SBRT+IMRT 'failure'

Sailor, just want to welcome you to Healingwell. I don't have answers to your questions I'm not that knowledgeable about that particular topic. But there are guys here who are,so stay tuned, they'll no doubt post some input for you pretty soon,.

Just one thing, have you had recurrence after SBRT + iMRT, or are you just asking in anticipation?

You are looking at ADT for the duration.....When you become hormone refractory then you move on to more advanced (and expensive) treatments..It's very difficult to get insurance companies to approve therapies that have not been PROVEN effective....

Hi Sr Sailor-

It would help if you'd include your diagnostic and treatment info in your signature. From what I can understand from your post, your PSA has now passed the nadir+2 level after the conclusion of your adjuvant ADT (which followed an attempt at curative treatment with IMRT with an SBRT boost)- is that correct?

If that's correct, the next step is to determine whether the biochemical recurrence is:
• a local recurrence, and/or
• a distant recurrence, or
• not a clinical recurrence at all.

You are correct that a PET/CT scan would be a good tool for doing that. There are many kinds of PET scans. The one you mentioned, NaF18, is pretty good, covered by most Medicare, and widely available, and with a PSA over 2, should tell you what you need to know. There's a C11 Choline PET that is sometimes covered by Medicare but only available at the Mayo Clinic. C11 Acetate is similar but is not covered by Medicare or insurance and is only available in a few places. There's a new generation of PET scans (e.g., PSMA) that is only available in clinical trials in the US but seem to be very good. NIH has a terrific and FREE clinical trial. There are also a few PET/MRIs out there, which are very precise. If you tell us where you are, we may be able to suggest a place. It is important that you do not have any hormone therapy before such staging, as it will interfere.

If they detect a local recurrence: something in the prostate or nearby, you can have a biopsy to confirm it and possibly have focal brachy, focal SBRT or cryo to get rid of it. It may be treatable in the pelvic lymph nodes too.

If they detect a distant recurrence and it is only a couple of spots, you may want to have SBRT on them. Often, that seems to at least slow it down.

If they don't detect anything, you may be having urinary retention or prostatitis that is raising your PSA from benign sources - again, a prostate biopsy (read by someone expert at that sort of thing) can help, an MRI or CT may show obstruction that can be removed, and sometimes antibiotics will bring it down. There's a diagnostic test called CellSearch that looks for circulating tumor cells. If all of that is negative, hormone therapy is diagnostic - if the PSA goes away on hormone therapy, it is most likely micrometastatic. However, the decision to start permanent (intermittent or continuous) hormone therapy is not automatic in such a case - there may be no benefit to early use until the PSADT is rapid or there is clinical evidence of progression.

You have to take all this one step at a time.

- Allen

Thanks - that helps.

So you were on Lupron until December 2014, which artificially depressed your PSA at the very least for several months afterward - that probably explains your March nadir. Then, as your body resumed testosterone production, it went back up, which is precisely what one might expect. (BTW - did they also monitor your T level in 3, 6 & 9/2015?) This is why they set biochemical recurrence at nadir+2 and not at a lower level. I see why the rise makes you anxious, especially considering your Dx, but I think it's important that you don't jump the gun. There's really nothing to "be prepared" for - you can only take it as it comes, and continue to monitor PSA every 3 months.

My PSA was 1.3 at 2 years after SBRT, so your current level does not sound very high to me.

- Allen