two items I did after surgery was 1) obtain a second opinion on the pathology from Dr. Epstein's group and 2) obtain Decipher genomic testing on the prostate cancer tissue. Epstein rounded me up to 4+5 calling the Grade 5 more than 5% which was not good and Decipher provided good results but still in the intermediate category. My first PSA at three months post-op was <0.10 which was good so that did not help make a decision for me.

Took a lot of study and thinking to make a decision after discussing with Uro and RO. It was Dr. Epstein that probably pushed me over the edge due to his comments.

All advised me that the choice was mine and that it is best to be fully healed up and past any continence and/or ED issues since adjuvant RT tends to stop progress on those items. My continence was fine early on but no progress on the ED front so I waited a little longer and finally said at age 67, I would rather significantly improve my odds than worry about the sex part. My wife, a cancer survivor, agreed with me 100% and said no big deal with the ED so get it done if it provides the best results

The rest is history. Only had minor side effects from the radiation and nothing long term to date. ED is still an issue after a couple of years but it seems to have little to do with married life now. Not sure what I would do at age 49 so he will just have to work through it after collecting all the information that helps make these decisions and I hope his three month PSA is <0.10 so he has time to fully evaluate options.
Posted 6/28/2021 11:11 PM (GMT 0)
BW,

As you think about options there is some research that indicates 6 months of hormone therapy in addition to the radiation has advantages.

https://www.medpagetoday.com/meetingcoverage/astro/75858

My radiation oncologist at Fox Chase Cancer Center (Dr Horwitz, quoted in the article) was pretty passionate about the use of hormones in addition to the radiation.

The big decisions that will need to be made are:
1) When to pull the trigger on the treatment (what psa level)
2) What to radiate (just the “fossa” or the entire pelvic area)
3) How long to use hormone therapy

I pulled the trigger at 0.10
Just the fossa.
6 months hormone therapy.

The advice on healing up is relevant. I am still dealing with incontinence issues and ED coming on 2 years after the initial surgery. I didnt want to wait.

After the above, I was non detect for about 12 months but recently became detectable but still less than 0.2 as of April 2021. Radiating my entire pelvis remains an option.
Posted 6/29/2021 2:16 AM (GMT 0)
BW - As a side note to Stephen’s comments, my RO was pretty insistent that hormone therapy did not provide any quantifiable benefit for those having adjuvant RT which is loosely described as starting within 6 months of surgery and having an undetectable PSA, <0.10, per the standard PSA testing. Salvage RT (rising PSA after surgery at some point) is another matter where hormone therapy has proven to be beneficial as Stephen noted. This was a “fringe benefit” for me that I did not expect so I checked it out at the time and was pretty much in line with current studies.

Stephen - I follow your posts since we have similar situations. I am sorry to hear that the beast seems to be returning since completing Lupron. It is still early and I hope that your PSA stabilizes given the tendency for RT to take some time to do its thing.
Posted 6/29/2021 3:20 AM (GMT 0)
Mumbo & Stephen
Always lots of options to consider & learn about to be prepared for decisions as they may come. I appreciate your personal experiences. My husband is so bummed about ED at his age right now that I don't know he would consider any RT at this point. Have to wait & see what the PSA does, especially with that darn EPE and positive margin!
Posted 6/29/2021 12:13 PM (GMT 0)
Maybe if you went go down to the funeral home to select and prepay for his arrangements he would figure out there no SE quite like death.
Posted 6/29/2021 12:53 PM (GMT 0)

Duck2 said...
Maybe if you went go down to the funeral home to select and prepay for his arrangements he would figure out there no SE quite like death.


And the fact that he doesn't think like that is what worries me. He's not in a good place right now.
Posted 6/29/2021 2:36 PM (GMT 0)
when you choose surgery as a primary treatment you roll the dice on SEs. it's hard for me to grok not wanting SRT because of SEs.
Posted 6/29/2021 3:28 PM (GMT 0)
F8
All the doctors we consulted with including 2 RO's rec surgery for my husband's case. All you have to do is read other forum brother's accounts to see that SE from ART & SRT can add to SE experienced from surgery.
What is important to some, may not be to others.
We are all different. Thankful you were able to take care of your PCa with RT and good results. Not fair to say we "rolled the dice on SE from surgery" when we went by what Dr's from different specialties told us. I'm sure you know, these decisions are not made lightly. Too late to look back now & play the what if game.
As of now, we haven't been advised to do ART or SRT. Just thought the article was interesting & that maybe others would appreciate the info.
Posted 6/29/2021 3:54 PM (GMT 0)
BW,

FYI....I think its great that you are getting yourself smart on PCa and thanks for the link!
Posted 6/29/2021 4:57 PM (GMT 0)

Mumbo said...
Stephen - I follow your posts since we have similar situations. I am sorry to hear that the beast seems to be returning since completing Lupron. It is still early and I hope that your PSA stabilizes given the tendency for RT to take some time to do its thing.

