2 Year PSA Results - Pretty much expected

LV,

I like your logic, and resolve.

It does fly in the face of conventional wisdom. I have seen studies that imply that earlier radiation gives better results down the road.

Do you have some links that back up your beliefs ?

My QOL is all shot to heck anyway, so that argument is not a big one.

I am curious as to the bqsis for your decsions.

Good luck.

LV,

The study that the oncologist from U of M cited didn't reference PSA levels at all, merely time from surgery. Their study indicated that is radiation was begun within 4 months of surgery, curative rates were increased around 15 %.

If the PC is in the local bed, be it from a positive margin, or a whatever, it really can go anywhere from there. Actually, it may go in search of testosterone which it likes to eat. So my way of thinking is that the sooner I can kill the little sucker while he is close by, my odds of a a cure are increased by some percent.

As a Gleason 9 I am very attuned to this discussion. That is why I am curious. I do not want to do radiation, but I am prepared to move quickly if I see any movement on PSA.

I have talked to another poster on here who's URO believes that HT may be a good first step in these situations also. Knock it down, maybe even kill it before it goes off to richer pastures in search of food.

I do believe that there is little hard proof that any approach is significantly better than another. The nomograms it seems would be asking a lot more questions if there was an ideal approach.

Les, I am in a similar situation to you, but higher Gleason and negative margins. My next PSA is about a week away and I am due to see the my uro later this month.

Do I have PCa? Almost certainly. Where is it? Don't know. If I knew it was still in the prostate bed, I'd opt for SRT with a good chance of killing it -- and maybe a few other things as well But if not in the prostate bed, SRT is a pointless exercise, with the potential to do a lot of harm.

So it's a waiting game. Enjoy each day as it comes. We will all die of something someday. For me it may be sooner rather than later, (bummer), but in the long run, we will all be equally dead. Today I am still alive, with no symptoms, so I will make the most of it.

Les,
I think what matters most is your gleson grade. A G6 or a 3+4 G7 may warrent waiting, but if a solid G8 or 9 the earlier the better. Doubling time is a good indicator of how fast it is growing.
JT

I am following the same protocol kinda. My psa jumped to .71 from .19 in three months. I am not going to do anything anytime soon. I feel great, I am running and swimming and enjoying life. When that thing gets up to 3 or 4 I will give it more thought. Until then I am living large. I went through radiation and ADT3 and I want to wait as long as I possibly can before doing that again.
Great post

thanks
Dale

LV-TX, your cancer is very likely still localized and therefore you are still eligible for a cure by salvage radiation...The longer you wait, the more time you are giving your G-6 cancer to figure out a way to metastasize..One the other hand, it may NEVER metastasize and therefore may never cause problems worth treating..But it seems to me, with cancer, even PC, the longer you wait, the more aggressive it becomes..Just My Humble Opinion....

I would not advise waiting, if one is going to do salvage.

"One of consistent variables associated with PSA relapse-free outcome has been PSA levels prior to salvage RT. Multiple studies examined various PSA cut-off levels and showed that the lower the PSA level at the time of salvage RT, the better the treatment outcome."
Richard Choo (Mayo Clinic)
Salvage Radiotherapy for Patients with PSA Relapse Following Radical Prostatectomy: Issues and Challenges
Cancer Res Treat. 2010 March; 42(1): 1–11
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2848745/?tool=pubmed


"The PSA level before SRT was a highly significant predictor of disease progression, with more favorable outcomes observed at low PSA levels. An estimated 48% of patients who received SRT alone at PSA levels of 0.50 ng/mL or less were free of progression at 6 years, compared with 26% for those treated at higher PSA levels. The ability to provide successful salvage treatment for approximately 50% of patients with "early" SRT is similar to the 52% to 57% relative risk reduction in the rate of PSA progression among high-risk patients randomly assigned to adjuvant radiotherapy versus observation after RP in two recent randomized trials. An important observation in our study is that the 6-year responses for those treated at PSA levels less than 0.50 ng/mL appeared to be durable. This evidence suggests that approximately 50% of patients with recurrent prostate cancer after RP may derive long-term benefit from SRT when it is administered at the earliest signs of recurrence."
Predicting the Outcome of Salvage Radiation Therapy for Recurrent Prostate Cancer After Radical Prostatectomy (Stephenson, et al)
Journal of Clinical Oncology, Vol 25, No 15 (May 20), 2007: pp. 2035-2041
Full text: http://jco.ascopubs.org/content/25/15/2035.full

"An undetectable PSA level following salvage radiation therapy is more frequently achieved in men with lower pre-radiation serum PSA and those without seminal vesicle or lymph node involvement."
Salvage radiation therapy for prostate specific antigen progression following radical prostatectomy: 10-year outcome estimates.
Pazona, Catalona, Han, Hawkins, Roehl
Journal of Urology 2005 Oct;174(4 Pt 1):1282-6.
http://www.ncbi.nlm.nih.gov/pubmed/16145393?dopt=Abstract

I'm a high Gleason case. So far PSA has been undetectable for 15 month. My next test is coming up in less than 2 weeks. I do the ultra sensitive test. I don't know what I'll do is it jumps up significantly.

All a big thank you for your posts and comments

To reply to the general statements made.

