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Why salvage radiation is bad.

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Posted 1/19/2015 3:37 AM (GMT 0)
I would agree with you 142, the facts laid out by TA will certainly help some in their decision making progress. In rereading his comments I think the point he is making is that surgery might be a less than optimal choice in some instances, one of them being when there is clear evidence that the Cancer has escaped the capsule.

This was , in fact, for me, not the only, but one of the important reasons my final decision was to do RALP. If my MRI had shown escape from the capsule, I might have opted for RT.
Posted 1/19/2015 4:29 AM (GMT 0)
Sorry to pile on dude1969, but I also don't think this is strictly "anti-surgery." It does, however, underscore some comments about how surgery gives you a second bite of the apple since you can always have surgery afterwards. From a first-hand perspective, I only have my uro to judge how this was described to me, but anecdotally based on many postings here it does seem to be mentioned in a cavalier fashion, similar to being handed a Monopoly "get out of a jail free" card. I think all that Allen is doing is stating it's not and giving folks some food for thought.

If you have a very good chance of the surgery being confined to the prostate than I think surgery can be a great choice, particularly if you have access to a top notch surgeon. I personally wanted to have surgery and I would have if there was a good chance that my treatment would have ended there. I was originally diagnosed as a G8 and when my slides were sent to Epstein for a second opinion I was so very much hoping they'd come back as a G7--since I wanted surgery that would have been enough to move me in that direction. Unfortunately, I was re-diagnosed as a G9 and that coupled with other staging info made me realize that it wasn't for me.

BTW, Allen points out that salvage radiation is also not a free pass and comes with its own complications. To me the biggest takeaway is that this disease really sucks.
Posted 1/19/2015 4:47 AM (GMT 0)
It's not just extra capsular extension that makes surgery a poor choice, but also cancer that is around the nerves and in the apex. ED and incontinence are much higher risks even if the cancer is contained.
Posted 1/19/2015 5:04 AM (GMT 0)
I absolutely agree that neither surgery nor radiation is a walk in the park.

TA -- two questions, considering my situation.

I failed surgery and SRT. I am back on HT after a brief HT vacation.
Anway, as you know (but repeating it for background) I had the C11 Choline Scan at Mayo.
They found my PC in one external illiac node. It was a very small amount but I have a real lousy PSADT.

Anyway, my SRT was to the prostate bed only. We are going to do it again, this time only to the nodes in the area (50 gys over 25 sessions). If my PSA responds again to the HT, we will do the radiation in mid-May so I can work this semester. My questions:

1) Is the SE profile for this new round of radiation (I was told they will not be re-radiating the prostate bed) just as bad as for SRT? I was told to expect less issues regarding rectal and urological stuff but maybe more GI problems.

2) You indicated that HT made the radiation worse. Yet Dr. Lam and the RO both indicated that it was actually helpful, making the radiation more effective and vice versa. I guess that's confusing as it appears your comments are the opposite of what my doctors say.
Mel
Posted 1/19/2015 5:11 AM (GMT 0)
I think a big issue is getting correctly staged. One of my criteria for my husband having surgery was that the cancer be confined to the prostate. My husband was told by 5 doctors - 3 surgeons and 2 RO's that his cancer appeared contained. Two doctors - a surgeon at MSKCC and an RO at Cornell told him that the distribution of cores positive for cancer was consistent with a cancer that was contained. My husband did have a lot of cores positive for cancer - 7 out of 12. Six were G6 and one was G7(3+4) and two cores had more than 50% volume of cancer. I have wondered if this might be a red flag for ECE (maybe it isn't).

My husband had an MRI done that showed no ECE. His post-surgery pathology was positive for EPE, although the margins were negative.

Although looking back is futile, I wonder if there was a test or step that we missed that could have identified the ECE. I guess my question is - is there a way to stage cancer more accurately than through a biopsy and an MRI?

Since my husband's last PSA was elevated, I am concerned that a salvage treatment may be in his future.
Posted 1/19/2015 5:27 AM (GMT 0)

island time said...
Why would anyone do this??[i.e., elect surgery when he is stage cT3, knowing beforehand he will have to have salvage radiation]

From what I've seen in my support groups, the biggest factor may be a psychological one. We all have that first, very natural reaction to "just cut it out." Some of us get past that instinct and make a more considered decision eventually - even when it's the same decision but done for different reasons. But for guys diagnosed with T3 right off the bat, they don't have the luxury of time to decide. Some may opt for hormone therapy to buy time, but some don't want that. And the first doctor they talk to is always a urologist. Many surgeons have that "hot dog" attitude that they can cut out anything - it's the self assurance that probably makes them good surgeons. The other side of the coin is that it's the arrogance that may keep the patient away from other therapies. We are all attracted to that air of self-confidence, especially when our world has been shattered. The cure is patient empowerment - giving the patient the tools he needs and the self-confidence to make his own decision.

