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SRT- Possibly my turn in the barrel

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Posted 8/30/2010 5:58 PM (GMT 0)
Well, I hadn't said nothing up til now, but it looks like I MAY be approaching a statistical reoccurance. Here's the details, from 2 seperate series of tests, one from my GP, the other from my Uro.

GP PSA Results
10/07- .008- first test after RRP
10/08- .02
10/09- .04
04/10- .06
08/10- .09

My Uro had:
10/07 .04
02/08 .04
06/08 .04
12/09 .04
06/09 .04
03/10 .06
09/10 .09

Now, I know that I still need some more data points, but the one in Nov. is gonna be a biggie, right? Only problem is the that one will be from a different lab than what he used until now. I can get my GP to test again Jan. 4, if needed.

I am like most here, I suppose, if it doesn't concern my immediate situation, I don't pay close attention to others threads, so have some catching up to do, I suppose. I know it's been said numerous times before, but I'd like to gather some info for my use.
Here's my questions.
What's the current thinking about the breakover point to determine reoccurance? .1, .15, .2?
Should I call and get my Uro test sooner, or wait until Nov.?
Do I read that the GP's tests indicate a doubling factor of a year?
What does that mean, if anything, as far as how quickly I should be working on this?
Does doubling time have a scale for when adjutant hormone therapy can/should be combined with SRT, or is that even anything to consider when/IF I reach the reoccurance point?


Here's the section from my post surgical path. report that mentions margins, etc:

Margins: Probable microscopic involvement of the left apical margin:
Remaining margins clear.
Extraprostatic extensdion: Not identified
Seminal Vessel invasion: None
Regional lymph nodes: See A above
Distant metastasis: Cannot be assessed
Perineural invasion: Microscopic intraprostatis perineural invasion is present (see guide to sections)
Venous invasion: None identified
Lymphatic invasion: None identified

Does anything in this path report, knowing the psa results for 3 years, predict a reoccurance?

What do you grizzled guru's suggest as my next few months course of action be?
Posted 8/30/2010 6:11 PM (GMT 0)
Dang it James. You have had enough going on, sorry to see this. SRT is controversial like everything else in recurring prostate cancer. I think 0.1 is enough because you have enough data to determine the PSADT (Doubling Time).

Why wait any longer ~ is only answerable by you. I don't see anything extraordinary in your pathology result. There was a possibility it comes back with that margin and it looks like it has.

Next few months, well that's up to you. You can wait, but there won't be any benefits to waiting. I would start looking into SRT techniques and pick one. You want to look into making sure the radiologist hits the pelvic area lymph nodes. If anything was creeping around that's where it usually starts. You might want to talk about hormonal therapy for a few months. Some studies are showing SRT with neo-adjuvant hormonal therapy is better. (Go to the MSK Nomograms on salvage radiation and plug your numbers in, estimate 85 gray)

Peace, and stay well...

Tony
Posted 8/30/2010 6:13 PM (GMT 0)
Good question James,

My uro stated that recurrence was 0.2...but he also stated he wants to see an increase above that to confirm. Also he doesn't see the rush to SRT as so many others here have indicated. Is my uro right..don't know for sure. Lots of white paper stating SRT should be done before it reaches the 0.5 mark.

Also...don't read into doubling time just yet...wait until you are over the 0.1 mark to assess that...too much variances when below that to give an accurate reading of doubling and velocity.

Hang in there
Posted 8/30/2010 6:40 PM (GMT 0)

James C. said...
What's the current thinking about the breakover point to determine reoccurance? .1, .15, .2?

Regarding your question above, I think that there is only one legitimate resource to answer this question; I would turn to the American Urological Associatioin's 2009 Update to the Prostate-Specific Antigen Best Practices document.

I looked it up for you, and it says:

The AUA defines biochemical recurrence as an initial PSA value ≥0.2 ng/mL followed by a subsequent confirmatory PSA value ≥0.2 ng/mL.

If you don't already have this bookmarked, here's the link.  http://www.auanet.org/content/GUidelines-and-quality-care/clinical-guidelines/main-reports/psa09.pdf

Lots of good info in this document which I consider to be one of the bibles of information.

good luck

------------------------

added later...

 

I should add that the threshold above is stated with full awareness of the recent large trials showing improved SRT results with those who undertook "immediate adjuvant radiotherapy" after BCR.  The level they called "immediate" in the study report was below 0.4ng/mL.  My point here is that I think that there has been some over-reaction to this study's result and some people are interperting that one should persue SRT much sooner.  If you don't have this study's link, I can send it to you.

Post Edited (Casey59) : 8/30/2010 1:03:53 PM (GMT-6)

Posted 8/30/2010 8:10 PM (GMT 0)
Casey, got it , thanks
Posted 8/30/2010 8:27 PM (GMT 0)
James,
Sorry about the escalating PSA. It looks like your doubling time is about 6 months. The numbers seems to indicate recurrence so waiting doesn't serve any purpose.
Posted 8/30/2010 9:14 PM (GMT 0)
James,

For as long as I have known you, I just always believed you were "cured" so to speak, a little surprised to see your post.

