When to pass on SRT

I am hearing and reading a lot now that has me second guessing my decision to have SRT. Specifically, the recent artical on the long term impact of cancer treatments, Dr Myers recent video on his PSA growth arrest program where he suggests that growth arrest be tried before jumping to SRT for a PSA only recurrence in certain patients, and a local prostate cancer support group Q&A with a medical and radiation oncologist where the RO stated that SRT is only curative in 33% of cases and that men should not have SRT unless it is likely that PCa is local. In my case it is not likely (> 50%) that it is local.

The issue is no longer relevant to me but I thought that it may be an interesting discussion to have.

Dr Walsh in his book states that statistics show that if a man has a G8-10 tumor,  surgery with a capsule contained tumor, undetectable post surgery PSA and a recurrences within a year or so, then it is more than likey the cancer is systematic and SRT will not be curative. Therefore when I had my BCR 1 year after apparently successful surgery I thought that I would be going to HT as a next step. I had consultations with my Uro, two ROs and two medical oncologists and was quite surprised when all 5 recommended SRT as a next step. All five acknowledged that the chance for a cure was less than 50%, with one of the medical oncologists stating that it would only be 30-40%. He followed up by saying even with those odds its worth a shot. It seemed to make sense to me at the time but now I'm not so sure. I did have a consult with Dr Myer just a few days before starting SRT. He didn't suggest holding off or that it was the wrong approach for me. We mostly discussed ADT3, other aspects of his program and next steps shoud SRT fail.

Is this part of the overtreatment problem, my SRT cost $110,000? And I was pushed a bit to start soon based upon studies that show SRT is most effort for men with PSAs of less than .5.

I would be interested to hear what others think and may be reading or hearing from their doctors.

Hi BB,

Why not just ask Myers straight out? I do, however, think that Gleason 8-10 cancers are a special case, and that the risk that SRT might be harmful and might not be effective have to be seen in light of the consequences of a lethal high-risk disease not being stopped. Dr. Myers once had a video about relative risk where he expressed concern about high risk patients not wanting to get treatment, or putting it off. That may be his reasoning in your case.

One factor making it less likely that SRT would be effective is your not having positive margins. That condition adds to the argument that the cancer is still local. It surely couldn't hurt to ask Myers if he would not consider growth arrest in your case now.

In my case, three oncologists, including Dr. Mark Scholz, recommended SRT. I know that none of us would wish to have what David has experienced. But many of us have been much luckier. My SRT had virtually no short-term side effects. Being only 7 months out, I can't say if it was successful in killing the cancer, of course. And frankly, given my stats, if it did kill the cancer, any long-term side effects from the SRT happening years from now are of far less a concern; if it didn't get the cancer, I'm afraid my life expectancy would not be long enough to experience the long-term side-effects.

Best of luck with your decision.

Nellie

The side-effects from NOT treating G8-10 cancers are well known...

When my surgery failed, I sought out the best RO I could find who had access to the most up to date equipment. HE thinks he cured me, time will tell...But the side-effects from the radiation treatment have been negligible..I was also on HT..The side-effects from that are far worse than the radiation..

At age 57 and a looming $110K medical bill, I suspect there are other issues here....

the time to pass on SRT is when you feel smarter than your doctors.  good luck with that one.

ed

 

Fairwind and Kark, In both of your cases there was evidence that PCa was still local (positive margin and EPE). I seems to me that SRT was clearly the next logical treatment. It was much less clear in my case. My tumor was completely contained in the prostate capsule with no evidence that any cells escaped. I had PNI which is thought to be the way PCa cells escape through blood vessels. A guess that it does come down to a crap-shoot as to whether SRT, it's side effects, and delayed effects are worth the perhaps 30% chance for a cure. BTW my radiation treatment wen wellt, very few SE's during treatment. I had a good RO and treatment facility, I traveled two hours each way daily for treatments. My continence did regress because of SRT. However, the thought of dealing with bladder or colon cancer in my late 60 or early 70's on top of PCa is a bit worrisome.


I do appreciate your comments and prospective. BB

BB,  Had I been going to Dr. Myers at the time my PSA began to rise, I certainly would have been interested in his "growth arrest" ideas.  Even now, I would like to try them just to avoid having to consider wide pelvic lymph node radiation.  The problem with living in the boondocks (Pensacola) is finding a doctor that has an interest in trying new ideas.  I don't know how far I will have to travel to get a prescription to Avodart.  His videos on growth arrest were interesting.

Carlos

BB,

It's that thought of bladder and/or colon cancer that has my oncologist really concerned for me right now. The risk is there for everyone that undergoes SRT even when the radiation is delivered correctly. In my case, I got slammed with 72 gys to a totally unprotected bladder. As you remember, I was not instructed to have a full bladder when I got the treatments.  Even though I had a suprapubic catheter in place to prevent any strictures during the 2 months of radiation, they still could have easily filled my bladder by clamping the cath, or syringing water up the cath, but the RO told me not to worry about it.  Her famous words:  "Don't worry about it, I got that covered."  The burning that started on the 4th treatment should have been a tell-tale sign to the RO, but she brushed it off, until near the end of treatments, and then, only vaguely admitted that perhaps there was some "scattering" going on with the radiation.  This, btw, is the crux of my malpractice case against the RO, which while has been slow, is starting to pick up legal speed as I write this  Suppose to get an update early next week on the status of my case.

