Need RP salvage radiation advise

Had my RP on 2-3-09 approx. 11 weeks ago. Had the nerve sparing procedure that ended with a positive margin on the right posterior of my prostate. Prior to surgery my psa was 1.7 with a gleason score of 3+3=6. My current psa is .26 and has not changed since surgery. Just had a bone scan and MRI last week and both were clear.

 

I am now trying to decide if there is any advantage to using Proton instead of Photon(IMRT) radiation for salvage. I have met with the two IMRT radiation docs for initial consultations and both seem good.

Got my third opinion on Thursday up at Loma Linda. Here is a brief synopsis on my initial consultation.

The doc spent over 2 hours with me going over my history, salvage situation, side effects possible, a brief physical exam, and a tentative plan. He has been at Loma Linda for 21 years.

For salvage he plans on targeting the prostate bed, seminal vesicles, and close surrounding area building up to 70-72 GY total (will shrink the target as treatments progress). Will then target my positive margin(right posterior) with up to 74GY. This is all just preliminary and will depend on what my CT scan looks like, along with other factors put together in the mapping and planning of treatment.

I do realize that the overall results appear to be similar whether using proton or photon in a salvage situation. The doc seems to think proton is the way to go if you have access to it. He has the ability to use either IMRT or proton. Higher GY dosage with potentially less side effects and very precise targeting are all plus's in my mind.

Since I live within driving distance of Loma Linda I will am planning to choose proton radiation for my salvage treatment since I have the option. Can't think of any reasons not to? I am scheduled for my CT scan with them next Tuesday unless I see a reason to change direction. Opinions from others have always been very helpful for me in making important decisions.

Any feedback or input is appreciated.

Thanks BoisePSABantam

I asked about hormonal therapy in conjunction with the proton treatment during my initial consultation. The doc said he would discuss it with other colleages and see what they had to say. He did indicate he didn't think it was necessary in my situation but wouldn't rule it out. He did say that there are some pretty unpleasant side effects that can occur with hormonal therapy. Some may go away quickly and some may continue for years. I will be seeing him again in the next week or so and see what plan he has come up with. I will defineately do whatever it takes!

Thanks

       CS53

Thanks JohnT

I will talk to my doc at Loma Linda tomorrow about having more tests by a prostate oncologist to verify no micromets. With a gleason score of 6, and no lymph node involvement wouldn't the chance of micromets be pretty slim?

Thanks

Thanks JohnT

I agree with you, best to know as much as possible. I am waiting to here back from my doc at Loma Linda. Doc said since I have a broad positive margin left from the RP it would probably be best not to take any chances. Hitting this stuff early appears to be best for success. On the DRE he performed on me he said he could feel a small amount of prostate tissue right where the positive margin is located. It is located close to my nuerovascular bundle. I believe the surgeon was not aggressive enough in that area trying to spare the nerves.

I will most likely make an appointment to see Dr. Sholtz.  I don't think I am a candidate for the Combidex MRI according to their web site. Not sure what other tests they can do since I have already had an MRI with contrast? Some good reading on Prostate Oncology Specialist web site using hormones and radiation.

Will some form of Adjuvant hormone therapy (along with the radiation) kill the micromets? Looks like it says treatment for up to 28 months is optimum? I am very worried about the possibility of micromets and would like to do whatever it takes to kill them off.

Thanks

CS53,

I doubt hormonal therapy would kill of every single Micro Met. The best treatment is to do whatever it takes in the short term to achieve a complete remission then maintain the remission in the long term. The preponderance of evidence I've read is that most men with PCa have some micro-mets. Its just that some have immune systems that keep them in check and others don't. Some men have PCa that is genetically aggressive and some don't. Find out if you have aggressive PCa or slow growing. You'll know by the PSA doubling time. If it's aggressive, I'd hit it with both radiation and ADT3 (1 year). If it's slow growing, hit it with radiation and take good care of yourself. Diet, exercise, practice relaxation techniques and go on vacations. Build up your immunity. Take a wait and see if your own body is going to smite it down.

I too am still learning about this disease. My father has been fighting it for 12 years and has had a bear of a time. But, he's still around. Still works at farm full time at 73!

Good Luck!

I think HT prior to radiation is a good recommendation. A lot of the experts recommended this for my father and the good news was that he didn't experience side effects until I believe after the first couple of months. SO, maybe you will get by with minimal side effects from the HT if you are on it for only 8 weeks. Either way, I think it is a good idea. (In my humble opinion) My father's oncologists recommended two years of HT because of the positive lymph node, even though he had an undetectable PSA following surgery. The studies show it is better to hit it early, so we did. It sounds like you have a great plan of attack, with a top notch facility. I think the anxiety lessens once you have your game plan in place. It causes a lot of anxiety for everyone waiting for all the tests and trying to decided on the best treatment, when there are no guarantees either way. Stay positive and swing away!

