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Recurrence options clarification

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Posted 3/19/2017 6:09 AM (GMT 0)
Hi all. My first post. I was diagnosed in late January and am doing the usual research and trying to educate myself. I will be 70 in August and my urologist/surgeon at Mayo in Jacksonville FL told me I am a good candidate for da Vinci or radiation. I'm working on my signature to gshow the chronology of events leading up to where I am now. Briefly, Gleason 3+4=7 with 3 positive cores. However, right now my question is simply this: I am aware of the cure stats of the different treatments, but I am confused by the treatment options for recurrence. I thought that was one advantage of surgery since radiation is available after surgery. I really was under the impression that the recurrence treatment options after radiation were slim and not very attractive. Then I read here that radiation has it's own treatment options. What might those be and are the post radiation treatment recurrence options as good as those available after da Vinci?
Posted 3/19/2017 12:42 PM (GMT 0)
Welcome, sorry you need to be here. Some of the other guys can chime in with stats and studies. If you start with radiation and then have a rising PSA at some point, I think your primary salvage option is then ADT (hormone therapy.)

As you say, there are salvage options post surgery - I'm a good example of that. At age 70 I'm a bit surprised your Doc would go the surgery route, usually about your age is the cutoff for being a surgery candidate.

I have no regrets about having surgery, pathology reported a positive lymph node so at that point the cat was out of the bag and I needed follow-up treatments.
Posted 3/19/2017 1:14 PM (GMT 0)
I thought that hormone therapy was the only real option for recurrence after initial radiation treatment and from what I read, that didn't seem like a particularly desirable way to go if there would possibly be an alternative. Just my thought at this point. My doctor recommended the da Vinci for me because I have been blessed with good health all my life, and am fortunately in very good physical condition other than the prostate cancer issue. He seems to think I will bounce back well so that is the way I am leaning currently. I met with a radiation oncologist at Mayo at my urologist's suggestion and that meeting went well. I can certainly see the attraction of the variety of radiation treatments that are available, and together with surgery, all having essentially the same cure rate. It just seems significant to me to have the radiation available as a first course of treatment in the unfortunate event of recurrence.
Posted 3/19/2017 1:17 PM (GMT 0)
If it is a local recurrence (no evidence of metastasis) there are several salvage treatment options, mostly of experimental nature. Salvage RT is not a god option as the total dose is now limited and therefore the chance of cure is low. Other options might be:

- Salvage radical prostatectomy
- Salvage ADT
- Salvage brachytherapy
- Salvage cryoablation
- Salvage high-intensity focused ultrasound (HIFU)
- Salvage lymph node dissection
Posted 3/19/2017 2:51 PM (GMT 0)
None of those salvage options would seem to be as desirable as having RT as a viable option for recurrence. Obviously, the perspective at that time may change one's thinking as it relates to effectively prolonging life. Side effects may have to be on the back burner depending on the extent of the recurrence at the time.
Posted 3/19/2017 2:57 PM (GMT 0)

19tarpon47 said...
. I thought that was one advantage of surgery since radiation is available after surgery. I really was under the impression that the recurrence treatment options after radiation were slim and not very attractive. Then I read here that radiation has it's own treatment options. What might those be and are the post radiation treatment recurrence options as good as those available after da Vinci?

Hello 19tar and welcome. