Immediate or delayed ADT after radiation/IMRT when psa rises to recurrent levels

Sorry for such a long mail thread.

My pca history and details are at the end of this post.

My detailed questions are further below, first some background on the topic:

My basic questions below relate to someone like myself who has had radiation (IMRT)
and not surgery as the original treatment, and who, after several years since
treatment, has seen their psa start rising, and that it has doubled in 5 months
(from 0.3 to 0.6 in my case, which also represented 3 sequential psa rises) which I
think are some of the criteria for it being viewed as recurrent --

and related to someone like myself whose recent bone scans, ct scans and prostate mri do not show anything at this
time. (psa was 0.6 when imaging was done).

I've read some studies or articles that seem to say that in certain cases, the results of
waiting to start ADT until certain criteria other than psa only recurrence
have been met, might
be acceptable and comparable to results of starting ADT immediately on psa defined
recurrence only. (There are also studies that say immediate adt on psa recurrence
is better)

Some of the studies on delayed adt mention that the other criteria that could indicate the need to
start ADT immediately (if not starting it at time of psa recurrence) would be
evidence of metastases and/or certain psa values some or a lot higher than psa
recurrence values and/or psa doubling within some short time frames, for example
less than 4 or less than 8 months and/or patient having symptoms that could
indicate pca spreading.

I think some reasons suggested for delayed ADT is to avoid some of the side
effects of ADT until the ADT is really needed, in the context of study results
showing no difference in survival
as well as perhaps not beginning sooner than is needed the time when the hormone resistance to adt
might start. (since that might relate to how long one was on adt)

However one argument I've read for immediate ADT is that starting it sooner can
help keep the progression from starting when psa is lower compared to delaying
when psa is higher and thus possibly more time for metastases to progress.


I realize this can be a controversial and debateable topic.

My history and details are at the end of this post.

I'd really value your thoughts, opinions and your experiences if applicable
on this topic to my questions below:

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My questions are:

1. High level question - When should ADT (hormone treatments) begin for
someone who is recurrent based on psa only criteria - now or later ?

(lets assume no other salvage treatments will be done)

That is, For my specific situation, should the ADT begin immediately ?

(my psa is 0.6, recurrence has been deemed to have occured, psa doubled in 5
months, but nothing has been seen in recent imaging done when psa was 0.6

OR

Can the ADT possibly be safely delayed until certain other criteria are met ?
(such as certain higher psa values, positive results of imaging tests and/or patient symptoms)


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2. LOWER level questions:

2a. LOWER LEVEL QUESTION related to psa value - Should the only criteria for starting ADT be some psa values or trends only, and if so,
should those psa values or trends be the same as the ones used to define psa recurrence ?
(which means the ADT start should be immediate)

OR

should/could those psa values be allowed to be some or a lot higher than the
psa post imrt recurrence usually accepted definition values ? (ie 3 sequential
rises, psa > 1.0 or 2.0 over the post treatment nadir, for example.)

I think I've seen both interpretations of this in my readings.
But I'm not clear on what those higher psa values are allowed to be.

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2b. LOWER LEVEL QUESTION related to psa doubling time

- For the cases where
ADT might be delayed after psa only recurrence, does a short psa doubling time
(ie less than 4-6 months) define a criteria for when ADT should start
immediately and not be delayed, even though the psa absolute values
might still be under some threshold criteria for defining recurrence (ie 1.0 or 2.0 over nadir)
---- and even though there is no positive results in the images ?

I'd read in some studies that seem to say that delayed ADT would not be ok if short psa doubling times exist, for example less than 4 or 8 months.
(or rather their study criteria required adt to start when there was short
psadt)

But its not completely clear to me if this psa doubling reason to start ADT is
absolute or only involves psa that starts at a certain higher value than mine, for example at 1.0 or 2.0 over the nadir, or at even higher values
(since my psa now is 0.6 even though its doubled in 5 months from 0.3)

or if the doubling itself, regardless of psa actual value, means one should start ADT immediately, regardless if scans are clear.


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2c. LOWER LEVEL QUESTION related to imaging test results

(1) - Should positive results of imaging tests be used as one of the criteria for
starting ADT versus starting adt only upon rise of psa values to meet
recurrence definition or some psa above some higher values than recurrence psa ?

I've seen this mentioned in some of the literature that discusses delaying ADT
until positive results are seen on images as well vs psa only values deciding when to start.

I've read that often sensitivity of imaging tests might not show anything until the psa is higher than it might be for a psa recurrence definition -
that is, have read that number to be a psa of 1.0 or even much greater,

For myself the sodium flouride bone scan, the abdominal and pelvic ct scan and the prostate mri did not show anything but my psa is 0.6, which means it could have been too low to show anything that is already there, but imaging tests can't see at this time.



(2) Thus I guess I am confused related to the benefit of waiting for imaging to show positive
results before starting adt in the case of those who view delayed adt as something
ok in general - it seems to mean that if/when eventually the images will show positive results,
that the progression was
happening all along, just did not show since psa was too low to show it.

if this is so, it seems that indeed time would have been lost in delaying adt
treatment until the images did show positive results ? But then the studies that said delayed adt was ok until images
showed positive results claimed no difference in outcomes with immediate adt on psa only
recurrence versus waiting to start adt until positive images showed.


or does it mean that sometimes regression defined by psa only does not mean
the pca is
spreading/has spread at all, and that is why the studies or opinions that call
for delayed adt say to wait until positive imaging results ?
(even though the psa at that time might be higher than psa recurrence values)


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Thanks for reading this post, and again I apologize for its length.