There may be medical reasons too. For example, known radiation sensitivity, previous pelvic radiation, prior history of urinary retention, inflammatory bowel issues, metal prostheses, and anatomical abnormalities. But then, salvage radiation would be out of the question as well.

- Allen
Posted 1/19/2015 6:04 AM (GMT 0)
I agree fully with TA's entire premise on SRT.

I am still HW PC's poster child of SRT damage. I do not believe any member here is as damaged, as I have been directly as the result of SRT.

I have been warning men here since 2009, shortly after my disastrous run of SRT ended, to think twice about SRT, and to make sure they really need it in the first place.

For starters, the odds of SRT working are low to begin with, 30-40% at best, often 10-20% in reality.

Even the greatest RO's can not assure you that your recurrence is even in your prostate bed.

Short term and especially long term radiation damage is greatly downplayed by most RO's.

And once you are damaged, very little can be done about it, most times it ends up being permanent damage to the body.

Long term damage can take years to manifest, even if short term damage clears up, and it can happen even 10 to 15 years out.

The risk of developing a secondary cancer as the result of the SRT can be much higher than many RO's report

Radiation Center's often ditch damaged patients, just as was done to me, once their treatments are over with. My urologist will vouch for this over his long career, as he often has to be the one to deal with all the "damaged" goods that the RO's dump off on him.

I have seen too many men at HW PC, rush into SRT, because of very minimal evidence of recurrence, recurrence, that would likely never harm them the rest of their natural life, often because of an obsession with ultra sensitive readings post surgery. Even if they rise to .20, do they not realize how truly microscopic amount of cancer that is?

It's been no fun having long term painful strictures, endless catheters, scopings, dialations, etc. as the result of SRT. It was no fun undergoing ileal conduit surgery and ending up with an Urostomy because of having my bladder and bladder neck being so burned by radiation, and peeing into a bag for the rest of my natural life.

And living with severe nerve damage, that can not be repaired, ever, is no way to live the rest of you life either, that with severe chronic fatigue that never, ever improves.

I am over 5 years out of SRT, and the damage still continues to get worse and worse over time, and for what? I still have rising PSA, as the SRT failed to address the cancer, as it more than likely, never, ever in my prostate bed in the first place, most is believed to have long escaped, perhaps even prior to my surgery via PNI, and is in the form of many micro mets scattered through out my body, all slowly growing, still too small to be picked up by scans.

Just something to think about. SRT is not just some easy back up step to a failed surgery, its an expensive and serious undertaking. The human body can generally heal from complex surgeries, but no one's body is designed to be burned by radiation, distorting the good flesh, and the good cells, along with the presumed bad.

Listen to what TA is telling you here, I am speaking from first hand knowledge, I am living painfully, as the result of SRT gone bad.
Posted 1/19/2015 6:04 AM (GMT 0)

Mel said...
I absolutely agree that neither surgery nor radiation is a walk in the park.


The subject of my post was salvage - not primary therapy - in the local area.

Mel said...
1) Is the SE profile for this new round of radiation (I was told they will not be re-radiating the prostate bed) just as bad as for SRT? I was told to expect less issues regarding rectal and urological stuff but maybe more GI problems.

I think they are correct that the only issues with whole pelvic RT (WPRT), if there are any, would be with the small bowel. My friend had no such issues.

Mel said...
2) You indicated that HT made the radiation worse. Yet Dr. Lam and the RO both indicated that it was actually helpful, making the radiation more effective and vice versa. I guess that's confusing as it appears your comments are the opposite of what my doctors say.

HT makes the sexual side effects of the radiation worse. Of course it makes the radiation more effective -- why else would they give it, knowing it has side effects? Sadly, "helpful" oncologically is often "unhelpful" in terms of morbidities.

