Start of a no good, very bad day

Just got the report that my ultra-sensitive PSA is 0.19. :(

As a reminder, I'm 10 weeks post-op from DaVinci RALP with clean margins and 1 positive lymph node out of 15. I don't want radiation... what would they radiate anyway? I expect ADT is the next step??

Ideas?

Tony

Hi Toni, sorry about that result, but you almost certainly will have to repeat that in order for the course of follow-up action to be put in motion. One number doesn´t tell a story.

I know that some oncologist recommend radiating prostate bed when PSA is above 0.2, or waiting until PSA rises to 2.0 (lymph node would then become visible on some more sensitive scans) and undergoing a more targeted radiation approach. At times, the lymph nodes can be removed surgically, and some skilled surgeons are able to get to them. If I were you, I would pursue this aggressively. An oncologist specializing in PC make a difference, a big one.

Don´t despair, there is much reason for hope, despite a bad day. You will have more good than bad days, for sure. I hope that others will chime in, we got a very knowledgable group here on HW.

I would get a retest, additionally you could be at less than 0.2 for a while. Your positive margin and lymph gland and having G7 (4+3) will very likely start you on ADT for a while and salvage radiation. If possible you should wait until incontinence subsides prior to starting salvage therapy. For what it is worth, I finished 39 treatments 2 days after this past Christmas with zero side effects, no urgency, no diarrhea, and no rectal problems. I did not change my eating habits nor my daily routine during treatment. I believe would be much harder to deal with than salvage therapy.

Tony said...
I don't want radiation... what would they radiate anyway?

They would radiate the full pelvic area -- the prostate bed and all the pelvic lymph nodes. I'm not saying it will cure you, it's just a chance. I don't know why you don't want radiation, but I strongly suggest talking to a radiation oncologist, and immediately, if you want a last stab at curative therapy. If you don't want radiation for some reason, Mayo offers an extended pelvic lymph node dissection - but they'd probably want evidence of no cancer in the prostate bed. There is no point in waiting for a re-test with a positive node - if that's something you want to try - you have to do it now.

- Allen

TSGlassman said...
Just got the report that my ultra-sensitive PSA is 0.19. :(

As a reminder, I'm 10 weeks post-op from DaVinci RALP with clean margins and 1 positive lymph node out of 15. I don't want radiation... what would they radiate anyway? I expect ADT is the next step??

Ideas?

Tony

Tony, that sucks! I'm sorry to hear it, Brother! I'll let other more knowledgeable folks comment on you best next step, and some already have. But there is always the retest! I've got my 2 year PSA next week! And I am a G9 with SVI and positive margin!

Post Edited (BillyBob@388) : 3/3/2016 6:55:48 PM (GMT-7)

There is certainly a danger of bladder, rectal and bowel toxicity from salvage radiation. Those are very real and I don't want to minimize that at all. But I recommend you talk to a radiation oncologist who can look at your individual anatomy and help you assess those risks. Diverticulitis is definitely not an issue that rules out radiation.

There was a randomized clinical trial that looked at whether adding RT to HT improved survival over HT alone among high risk men. This was as primary therapy rather than salvage. Deaths from prostate cancer were reduced by 57% by the addition of RT.

Final Report of the Intergroup Randomized Study of Combined Androgen-Deprivation Therapy Plus Radiotherapy Versus Androgen-Deprivation Therapy Alone in Locally Advanced Prostate Cancer

The early results of a major clinical trial last year showed that in men diagnosed with cancerous LNs, primary radiation to the whole pelvis increased the time to recurrence. Whether that benefit will be sustained over time is anyone's guess. The toxicity rates were low.

ADT and radiation for first-line treatment of node-positive (N1) prostate cancer (STAMPEDE trial details)

Several other studies showed a similar benefit to whole pelvic radiation over ADT alone in the primary setting:

ADT and radiation for first-line treatment of node-positive (N1) prostate cancer

The more relevant question for you is whether salvage radiation has any benefit after positive lymph nodes (N1) have been detected. The data are less clear: 2 studies say yes, 1 says no. These are all database analyses, so there is nothing definitive. Here are the studies:

The Impact of Definitive Local Therapy for Lymph Node-Positive Prostate Cancer: A Population-Based Study
Impact of Adjuvant Radiotherapy on Survival of Patients With Node-Positive Prostate Cancer
Patterns of care and outcomes of radiotherapy for lymph node positivity after radical prostatectomy

I suggest you look over all of these studies, or better yet, go over them with a radiation oncologist, before deciding. But do it quickly.

- Allen

Because all the studies of adjuvant (immediate radiation - within 3 months of surgery) radiation vs wait-and-see have found an advantage to adjuvant. More recent data seem to indicate that early salvage - waiting for uPSA to exceed 0.03 may be equivalent in outcomes to adjuvant radiation, but you are already well past that point. You already have EPE and a positive lymph node. Once lymph nodes are infected, the cancer has a route of traveling through the lymph into systemic circulation - after that point a cure is impossible with current treatments.No one can predict when that will occur, or if it has already occurred. But if you wait for a sure indication of it, it is too late.

They normally wait 2 months for ADT to sensitize the cancer to radiation before beginning. And the cancer probably will not metastasize for some time after you start ADT. So you have that time to decide.

A good radiation oncologist, like Anthony Zietman at Mass General, knows a lot more about the side effects and the odds of cancer control than you'll ever be able to figure out on your own. I suggest you tap into his formidable experience and knowledge base to help you make this decision.

- Allen

I really have to question surgery in the first place and didn't your uro say it would most likely -- like maybe in the 70s -- require SR afterwards? sorry man.

ed

I wish TA would post to this board so we all could benefit!
TS: unfortunately as Stage pt3 you are high risk. I'm sorry to hear about your aversion to SRT but that along with ADT is the standard of care for you. And all remaining pelvic lymph nodes should be radiated as well.
Bob

Tony - if you decide to go with radiation, we may be on about the same schedule. I'm 15 months out from surgery, but PSA now appears to be rising quickly. Dr. Zeitman is my RO - will consult the end of this month.

Best to you.
Wilderness.

I am right behind you. Had surgery in Nov 2014, three undetected readings but last Oct it went up to .05, followed by .07 in Jan 2016. Will have another test in April. If it goes up, I will have radiation this summer. No need to monkey around. As Marvin Gaye says lets get it on. If I am fortunate I will have a cure but time will tell.