When to pull the SRT trigger

It takes time to recover from surgery..Yes, if needed, start SRT as soon as possible after surgery but you want any incontinence issues resolved before you start R/T as the radiation tends to stop progress on that front..I would also insist that an up to date LINAC be used to administer the radiation..

Much of the treatment planning goes on backstage..The insurance companies don't pay unless certain guidelines are met. The same goes for when to start some of the new promising drugs..You have to show them bone mets before they will approve treatment...These drugs might do much better if started earlier...

For what it's worth my Urologist says we'll move to the next step at 0.03. I'm in Sweden, free health care so no insurance rules to worry about and ultra sensitive testing. My first PSA (post op) will be in June so will follow this discussion with interest.
Cheers, Doug

Good to see confirmation of something being effective the way I thought it was.

I had no problems with delays. I was 0.1 after surgery and they said that if it went to 0.2 they'd want to do SRT. I was up to 0.4 within months, and within about 5 minutes of the uro telling me that he had had the receptionost make an appointment with the RT guys, and I was talking to them a week later. And a few months later the SRT got my PSA down from 0.4 to undectable, so I clearly had it at the right time.
(Also the uro sat in on the discussion the RT team had when they were planning how to aim the beams etc. I guess they took on board his input on whereabouts in the prostate bed there was the biggest chance of there being something nasty on the basis of the post-op pathology - my tumours were at the top of the prostae and towards the back and had spread into the seminal vesicles, so I'm guessing it may have been the case that the surgery left behind something in that area that was outside the prostate, but which the SRT caught.)

Doug - sorry you have the complication of being treated via an interpreter. I can speak Dutch okay, but it still gets complicated. I have to remind myself that even if I was in the UK I would have trouble understanding everything that a medical specialist said to me. My experience in Sweden has always been that they speak good English. (I have lots of family connections to Sweden and my dad even had his appendix taken out at the Karolinska in Stockholm many years ago without there being a language problem.) Also interested that you were G9 with such a low PSA. l expect this may be a rason they want to do SRT at a lower score - but I hope you never need it!

Alf

Post Edited (English Alf) : 3/24/2014 4:05:14 AM (GMT-6)

proscapt said...
Viperguy, I'm pretty much in the same position as you in terms of staring SRT in the face. I came out of surgery four years ago with a PSA of <.01 but it's been rising fairly steadily ever since that is almost hit .1


phenom - I would really encourage you to check out the Sloan Memorial Kettering Cancer Center nomogram to get an understanding of the factors that can make the success odds 70% for one person and 35% for someone else. It is a combination of multiple factors including doubling time, Gleason, pathology, years between surgery and recurrence, radiation dose, whether adjuvant hormonal therapy is given, and so on. You can key in your own numbers and some hypotheticals and assess your odds.

I believe this article has it right.

From what Myers and Scholz and others have said, if there is a clear pattern of rising PSA then it is good to initiate SRT early and not wait until the official threshold of 0.2+ a confirming reading. I know many on this site disagree and I don't attempt or expect to change anyone's mind. As the article indicates there is not much curative potential lost between a PSA of 0.1 and a PSA of 0.2, but why give any of it away? That is my personal view.

I believe the threshold of .2 is a holdover from earlier days before ultrasensitive testing became widely available.

As one doctor said to me, the kinetics (trend) are more important than the actual absolute number. This is an important complicating factor. For example, one patient may come back from surgery with a .05 and then have their PSA bounce around between .05 and .1 for three years without a clear trend. That patient does not need to run in for SRT.

Take another patient, with the same Gleason and pathology, comes back from surgery with a PSA of .01 and then sees it rise to .1 fairly steadily over three years. That patient should probably making plans for SRT.

Of course the other factors do matter. The patient with a Gleason six for example could probably let it go longer than a Gleason seven without significant increase in risk..

I found it really helpful to go to the Sloan Memorial Kettering Cancer Center website and use their nomogram for predicting success of SRT. You can enter different numbers and see how it changes the odds. you can decide for yourself whether you think it's worth waiting, with you want to burn up a little bit of curative odds for a little bit more time without side effects and/or the possibility that the increase might stop on its own.

I checked out the Sloan thing you mentioned about PSA doubling times and SRT. It appears using Neoadjuvant Hormones along with SRT jumps your chances for a cancer free life by about 10% with my current gleason scores. That will be something I would definitely discuss with my Uro when the time comes. Thank you for sharing this information, you guys are super. I personally sympathize with anybody fighting this disease. Moral support and information really help.

When or whether to start SRT depends on your prognosis. If PCa is localized after RP based on negative EPE, SVI, Margins, nodes then SRT when PSA is >.2 is recommended and effective. I just spoke to my Johns Hopkins surgeon after PSA of .2 five months post op. I had very poor pathological prognosis ( g9, EPE, SVI, pos margin) . Basically my PCa has left the barn and SRT won't benefit. He says Dr Walsh, the guru of PCa would recommend waiting for mets then starting HT. Dr Walsh thinks SRT and ADT cause nothing but bad side effects for no benefits with stage pt3b PCa so why put the patient thru it? He said spot RT after mets is effective whereas shotgun RT is of no benefit and potentially harmful to gastro intestinal system. I'm 70 and my doc said I'd be alive at age 80 without SET or ADT.
Bob

I had surgery with a clean pathology report. Tumor was completely confined to the prostate, yet I had a recurrence 9 months after surgery, PSA of .07. I was told to wait 3 more months. With what I know today, I wouldn't have waited. PSA jumped to .28 after 3 months and was at .5 3 months later just before the start of SRT. 