Post Edited (Tall Allen) : 1/19/2015 12:28:24 AM (GMT-7)

Posted 1/19/2015 6:18 AM (GMT 0)
Bluebird,

I agree that accurate clinical staging can be problematic. I think a 3 Tesla MRI (or a 1.5 T MRI with endorectal coil) is about as good a current technology gets for ECE detection. MSK and Cornell would have the best up-to-date technology, I assume. Maybe a CDUS in the right hands is about as good. But a small amount of GS 3+4 might not show up even with all kinds of parametric MRIs or CDUS. This is why a clinical T3 diagnosis is such a red flag. It is a hard thing to detect, but if it is detected these days, that means that there is some serious tumor outgrowth occurring.

- Allen
Posted 1/19/2015 7:22 AM (GMT 0)
Allen,

I'm not sure what you mean by a clinical T3 diagnosis. My husband's stage was T1 before surgery. Is a clinical stage the stage before surgery (determined I believe by the exam) or the stage after surgery (determined by the pathology report)? Are you saying that if a T3 is detected before surgery there is serious tumor outgrowth occurring?

Thanks for your reply. It helps me to feel that we did the best we could when choosing my husband's primary therapy.
Posted 1/19/2015 7:35 AM (GMT 0)
"Clinical" (c) means before surgery - from a DRE, ultrasound, MRI or any other imaging study they do. "Pathological" (p) means what they learned from looking at the excised prostate in the lab after surgery. Clinical cT3 has a more dire prognosis than pT3 found only by pathological examination afterwards.
Posted 1/19/2015 1:49 PM (GMT 0)
I'm curious. I was dx. 5 1/4 years ago. I had a G4+3, with a reading at Ford Hospital G 3+4. It was in 5/12 cores. I consulted with a variety of medicos and surgery was recommended.

That wasn't so long ago. As it turned out surgery failed.
Nobody ever mentioned an MRI or anything else.
Why?

(I assume the newer MRI's were just experimental then?).

Mel
Posted 1/19/2015 3:01 PM (GMT 0)
We met with 3 surgeons. Dr. X does not do MRI's. He said that he does not think they provide accurate information. He also said that he thinks it is unethical to operate on a prostate where it is known that the cancer is not contained.

Dr. Y, at MSKCC wants an MRI done a few days before he performs surgery. He only uses an MRI as a guide to performing surgery, not as a tool in deciding if surgery is necessary. He told us that he thinks surgery provides a value even if it is known that the cancer is not contained.

Dr. Z, my husband's surgeon, always has an MRI done. He never discussed with us why he wanted it done. When he looked at my husband's MRI results he said that the tumor was contained, but starting to get aggressive. I read the MRI report and it specifically says "no extra-capsular extension". So I guess an MRI cannot always detect small amounts of G7 (3+4) cancer.
Posted 1/19/2015 3:19 PM (GMT 0)
This is an interesting thread, and I guess somewhat timely for me.

I had surgery as my primary treatment back in May 2011. The post-up pathology was not exactly the best: Gleason downgraded to 6 (yeah for me!) but EPE could not be determined and I had a focal positive margin. Final staging was pT2cpN0. You can review my post-op pathology by clicking here.

Since then, my PSA slowly rose until Feb 2014 after which I started taking Avodart in hopes of slowing the velocity of the PSA rise, though I was well aware that an eventual BCR was most likely. You can see my entire PSA history since surgery to today by clicking on the link in my signature below.

Fast forward to today. I just got back my quarterly PSA test and I am now up to .041.

A recent post on the forum suggested that for folks with an aggressive post-op pathology with an increasing PSA beyond .03, they should consider receiving SRT in hopes of arresting and possibly curing the cancer. That post is located here.

So it seems I'm approaching a quandary: Do I treat now, do I treat later, or not at all?

With all the potential dangers surrounding SRT, how do I determine if and when to treat my G6 cancer, which I'm assuming may or may not be indolent? As David (Purgatory) alluded to earlier, is it necessary to treat something that may never lead to any harm on its own?
Posted 1/19/2015 3:39 PM (GMT 0)
Personally I wouldn't be in a rush to treat a G6 with that low of a PSA. The 0.03 is more for the G8's and above as I understand it.