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MY HISTORY

A.initial diagnosis and treatment

I am now 68 and 1/2
diagnosed 9/2010
gleason 7 (4+3) in multiple cores
4 cores - 4+3 90% of core
2 cores - 3+3 - 5-10%

NO surgery happened
pre- IMRT ADT with lupron - 1/2011 thru 6/20`only
IMRT - 5/2011 - 6/2011

No further ADT since 6/2011
No salvage treatments will happen

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B. PSA history after diagnosis and treatment with IMRT - no surgery was done

01/2011 - 08/2011 - < 0.1 (am assuming due to lupron given from 1/11 - 7/11) (7 months)
09/2011 - 12/2011 - 0.1 except for one 0.2 (3 months)
01/2012 - 06/2012 - <0.1 except for one .1 (6 months)

- I don't know if the 3 psa increases below were related to a bounce or thyroiditis I had during that time
08/2012 - 0.3
09/2012 - 0.2
10/2012 - 0.2

11/2012 - 8/2013 - 0.1 - (9 months)
09/10/2013 - I had a sigmoidoscopy and DRE
09/18/2013 - 0.2 (first time it went to 0.2 - I blamed DRE but as seen later, psa did not return to 0.1 later.

09/2013 thru 02/2014 - 0.2 for 5 months
03/2014 thru 09/2014 - psa alternated between 0.2 and 0.3 each month and finally stayed at 0.3 starting 09/2014

09/2014 thru 01/15/2015- 0.3 - for 4 months

2/25/2015 - 0.4
4/14/2015 - 0.5
5/15/2015 - 0.5
6/22/2015 - 0.6
7/26/2015 - 0.6

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C. how long psa took to double

0.2 > 0.4 - 8 months

0.3 > 0.6 - 5 months
(01/15/15 thru 06/22/2015) - using last time psa was 0.3 as starting point)

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D. Recent image scans happened when psa went to 0.6

a. CT abdomen and pelvis with contrast - 8/2015
b. Sodium Flouride PET bone scan - 8/2015
c. prostate MRI - 8/2015

-- no growths or other pca related problems were seen

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E. am not taking any ADT related or other pca related medications at this time

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F. Alkaline phosphatase - has always been in high part of the range, but most recent lab showed for the first time,
it being 1 over the high end of the range - 118 (117)

Tomw-

You are mistaken in your belief that a few rises in PSA after radiation constitutes biochemical failure. The radiation oncologists (ASTRO) all got together in Phoenix in 2005 and changed the definition to nadir+2 just because of cases like yours. Analysis showed that the older "ASTRO" definition of 3 consecutive rises at low PSA levels led to vast amounts of overtreatment. You still have an intact prostate and it is subject to PSA fluctuations from any number of causes (e.g., prostatitis, urinary retention). I'm frankly surprised that your doctors let you have all those unnecessary tests.

If your PSA reaches 2.1 ng/ml, you can consider biopsy to determine if there is real local clinical progression and salvage options, until then, try not to go over the deep end about this.

- Allen

The other replies are correct. First make sure your prostate is clear of disease by biopsy, scans, ultrasound etc. before getting a C11 scan.

This is the original poster.

Thanks to all for your encouraging words about where I'm at now in context
of my psa and that my situation would not be viewed as recurrent yet if
the phoenix definition was used.

However, since it does keep going up, and the doubling time also continues to
be short, and thus ADT might still be on the horizon, thus I'd still value your input and opinions related to my original questions, and rightly or wrongly, this is a topic that is important for me to understand.

Thus I wanted to ask in relation
to my original questions, if we can just assume for this discussion:

1. that my psa is 2.1, and as per phoenix criteria, it is now recurrent,
as mentioned in one of the replies that the 2.1 would meet that criteria
since the nadir was 0.1

2. that imaging done when it is at this 2.1 does not show anything
(and I won't be able to go to the places that do the choline scans)


With that in mind, could you look again at my original questions ?

To summarize them:

1. should psa recurrence be the sole decision to start adt if nothing shows in images ?

or

should starting of adt wait until images do show definite things,
(even though at that time psa will be higher, at least if current trends continue ?


2. should short psa doubling time in itself be a reason to start adt after recurrence
has happened, even though images at that time do not show anything ?



The questions in the original post give more detail and context.

Thanks again.

Tomhw - perhaps those are questions on which MOs would differ and there are both risk and opportunity in any course you choose. When I imagine arriving at a similar crossroads I resolve to identify an MO I respect & with whom I sense common values and follow his recommended course. ..much as I did re surgery.

It surely is not easy, but I think even for one with medical training and current research knowledge there isn't an "answer"

Best to you.

Wilderness

If it were me, I would be searching for and identifying medical oncologists in the area that specialize with prostate cancer. You may even have consults to determine who you would be comfortable with in the future.

This will give you peace of mind having taken current action and identify the current direction they recommend. They might even take over the management of your PSA monitoring. As TA and others have stated, you won't yet know what may be done. The rise in PSA may not be indicative of cancer, hopefully. But if it is, you will be in front of the curve and have greater confidence in your actions.

Being high risk, I established such a relationship with a medical oncologist after my dx. He concurred on my initial treatment methods and the doctors I was choosing. This elevated my confidence many fold. He has never been on the treatment team and we both hope he won't be needed. But if I recur, he has all my files from the other docs and a well established relationship.