Anyway, I was going to pass on SRT because I read Walsh's book also. Being a G8 with a capsule contained tumor, quick BCR and a rapid doubling time, it was likely that my cancer was not local. I was convinced by Doctors I spoke with to hit it hard even though a cure was unlikely. I had SRT, pelvis (no nodes) and 12 month ADT3. So far it has given me a remission period of over 30 months. I hate to think of where I would be today if I waited until I had mets before I had any additional treatment.

Treatment really worked out for me even if my continence regressed a bit. Perhaps my decision would have been difference if I was 68 instead of 58 at the time.

Bob (Break60)

Your thinking, and Walsh's, matches so much of what my own oncologist has been telling me the past 3 years.

Too many men jump the SRT wagon, way before it's needed, and in many cases, it does not work or stop the cancer - because the cancer wasn't in the prostate bed in the first place. I would like to see even one RO prove to the patient that it is there. They can't do it, no way to detect it. It's just a best guess, at best. Studies have been shown that if SRT is going to work, it can be safely done as high as PSA of .50, so why should one take the risk of radiation damage before that point?

My doctor has always agreed with Walsh about not rushing into HT as well. Both do not believe in the early or pre-emptive use of HT in most cases. Again, subjects men to a lot of bad side effects, or even leads to more serious health issues, i.e. heart problems. They both believe in waiting to there is some evidence of something really going on, then go for the HT. This is the path I have been on for over 3 years now. Other than a steady rising PSA, I have no evidence of mets anywhere in my body, so if nothing else, I am being spared even more side effects than I already am dealing with because of SRT heavy damage.

This is one problem, and its a pet peeve of mind (not saying I am 100% right), of constant PSA testing and PSA anxiety/worry post treatment, and the main reason that ultra sensitive PSA testing causes more harm to the patient than good.

Yes, undetectable is viewed as <.10, but just because one nears or exceeds .10, it doesn't mean something terrible is going to jump up and destroy you. Even at .20, there is so little cancer present, that it does not pose any kind of harm or threat to the patient. Too many get hung up on minsicule PSA rise, and in turn, they begin to convince themselves that they are in dire need of additional treatments.

I do not believe this is good enough to take on a secondary treatment, just based on small PSA rises. Even the doubling time arguments I see here, are over rated in my personal opinion, and that of my doctor. Again, too many are lured into the wonders of ultra sensitive testing. When you are dealing with PSA numbers well under .50, these microscopic rises some report, i.e., going from .002 to .004, are all but meaningless in the bigger picture of things. Yes it means that it doubled, but it still doesn't mean anything is really wrong. Still well within "noise" and testing variances. Now if you have a post treatment PSA that goes from 2.0 to 4.0 in a short period of time, that is much more serious, but not that of the example listed above.

My doctor feels that far too many men either talk themselves into additional treatments either based on anxiety in general, or hidden fear - more so than on the actual facts of their PC case. Or, as he has put it, he has problems with RO's pushing patients the moment their PSA rise to .10, the dreaded detectable point that all of us have come to accept. There's so much money being made with SRT, so it is suspect how quick that many RO's want patients to jump on the SRT band wagon.

I just think these are things to think about. Our treatment decisions should never be rushed - think we all agree on that, but they should also be based on pure facts of each patient's particular PC case and history, and treatments should never be made based on any aspect of fear, anxiety, or worry.

This notion of "throwing everything at it" sounds tough and noble, but that doesn't mean it's really the best course of action. One has to think of the potential harms and side effects, aside from fighting the PC, that is being done to one's body in the name of treatment. Got to act factually, not emotionally.

Know this post won't be a popular one, but just wanted to say my peace, and it is just my unprofessional opinion. And its based on what I have learned first hand, and what I have witnessed here at HW after 5 plus years. Not an expert on anything.

David in SC

I have, quite a while ago and they are very positive. I totally agree with your last paragraph and have played with variations of the worst kind making my gleason a 10 adding positive margins etc.The time frame of undetectable since op is always a constant.i.e. its always what it is actually, I don't do variables. on that. hey I'm cool with my results, Im living into my 90's maybe crack 100 with or without pca. Heck I may just give the devil his pound of flesh in the end. Poor ting, he's got moxie I'll give him that, that and five bucks will give him a footlong right where it belongs. BTW my post had no hidden agenda, I wasn't aware you knew that and wanted to throw it in, for your consideration…. fo real

I honestly don't know how anyone with a .05 reading could think they are in any kind of danger. It baffles me. As I said, even at .10, doesn't mean the sky is falling. Life is way too short, to worry about something that hasn't even happened, and may never happen to someone fortunate enough to have PSA readings that low.

David (Purgatory),
Your post hit home. The RO has been pushing for SRT for my husband, even though he is on a feeding tube because of radiation damage from his tonsil cancer treatment 10 years ago. My brother-in-law made the comment "They're chasing the cancer rabbit and the man is starving to death."

Purgatory,
I'm pretty sure I will have to make some decisions in the near future regarding further treatment. SRT will not be something I will consider. I see no logic in it at all. I plan on AS until there is something definitive to treat(as proven to me). As you can see in my signature, my numbers according to mainstream thoughts, I should have opted for RT as an initial treatment. I couldn't see the logic in that either. Maybe there's more money in RT, maybe they want more numbers for their trials. Who knows? I'm going to focus on QOL not cure. Thanks for being so active on this forum, you've certainly helped me in more ways than one!

Cheers, Doug