I struggled with Proton vs Photon when I was making my decision and it really boiled down to convenience, money, and long term results.  I live in Mississippi so Loma Linda would have been tough on me and my young family and much more expensive.  My radiologist also convinced me that while Proton looked very promising it does not have the long term track record of photon, there is no doubt about the effectiveness of photons if they hit the target with sufficent doseage.  The real advantage it seems to me with Proton is the ability to do less damage to surrounding tissue but that doesn't make much since in a salvage situation when you are basically carpet bombing the pelvic and prostate bed area.  The surrounding tissue damage argument has been mitigated in recent years with the accuracy of IMRT.  For what it is worth I am doing well so far and have my annual PSA coming up in August and hoping for good results, at this time I have no negative side effects from the IMRT.  Good luck.

CS53,


I understand your fears. Most of us do. Take Heart!

1) You are very lucky to have such superior medical care. If you're able to go to Loma Linda and see Dr. Sholtz, you are in great hands. Try Living in some smaller towns where recurrence = being ignored.
2)You don't have Brain, Pancreatic, Liver, Lung, or other nasty cancer. Prostate cancer can be mitigated in every stage. It may not be what you want, but you'll be here for a very long time. Like decades.
3) medical advances in the treatment of PCa are incredible. Provenge and other treatments will likely cure the condition sooner than later. Your job is to just make it that Great Day! Do So!


Good luck and take it easy.

Thanks Pelahatchie

Glad to hear you are doing well using IMRT. I also struggled with which form of radiation to use. I do realize results are similar in a salvage situation using either Proton or IMRT. I guess I am basing my decision on a couple of things. Proton allows a higher dosage with potentially less side effects (everything I read says more radiation is better to a point). The doc has the ability to use either Proton or Photon and seems to think Proton is the way to go if you have access to it. I live within driving distance of Loma Linda so I really see no negative reason not to use Proton radiation? If anyone has a differing opinion or see's things differently your suggestions are greatly appreciated.

Thanks

CS53,
Ask your doctor about Casodex and Proscar along with the Lupron. ADT3 is more effective than mono therapy and adds very little to the side affects.
JT

Just an update here. I decided on adjuvant treatment. I start hormone treatment(ADT3) on Tuesday. Going to give the hormones approx. 8 weeks to weaken the cancer and then start radiation.

Any idea how important it is to choose a radiation doc that is well versed in salvage? Most I have talked with do very little for obvious reasons. Not sure there is any magic strategy that is employed? Thanks for all your input and suggestions.

Another update:

Started ADT3 HT the first week of May (psa now undectable as expected) with planned adjuvant proton RT starting 8-12 weeks later. A few weeks ago I decided to consult with Dr. Mark Scholz of Prostate Oncology Specialist. I have heard he is one of the top experts on prostate cancer. I wanted to get his opinion on my plan moving forward.

DR. Scholz DRE exam revealed a small area of nodularity in the distal right prostate fossa.  This is consistent with my positive margin located on the right posterior lobe.

A Color Doppler Ultrasound was performed showing approximately 7 cubic centimeters of retained prostate tissue. There was no overt hypervascularity suggestive of aggressive cancer.

Dr. Scholz ordered a more thorough pathologic review of my original slides and prostate tissue by Dr. Bostwick to determine how extensively positive the margins are and also to do some additional tumor markers such as Ki67, p53 and p27 to determine the aggressiveness of the tumor. These are proteins that can be used to predict recurrence.

Results came back with protein markers all in my favor for low recurrence. Gleason score of 6 remained the same.

What is worrisome is that very little cancer was found in my prostate biopsy. My initial biopsy pre op showed grade 3+3=6 adenocarcinoma in the right base, right mid gland and in the left mid gland. The core involvement was 30%, 25% and 5% respectively of those areas. This leads us to believe there was definitely cancer left behind in that 7 cubic centimeters of prostate tissue.

Doc says about 50% of patients who have positive margins after surgery will never have a recurrence.  The benefit of radiation, which will almost certainly be curative, needs to be weight against the possibility of erectile dysfunction which may occur in about 1/3 of cases.

He is leaning towards 6 months of hormone blockade and then stop and monitor the situation over time versus immediate radiation. So now I have another decision to make. Seems like they never end. However I am happy with all the positive news and fortunate to have some options.

Sorry for the long winded post. I am looking for help once again. Any opinions, suggestions, or advise on what might be best from all the wonderful people of this forum would be greatly appreciated. Thanks soooo much.

Thanks
       CS53

Has anyone seen any "long-term" studies that compare the efficacy of using proton versus photon radiation for adjuvant or salvage treatment?