Very early salvage radiation has up to 4-fold better outcomes and saves lives

This study came out of U Mich and UT Southwest, they found that men had much better outcomes if they were treated with salvage radiation (SRT) at the earliest detectable PSA after prostatectomy. Here, "earliest" meant with a PSA as low as 0.01-0.2. Those who waited until PSA was 0.2-0.5 did twice as badly. Those who waited until PSA was over 0.5 did 4 times as badly.

Badly on what?
• On biochemical recurrence after SRT
• On having to go on lifelong, salvage ADT
• On having metastases detected
• On dying of prostate cancer

Four times worse on all the above.

Adjuvant ADT with SRT improved outcomes by 40%

In fact, 91% of the variance in biochemical failures after SRT was predictable by the PSA at which the patient began SRT.

The authors wrote, "Our data would suggest potentially a traditional cut-off of 0.2 to define biochemical failure may be too late, and that at the first sign of a detectable PSA that SRT (or SRT + ADT) should be initiated."

There may be reasons not to do SRT, but there is no reason not to talk to a radiation oncologist about it.

Very early salvage radiation has up to 4-fold better outcomes and saves lives

Allen,

You post about SRT as a treatment option and wondered if in my husbands case which is:

He had RP but was never undetectable, as his PSA was 1.3 after surgery.

Our Urologist recommended SRT, however after reading David's horror stories about SRT, something told me to investigate.

Just curious: and this is a what if-
If my husbands PSA was <.02 after RP would you still feel SRT could have been successful for my husband ?

Thanks,

BOOGEE

Thanks Tall Allen,

I am taking a PSA test every three months. My PSA has went from .05 to .07 back to .06 for the past year. I plan to test again in Oct and if it increases then we will decide to radiate.

This is provocative - brings up some questions for me.

Does it correct for men whose PSAs never went as low as .2 after surgery? They likely have poorer prognoses but no opportunity to be in the .01/.2 cohort.

Does it correct for men who have very low PSA's which persist and who never have radiation? They would do well without radiation as well. Did some of them have unnecessary radiation?

Does it correct for men who have very low PSA's which subsequently rise with slow doubling times who decide to forego radiation and thrive (pCa wise) without it.

Could it be that some in the .01/.2 cohort would have done equally well without further treatment?

My post RP PSA has been as high as .06 but was at last test undetectable - is that unusual?

Howard- there are several things to take into account - 0.03 predicts full recurrence in men with adverse pathology or in men with steadily increasing uPSA, even without adverse pathology. But some guys may have had "semi" adverse pathology - say, focal positive margins or Gleason 6 at the margin, and uPSA may be pretty stable at some low number. If you're borderline, Decipher may be useful.

rcroller- I prefer to think of it as "increasing the risk" rather than "missing the boat." And all this is pretty new info. The first analyses from uPSAs really didn't start coming in until a couple of years ago. It was the 3 randomized trials (all in the last 5 years) that showed that adjuvant radiation had better outcomes than waiting that really changed thinking about this. Then, worried about all the overtreatment that adjuvant radiation would cause, doctors started to look for a surer indicator that radiation would really be needed. It looks like uPSA fits the bill. But I would agree that a randomized trial of uPSA vs. regular PSA would be needed for irrefutable proof. Until we get that (maybe never) we go with what we learn along the way.

Wilderness- The article says, "Researchers did not have data on PSA doubling time and velocity, and the number who had persistently elevated PSA, all of which almost certainly would affect outcomes." You asked, "Could it be that some in the .01/.2 cohort would have done equally well without further treatment?" Of course "some" would be overtreated, but which ones? Each person has to decide if he's willing to bet that he's in that "some" category, knowing that if his PSA does go up, his chances of a cure goes down. Statistics only can tell us the group probability, not what will happen to the individual.

Jim- I was just saying pretty much the same thing to someone today -- the pace of change in medical knowledge and technology is dizzying. That is especially true of the very varied disease that brought us all here. If you followed my articles on the ProtecT trial, the problem really hits home - by the time we have long enough term data to prove anything (and PC is usually a very slow moving cancer -which we are grateful for - but it means that it takes many years to really "prove" anything) the proof we get is irrelevant to the decisions we have to make today. In that trial, the radiation and active surveillance protocols were vastly different from how those treatments are today.

Allen,

Now that we DO know he has mets ( however not knowing that at the time) after RP would that have been a treatment we should have followed as our Urologist suggested?

BOOGEE

Fairwind,

As it says in the article: "The "later salvage group" had outcomes that were about four times as poor as those who had "very early salvage." This was true after correcting for all the variables (like Gleason score and positive margins) that would have made a difference."

Yes, pathology Gleason score is certainly a risk factor. What was significant here was that even after correcting for Gleason score, waiting for a higher PSA was 4 times as risky as treating at the lowest detectable PSA. So a man with a Gleason score of 9 had a 4X higher risk of dying in 10 years if he waited for a PSA>0.5

Thank you for the response Tall Allen. I stand corrected. I finished SRT session 12 of 38 today. My last known uPSA was 0.149 but that was weeks before starting SRT so I actually don't my actual uPSA at the start of treatment. The RO suggested there was no point in getting another uPSA before tx as nothing would change. It is what it is. Possible bone mets from bone scan could not be confirmed or denied so forward we went. The RO insists he is proceeding as though there will be a cure. I don't know why I'm feeling so pessimistic but I am. I wish I had a more positive outlook. I read all this stuff and it confirms to me that my intuition five years ago was right. I should have insisted on ART at the time. The Uro talked about over treatment and Side effects and I went along with it. Oh well, we are where we are and I can only hope that SRT is effective. Time will tell. Anyhow, thanks for your response.

Does anyone knows a good MO and RO on Long Island
Or should I have to go to the city for SRT?
Thanks all for your help
Mine went from .03 to .07 in 6 months after surgery 4 years ago, stage 2, g 7(3+4), pm and Extra capsule extension

Im glad to see TA's response to willderness...I have never seen him mention that before i...to be fair I might have missed it...it has always been my contention that early srt results are skewed heavily by those whose cancer will never progress yet are included as being "cured" by srt... this is not an incidental...this is real.. I still feel that when the technology is there...it must be used...and that studies
create the need for that that may or may not be there... a study is an attempted answer to a question...its veracity...is a chimera of a later possibilty... and may lead to truth...but by itself can be a "devil's" tail...keep this in mind as you search for the magic bullet...