Thanks mumbo....I have not yet begun to fight! smile I will be getting my bloodwork in July and we will see how it goes. basically until I reach 0.2 every MO I talked to was like...."so". smile So I am going with that.

I did send a saliva sample away for germline genetic testing and will be getting the results of that in a couple of days.
Posted 6/29/2021 6:26 PM (GMT 0)

F8 said...
when you choose surgery as a primary treatment you roll the dice on SEs.

Same can be accurately said for ANY PCa treatment. For me the SE's, over time, from SRT have been much worse than anything I experienced from surgery.

We are all unique, have differing experiences, and world class physicians don't know for sure, but keep learning, so should we. There are no absolute answers.

BWeaver and Stephen S are doing the best they can. Keep the faith!
Posted 6/29/2021 10:48 PM (GMT 0)

garyi said...

F8 said...
when you choose surgery as a primary treatment you roll the dice on SEs.

Same can be accurately said for ANY PCa treatment. For me the SE's, over time, from SRT have been much worse than anything I experienced from surgery.

We are all unique, have differing experiences, and world class physicians don't know for sure, but keep learning, so should we. There are no absolute answers.

BWeaver and Stephen S are doing the best they can. Keep the faith!


#########

SRT is not the same as as radiation as a primary treatment. in fact what you are saying reinforces what i said
Posted 6/30/2021 1:45 AM (GMT 0)
BW - The best resource I found was a Cleveland Clinic calculator that looked at post surgery outcomes with and without Adjuvant RT. You want to look at the study (2) results which should give you some idea of the benefit of ART based on that study.

https://riskcalc.org/prostatecancerpredictingpostradicalprostatectomy/

Stephen - I did the genetic counseling and testing mainly for my two sons since my Dad has PCa also. Nothing came up which is probably good but it would be nice to find something to blame other than my Dad smile
Posted 6/30/2021 2:15 AM (GMT 0)
Thanks Mumbo. I'll definitely check this out.
Posted 6/30/2021 9:41 AM (GMT 0)
I have been using the mskcc calculator for post-prostatectomy risk. Comparing with Cleveland they have some common faults and some stricking differences. Main common fault: they group all primary and secondary cases 4 and 5, 5+3 is like 4+3 and 5+4, even 5+5, is like 4+4, to calculate BR risk (maybe because of lack of robust statistics for the 5 cases, whose risk is clearly understimated). Main difference: the calculated risk for BR for contained cases (no margins or extensions in the path report) for Gleason 4+3 and higher is much bigger in mskcc than in Cleveland (about 40-50% in mskcc vs 85% in Cleveland for the 10-year survival probability).
Posted 6/30/2021 12:19 PM (GMT 0)
jmadrid - As I recall, only the Cleveland Clinic calculator lets the user address ART after surgery based on the (2) study results. The others do not include ART or use SRT which requires rising PSA information which does not exist for ART by definition. The 40% -> 85% is when ART is toggled on and off as I recall.

I think the D’Amico information is presenting similar benefits to ART. I agree that all these calculators are simplistic and do not reflect the nuances of all the possibilities with is why they are just pieces of information that help guide decisions and do not make the decisions.
Posted 6/30/2021 2:32 PM (GMT 0)
Mumbo, thanks for the information. I got my Cleveland numbers without including adjuvant radiation. Do these survival data include BR survival after SRT? Otherwise, they are kind of reassuring for contained cases when they are compared with the sobering results shown by mskcc. If somebody has made his made his mind about his expectations based on one of these tools, it would be better he also knows the other (I prefer to be confussed is than to be wrong).
Posted 7/1/2021 2:40 AM (GMT 0)
The Cleveland Clinic calculator is binary, with or without ART for BCR at 10 years based on the study they reference. They do not analyze SRT.

From my studies in recent years, the high risk people seem to benefit from ART the most. This would be a high Gleason score and other compromising factors. It is not so clear with less serious situations and early SRT may be just as good.
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