Cheers, Doug
Posted 1/19/2015 3:59 PM (GMT 0)
This is very confusing for me. Se my numbers below. Clearly Im not as educated as I should be. I thought the HDR Brachy radiation was the right move for my ( what I was told) was most very likely contained prostate cancer. The HDR is scheduled in 10 days. Is radiation going the wrong route.. Who knows? Two readings of my slides came back all G6 5/12 cores. Is there not anything, pharma etc, that will "assist" the healthy cells that are being bombarded with the HDR Brachy recover more quickly and be as strong as they were, while allowing the cancerous cells to be negated. The URO did tell me that if this does not work then really there is not much of a backup treatment plan (part of his spiel he has to give he says) ... maybe I should do nothing.... I am sick of this constant conflict of info. but that is what it is.
Posted 1/19/2015 4:21 PM (GMT 0)
BenSam,

What I got from it is this:

My urologist who did the biopsy, when advising surgery as the best route for me, used three reasons that surgery was the best:

1.  "Radiation can be a back up to surgery but surgery isn't a good back up to radiation".

2.  "I'm better than most surgeons so ....."

3.  "You should want to get it out....."

Tall Allen is saying it's not as easy on #1 as some take it or as some urologists present it.  Urologists (surgeons) like mine deal with Radiation failures when trying to do surgery (my dad's urologists commented on his bladder cancer radiation once as being 'spongy'.), but I doubt many urologists are around when they have to radiate after the prostate is gone.

I think you've chosen an excellent path.  None of it is ideal of course, but I'm feeling good about my own experience.  Last night after reading this thread I researched and found a great report from a RO out in Oakland (He's written with Demenes) about how the HDR varies from each point in the cathaters to directly hit the cancerous cells while limiting exposure to other organs.  This is quite different than shooting radiation from outside the body, imo.  Although that has improved dramatically as well over the past few years.

Posted 1/19/2015 4:25 PM (GMT 0)
BenSam,

Tall Allen was writing quite specifically about "salvage" radiation -- radiation given after prostate surgery has failed to suppress PSA increases, suggesting that the disease remains active. Most of his concern is about radiating tissues already traumatized by the surgery. He is not talking about cases like yours.

With so many positive cores you are sort-of borderline for AS although there are well-regarded AS programs that would take you, I think. But AS is quite different from "doing nothing" and HDR brachy is a good choice of treatment for you.
Posted 1/19/2015 4:32 PM (GMT 0)
Better understood. Thank u PeterDisAbelard. I was told by several DOCS that I am just outside of the AS range due to the number of cores.... 2 @ 60%...
Posted 1/19/2015 5:01 PM (GMT 0)
@Allen...excellent thread - and very valuable info for men to consider.

@BenSam...I'll be repetitive since I know you have some anxiety about your choice. Allen's comments are definitely NOT applicable to your situation. HDR as a primary treatment is a whole different animal than SRT which is post-treatment (usually post surgery). You have made an excellent choice and are a great candidate for that choice since you have opted out of AS. The "operation" is minimally invasive, the curative results are likely to be excellent and your chances of long term onerous SE's are greatly reduced compared to surgery. I know it's easy for me to say but -- be happy and try to relax a bit.

Jim
Posted 1/19/2015 5:03 PM (GMT 0)
I believe TA is completely right. My new mantra is, TA researched, it must be correct.
Posted 1/19/2015 5:08 PM (GMT 0)
What I didn't want to do here is frighten people away from salvage radiation when they really need it. I just wanted to give a healthy respect for the risks involved. This has nothing whatever to do with primary radiation, BenSam

John (HD-Rider). Even a GS6, if left behind, can eventually progress to something that can metastasize. It's true that it might remain just a GS6 for the rest of your life. The nice thing about the low grade is that if you decide to go for SRT, ADT would likely not be needed with it. I've heard of biopsies of the anastomosis or the prostate bed, but I don't know how useful or productive they are.Have you met with an RO yet?
Posted 1/19/2015 5:09 PM (GMT 0)

Dewayne said...
Last night after reading this thread I researched and found a great report from a RO out in Oakland (He's written with Demenes) about how the HDR varies from each point in the cathaters to directly hit the cancerous cells while limiting exposure to other organs.

Dewayne, could you post or email me a link for that report? Thanks.
Posted 1/19/2015 8:26 PM (GMT 0)
My biggest gripe about those who choose surgery over alternatives just because of possible SRT, rarely knows it only has about a 30% success rate.
Posted 1/19/2015 10:08 PM (GMT 0)
This thread has scared the hell out of me as I've just recently organised to undergo SRT!
I guess what stands out is the quoted 30% success rate which to me is a potential deal breaker when SEs are considered!

Has me thinking...should I wait longer to see how the PSA numbers go?
How long have I got if I just do nothing?
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