I am a gleason 7 (3+4) which as pointed out can be very unpredictable. Gleason 7 can behave like a 6 or more aggressive like a 8. General rule is that Gleason sums of 8 or higher are at high risk and required agressive therapy in any setting, primary or secondary. So the Active Surveillance on my part is solely because right now my cancer is acting more like a gleason 6 and not like a gleason 8. Which means more of the grade 3 cells were left behind after surgery.

Micro-mets...sure that is a possibility I did have PNI on biopsy. But not likely. Pre-surgery PSA level, post surgery gleason sum, negative SVI and Lymph nodes and only a single positive margin all indicate local recurrence only. Active Surveillance in recurrent setting has it's risks, but that risk is extremely small given the stats I have.

SRT should be done at earliest stages of recurrence. Very true...won't argue with anyone on that. But what is considered low. A 0.5 or 0.6 and below is what is considered low levels. The higher the risk someone has, then the earlier the need to start. I am low risk and I can hold off for a few more months or years maybe. Can it progress...sure that is why Active Surveillance doesn't mean doing nothing...it means monitoring on a regular basis and take action when deemed appropriate.

Why wait? Sure at some point I will need additional therapy. I have known this for the last 2 years. My first 3 month PSA after surgery was .06 So many of you here are at the level now and are looking into what comes next...some with anxiety and others not so much. I stand by the fact that the kinetics of your particular disease will dictate what you do next, treat early or later. In my case I have been able to hold off. (Your mileage may vary)

The other reason unrelated to the disease for waiting is that I will retire at the end of next year. The treatment center is an hour each way from either work or home. The company I work for downsized and has been sold and with the reduction in work staff, my plate at work is quite full. So taking time off daily from work for treatment isn't something I want to do right now...BUT if the disease progression increases to the point that the risk management will be counter-productive then I will have to pull the trigger. So if I don't have to right now...I wont.

I have been a member of this forum for the last couple of years. During this time I have seen a shift towards recommending Active Surveillance to those low risk newly diagnosed men. I applaud everyone for helping those men to look into this method. They are just as scared and anxious at their diagnosis as we were when diagnosed. We advise newly diagnosed men that it isn't necessary to rush to treatment with low risk case. We help them define their risk based on our own research and experience. But when it comes to recurrence, we still tend to lump all recurrence in the same risk catagory. That they are all dangerous and need to be treated early and hard. But is that really the case for everyone with a recurrence. I don't think so. I believe that recurrence has it's risk defined on the kinetics of the cancer itself. Which is highly individualized. We already know that no two people have the identical cancer and that they will not have the same benefit from any form of treatment...primary or secondary.

With more men that have chosen surgery for their primary treatment because of early PSA detection, so does the number of recurrence increase. It is a fact that nearly 30% of all surgeries will have a positive margin and a local recurrence as a result. I don't believe that those men (myself included) with this type of a recurrence should be lumped in with those men that had EPE, SVI or Lymph node or other factors that place them into high risk.

I am just one voice amoung many men that have or will have a recurrence, and I am just saying...take a hard look at your own particular disease and evaluate your risks for yourself. Don't fall into the trap that one size fits all. Am I wrong? That is the risk I take, but with the cards I am playing with...it's a pretty good risk.

Best of luck to all that fight this disease and I hope to calm the fears and anxiety for those with a low risk recurrence.

les, you are a great guy, with a great story. i have to be blunt, hopefully not rude, i think you are in "recurrance denial". the rules and logic of AS, which i think is a great breakthrough here at HW, does not apply to you in any sense of the word. AS only has to do with a "pre-treatment" plan after a PC dx. has nothing to do with recurrance issues. you had PNI, every single rad oncologist i spoke to emphathized the worry about PNI, interestesting, because almost all surgeons poo-poo the subject, even the great Walsh downplays it. The rad docs don't, they realize that with PNI you have many clear giant paths to allow rogue cells and clusters to escape anywhere.

not telling you what to do, will still support you no matter what. you need to stand outside your current frame of mind, and i honestly believe you are making or about to make a mega mistake in your journey. i wish i could feel wrong about what i said. even though, for me, srt was the chain of motions that all but destroyed me because of side effects, it was still the only thing that is giving me any chance of survival, i too am a gleason 7, with extrem velocity issues.

re-think things brother, thats all i ask

david in sc

David, your mention of perineural invasion got me to run to my Walsh book and you are right about what surgeons think of PNI. Walsh says in his book, "some noted pathologists have suggested that it should not even be commented on when found in a biopsy, because it's not worth worrying about." Just another contradiction with this darn disease that we have to cope with I suppose.

Les' thread is of great interest to many of us. It is something that I have been curious about, that is, can AS be applied to men AFTER their PCa treatments? Can a cleansing change to healthful foods and drinks boost our immune systems sufficiently to actually kill PCa cells? That is the million dollar question for me. There is probably insufficient research to make a valid conclusion because, let's face it, there's no money in it.

So Les, what changes are you making in your diet, if any?

Last month I experimented with this subject prior to my last PSA test. I ate and drank nothing but healthy foods and drinks, including tomato sauce with lots of garlic, blueberry smoothies galore, (and no cheating!!!) and my PSA came back to .02 from 05. I know, I know this is an extremely unscientific test and a very limited sample. It's just my personal experience. However, the food we consume does have a huge effect on cancer, in both directions, IMHO.

Les,
You are well informed and have a very logical and reasonable plan. You recognize that there are some risks and are willing to accept them. I think that this is a very appropriate way to approach any treatment decisions.
JT