In my area, the doctors tell me, that 3 consecutives rises above .10 constitute recurrance. They also, here, use .20 as the line in the sand to start SRT for the best results. I wouldn't want to wait as suggested above to it gets to that level before deciding.

It would seem likely that you are on the verge of having recurrance, so as some of the other suggested, there's no good reason to delay a decision until it jumps up much higher.

I would wait for that November reading (that is my next important PSA mark too, post SRT). If you haven't jumped over the .10 mark then, I would check again in January and reeavluate the situation.

With all the radiation oncologisits I met with prior to choosing, again in my area, they all felt like SRT above .50 is futile at best. But you will get a lot of opinions on that.

Hoping that you don't need this path, hoping the best for you.

David in SC
Posted 8/30/2010 9:23 PM (GMT 0)
The experts I see at Ford Hospital won't even consider a BCR until the PSA goes above 0.1. But even then generally they say 0.20 as the time to see a radiation expert.

I'm surprised so many people are telling you to rush into SRT. I have read studies that show a definite advantage to doing SRT before the PSA gets above 0.50. In fact, I think the differences were startling. As I recall it was like a 30% success vs. 48% success for those starting earlier. But I don't think there is any evidence supporting a start of SRT this early.

Mel

Posted 8/30/2010 9:25 PM (GMT 0)
Mel, I think you read the same report I did...the one I mentioned above...
Posted 8/30/2010 9:29 PM (GMT 0)
Well, Casey and Mel, like all things PC, there is no one definitive answer to this question, and even the experts vary much in their answers. Once again, the patient (in this case, James), will have to talk to some experts in his area, and make a tough decision on what he feels is best.

In the past year here at HW, there has been a boatload of us that had to go down that route, so there's plenty of logs, journals, and accounts of the process to study.

David in SC
Posted 8/30/2010 9:31 PM (GMT 0)
Hi James,

Sorry to hear that your PSA isn't quite as low as you expected. From what I've read and from what my medical experts have told me, SRT has the best chance of success when done as soon as a recurrence is suspected or confirmed. In my case, I did decide to have the SRT when, after 3 consecutive increases, the PSA reached .08. Not sure if I jumped the gun a bit, but at the start of SRT the PSA had reached .1. Thus far, I do not regret having started SRT so soon. Hope that my story helps a bit.

Good luck and all the best to you.

Mag

Post Edited (Magaboo) : 8/30/2010 11:30:38 PM (GMT-6)

Posted 8/30/2010 10:09 PM (GMT 0)
James,
You may not remember that I was already loosely scheduled for IGRT when I joined the board. In my case, there was a post-Davinci path of 4+5 and positive margins.
So, at the strong urging of my uro/surgeon, I did not wait for a psa rise, and was working more on improving continence.
As to PSA, he does not even do the ultra-sensitive PSA, so the first detectable would be a 0.1 in his scheme. I don't regret (yet) having started early, but a few folks would debate that I pulled the trigger too early.

As the others had said, you were supposed to be done and over with this. I hope for the best for you, and will offer what support I can if you go the IGRT route.
Posted 8/30/2010 10:48 PM (GMT 0)
OK James... now that we have definitely answered your question...LOL.

Isn't it amazing how PC has such an unpredictable mind of its own...although we do a lot of predicting via nomographs, etc.

Speaking of which, I wonder if you should try the MSK nomographs. You can input data for starting SRT now or starting it later at a higher PSA. I'm not sure if the nomograph will allow you to input a PSA below o.1, but you can try and see if there is a major difference.

Mel

Posted 8/30/2010 11:58 PM (GMT 0)
Just looking the two sets of data and their dates, I think (and hope) that you might not be in trouble now. If you look at the two sets, the main difference is the GP has some low numbers thrown in there early that make make the .06 that both the uro and the gp had in the most recent tests look like a big jump. The low numbers from the gp appear to say there is a worrisome rise but the uro numbers were done a the more or less even entervals of 3-4 months and they don'y look bad at all, IMHO. It could be looked at as you being a 0.04 from the beginning and last a 0.06. I hope your next two tests will ease your worries. Anyway, I know this must be disturbing but lets hope this is just some noise.
Ron
Posted 8/31/2010 1:24 AM (GMT 0)
James, in an earlier reply, I addressed your first question on what is considered biochemical recurrence.

In this post, I wanted to make sure that you have the link to the landmark Stephenson (et al) paper which presents the statistics of men who got salvage radiotherapy, stratified by their risk factors.

http://jco.ascopubs.org/content/25/15/2035.full.pdf+html

You don't need this now, but it's good to brush up on what the big thinkers are saying.
Posted 8/31/2010 1:53 AM (GMT 0)
Sorry to hear about the possbility of your PSA rising. I know you will make the decision that is right for you. You have a lot of knowledge and a lot of people to bounce ideas off of. Keep us posted.
Posted 8/31/2010 2:10 AM (GMT 0)
James,

I reread my post, and seems that I said:

"and will offer what support I can if you go the IGRT route." smhair

1)Take foot from mouth.

