Salvage Radiation Question

I posted recently about my PSA going from about 0.03 for the past 7 or 8 years to 0.05 this year. Prostate removed in 2015. Gleason 6, confirmed after surgery. 1 open margin of less than 1 mm. My urologist sent me to the radiologist for a consultation. The radiologist scared the heck out of me with all the possible side effects, including a good change of other cancers developing from the salvage radiation. He said I would need yearly colonoscopies and bladder scans, and other cancers such as lung and brain cancer could develop from it. Plus no guarantee they will even get the prostate cancer cells. Anyone have an opinion on this? Based on the meeting, I feel like its less of a risk to NOT get the radiation.
The other question I never can get answered is this. Since I was Gleason 6, would the cancer cells left in me still be Gleason 6? If that's the case and Gleason 6 does not metastasize, what would my risk be?
Thanks in advance,
Tom

Hi Tom…A recent veteran’s Administration study of the risks of secondary cancers from radiation treatment for prostate cancer was shown to be very low. Prostate radiation only slightly increases the risks of another cancer. The risk in that study was determined to be .5% higher. You can do a ‘search’ to find the details in that study.

I view medicine as an evolving science with very little being absolute. Every treatment option including active surveillance has some associated risks. I believe radiation treatment is getting better every year and the treatment risks associated with it to be indeed very low and acceptable. Keep asking questions…informed decisions are always best. Best wishes…Terry

TomC - Everything in cancer treatment is a risk/reward proposition. Sometimes it is obvious like, "you will die in 3 months if you don't do this". I had adjuvant radiation 5 months after surgery since the recurrence odds were in my favor with a high risk situation. It was strictly a probability evaluation in my mind vs radiation stopping ED recovery and possible RT risk. The secondary risk of cancer was stated as being very low in 2019. My URO and RO explained the plus and minuses of the situation and basically said it is my decision, period.

Your RO seems to have become a bit negative and trying cover his rear in a major way. There is a probability that you will get some cancer, related or not related to the prostate situation. RT may up that percentage a tad in the rectum and bladder area but the remaining risk is still there. There is also some evidence that ART and SRT have less risk than primary RT treatment, probably due to less dosage in a more generalized area.

Since your pathology was confirmed at G6, it would point to the increase probably being in the local area vs. a widespread metastatic situation. However, your PSA is way too low to do a PSMA scan that might show where the new PSA is coming from and remove some doubt. That is the Catch-22 with low PSA increases where you think something is going on yet there is nothing that can be done to confirm the what and where of a cause.

It is probably most prudent to just wait and monitor PSA for a while. I seem to recall URO and RO saying to make sure I keep getting my colonoscopies (5 yr for me) but no mention about special bladder precautions. Just had a colonscopy and reminded the GI doc to check the radiated area. He said all was well with some minor evidence of previous RT in rectum but nothing wrong.

I also recall the RO handing me a list before treatment of all the possible side effects which would scare anyone if he did not discuss each one with me and his experience with each one with his equipment.

It also might be good to find another RO for a second opinion that might make more sense to you as noted above.

My $0.02.....the Radiation Oncologist told me that my adjuvent radiation therapy would raise my chance of another cancer by about 2% over the rest of my life. (I now worry more about sunshine, radar and other microwaves) I got 72 Gy adjuvent RT 3 months after RARP and starting leuprolide chemotherapy in 2013. When I got the ORIOLE style area + spot radiation treatment for mets 3 years ago little mention was made of an increase in risk. PSA had to hit 3.0 before I got the axumin F18 PET scan.

I am 73 so I get regular colonoscopies anyways. No cancer, no strictures, doc said 7 years to next one rather than 5 due to healthy colon etc. PSA test every 3 months still, but not a ultra-high sensitive like you are getting, just "less than 0.1". If PSA goes up then I will wait until it gets back to 3.0 before getting another PET scan.

There is always some variance in what the technician can see on the slide under the microscope for the evaluation. If they see mostly Gleason 3's and 4's, then you get appraised at G7(3+4). A recount after surgery may then give you a different score as they have your prostate on a bench and can slice/dice as needed to be more accurate.
Gleason 3 cells are just messed up cells that don't function as well as healthy cells. That is due to a flaw or break in their DNA which may or may not have been repaired. That flaw could be caused by many things (toxic chemicals, radiation, replication errors, aging, etc). G 4's have more DNA damage/repairs and accumulate more with time. G 4's sit in 1 place, grow bigger and reproduce, so the tumor grows. G 4's can then turn into G 5's. Gleason 5's can move around, invade other cells, pry apart cell walls to enter blood/lymph vessels, nearby organs & nerves and spread the cancer remotely (metastasize it).

If the tech only sees G6(3+3) than the chances are very high there weren't any G 4' or G 5's to see. Remaining observant is wise, however.

Tom: happy to discuss offline. Same..exact..situation...including a very very low decipher score of .12 Happy to discuss where I am at.

Tom - Interpreting prostate cell patterns is not an exact science so you are never sure if the assessment is 100% correct or not. The biopsy is the most uncertain due to sampling probability and the actual prostate pathology is better but different pathologists can come to differing conclusions with identical information.

So there could be a some rogue pattern 4 cells in your cancer that was not observed or some pattern 3 cells are continuing to grow somewhere nearby which is reflected in the very small numbers being monitored.

My PCa kept getting redefined as I went through the process thus made ART a prudent choice for me. For many, waiting until PSA gets to 0.10 to 0.20 makes much more sense and is still part of the "early" treatment process. Many studies say that 0.20 to 0.50 is "early" but I would never want to push the limits of any studies with my cancer. The troubling part is that current PSMA scans don't help much until PSA is 0.50 so hard to verify much until then.

I think you are in the category of waiting and not worrying at all until 0.10 then no worries, just start investigating options at that time.

My first PSA post surgery was .40 so I didn't have to concern myself with decision-making. I was getting SRT 4 months after surgery with a six month course of ADT. That was six years ago and I've been undetectable since. However, I did get radiation cystitis last year- dealing with hematuria (blood in urine). That has not been pleasant but I've done Hyperbaric Treatments which has helped. I'm on a regular 3-5 year colonoscopy schedule.

Thank you for that encouraging news. I think I need a more optimistic RO!

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