By the time I see my doctor again, he is suppose to have a virtual colonoscopy and virtual bladder scan arranged. He, and my uro, feel its too risky for me to have a conventional colonoscopy due to the radiation damage, and with my bladder, there is no way to have the bladder tested without having a day operation, as the entrance and the exit to my bladder were sealed off after my urostomy surgery in 11/10..

He said with that much radiation hitting such a confined area, he considered me at extreme risk for either or both types of secondary cancers. Just what I need to be dealing with. Originally, I had hoped that my uro/surgeon would have removed the damaged bladder at the time of that last operation, but he said under the guidelines, he was not justified to do so, nor would the insurance have paid for the additional surgical time. He said it would have added at least another 3 hours of surgery.

I wished he had, while they had me cut open, and since my recovery time was so long as it was. The only suspicious sympton I have, is that I am still getting bladder spasms daily, and they are increasing both in number, and in intensity of pain.

I have had bladder spasms continuously since the end of 2008 (hard to believe), but they are getting worse, which makes no sense, since nothing can enter or exit my bladder, so right now, its a suspicious sign that something is irratating the walls of the bladder.

The thought of having to undergo another major abdomimal surgery is beyond my current scope of understanding. That last op almost did me in. But I have to face whatever lies ahead regardless. I won't feel safe or secure until these tests are ran, and hopefully there will be no presence of either cancer.

David in SC

Post Edited (Purgatory) : 6/8/2012 1:39:52 PM (GMT-6)

Impatient:

That's an interesting view. Two of the three RO's I met with, strongly didn't want to mix HT with SRT, as they said that the HT would prevent them from knowing accuratley if the SRT was doing the job. They didnt want anything else in the mix. It always amazes me, how so many different opinions can arise from the same type of doctors.

david

David, my doc did not recommend HT for my case. Whether that was because I was already low T, or because of the reason you state, I do not know. However, if HT helps SRT (and I know of at least one study that indicates that it does), I would think that would trump knowing soon whether it was working or not. My RO did state that my low T would probably help the SRT do its trick.
Jeff

bb,

enjoy portsmouth. we went there often when we lived in NH. you have to spend time in historic strawbery banke, if you haven't before. there is an awesome cemetery there, where people come from all over the world to do tombstone tracings.

david

Dave, having a good time. Dinner at the Portsmouth Brewing Co tonight. Traffic was horrible on 495 comming up.

Newspaper, seems like we are in the same boat. Did you also have a capsule contained tumor? Was SRT the consensus of your doctors? I am wondering if there is now a change in thinking? BB

David:

I think HT with/before SRT is starting to become more and more the standard of care.

You obviously have a concern regarding bladder cancer. Hope you get a clean bill of health there.

Mel

BB_Fan,

Yes my surgery was squeaky clean -- margins, seminal vessels, not a day of incontinence.  Classic "successful surgery"  except....

When recurrence became apparent, I opted for the max treatment available at Sloan-Kettering in New York City, which was radiation to the bed, the pelvic lymph, plus six months HT.  My oncologists (medical and radiation) indicated that HT might mask whether radiation worked or not for six months or so, but weighing this against my situation, the decision was not hard.  Nor did the physicians at Sloan try to mask the likelihood of success from SRT--  roughly 30%, give or take.  My original surgeon here in upstate New York was not as forthcoming about my situation.

I am not particularly optimistic about the eventual outcome, perhaps because my ethnic background is Irish?  I am old enough to remember when new movies by Ingmar Bergman were a big deal.  In the Seventh Seal a Knight and his Squire return from the Crusades to a Scandanavia ravaged by the Plague.  Death appears, and the Knight bargains for a chess match to extend his life. The Knight's journey continues, interspersed with the match. The Knight plays very well, makes some excellent moves, and delays his opponent, but in the end...

That's how I see my situation.  I will make every move I reasonably can, and try to delay my opponent for as long as possible.  Overcast here in upstate New York today, but a good day.  My wife and I are off to see Promethius. Best wishes to all.

Newspaper Lover

Age 68

DaVinci surgery 11/09. Clean margins, clean seminal vessels.

Rising PSA noted 06/11

Gleason 8

Time to recurrrence 18 months

Three month doubling time (summer 2011).

PSA rose from .07 on 06/11 to .17 on 11/11.

MRIs and bone scans negative so far.

Started Lupron/Casodex 12/11

Began IMRT 02/20/12.

Finished IMRT 04/16/12

PSA follow up in July, 2012.