2) Restate.

3) You have my support in whatever you decide. If you go the IGRT route, I will share whatever might be of help, having done that.

Posted 8/31/2010 2:18 AM (GMT 0)

James C. said...
Does doubling time have a scale for when adjutant hormone therapy can/should be combined with SRT, or is that even anything to consider when/IF I reach the reoccurance point?

Regarding the question above, I believe the root of your question (correct me if I'm wrong) is about whether the (possible) recurrence would be local or distant.  As you know, no imaging can reveal this in early stages, so doctors typically look to the "rules of thumb."  So, I am interperting your question to be "what are the rules of thumb for distant vs. local recurrence?"

Men most prone to distant metastases will have one or more of these conditions:

  • Gleason scores of 8 or higher
  • cancer found in their seminal vesicles and lymph nodes during surgery, or
  • a rise in PSA within a year after surgery.

You, I note from your signature, had none of these conditions. 

Did I interpret your question properly, or were you really asking something different?

 

These days I have to put lots of disclaimers and notes asking people to read closely what I wrote.  Please note that I did not say that men with these conditions will have distant metastases...what I did say is that they will be prone to distant metastases.  It's a medical rule of thumb.  There will be exceptions, but this is what is "likely."  [Sorry for the anal point of emphasis; don't want anyone flying off the handle at me for words they thought I wrote.]

Post Edited (Casey59) : 8/30/2010 8:24:27 PM (GMT-6)

Posted 8/31/2010 3:04 AM (GMT 0)
James,

sorry you have to worry about your PSA. I wanted to make a point about PSADT and consequntly how much in the hurry you should be.

My onc doc told me when my PSA started going up that at these low numbers you cannot compute PSADT reliably.

I think you should wait and see what your next reading will be before you even consider doing anything.

Just my 2 cents.

Greg
Posted 8/31/2010 3:34 AM (GMT 0)
Casey:

Got a question for you regarding your comment about being prone to distant mets.

Look at my signature. Suppose my PSA continues to rise slowly.

If it hits .1 in a year, am I more prone to distant mets?

I think it's hard to even say that. I have read that a positive margin would suggest a local situation with a decent chance of SRT working

Mel

Posted 8/31/2010 4:40 AM (GMT 0)
James,

I am truly sorry for your situation because I felt from your stats you were out of the woods on this cancer and you are a great moderator. Maybe you still are out of the woods.  Everybody says until you hit .1 don't worry about anything. I've had 5 0 psa's and felt I could relax a little about this, your situation gives me pause for thought. Although this has nothing  really to do with your situation I think your stats show that AS which is being pushed big time in other threads for us gleason 6 guys is still a gamble. And I realize you went and had the surgery like I did. I really don't believe that 7/10 guys with gleason 6 will do fine by sitting  back and waiting for further testing to see if our cancer is growing. The implication is that they can catch any progression in time to ensure the same outcome. So why risk ED and incontinence? I just don't believe it. With all the tests they have, including doppler studies, you still take a risk by not treating this cancer.  Your situation (and mine) demonstrate that it's best to treat this cancer as soon as possible because it is so unpredictable, REGARDLESS OF GLEASON SCORE! Imagine what could have happened if you just sat back and waited to treat this cancer at a later time. If I was in your shoes I would wait for one more PSA test and then decide what to do. I am sure that if you need salvage radiation therapy you will do fine and live a long and productive life. God bless you for all you've contributed to this forum....

Posted 8/31/2010 4:41 AM (GMT 0)
signature follows
Posted 8/31/2010 4:42 AM (GMT 0)
ssssss
Posted 8/31/2010 10:50 AM (GMT 0)

James,

This is a complicated issue for us G6 guys.  I have seen quite a few people on yananow.net that were G6 and had a PSA come back only to stop at around .2  without any secondary therapy.  One guy has been at .2 for 10 years now.  Epstien even talks about this with G6 people.  It is a hard call to decide if you get radiation or just do nothing to see if it stops rising.  If yours even is.  It could be benign tissue left behind growing back or just a minute tumor that may never progress.

It's a delima for the G6 people..You just need to wait until at least Jan. 2011 to see what is going on.

Although you did have a positive margin and perineural invasion so I would watch it close to.   SRT should get it all for you if you have reccurence it is probably local....

Post Edited (ChrisR) : 8/31/2010 4:54:13 AM (GMT-6)

Posted 8/31/2010 12:34 PM (GMT 0)
Hi James,
Sorry to hear of your numbers rising. I had 4 rises when mine hit .1. I guess this is an individual decision for each of us. I, like Magaboo, certainly have no regrets on starting SRT when I did. My Doc said that with confirmed recurrence the earlier the better. Your 2 sets of readings are a bit confusing. I am guessing 2 different test? My Uro groups test just goes down to 0.04 and looks like the same with yours.

At any rate good luck with all this and the decisions. You are a great Mod here and we are pulling for you!!

David
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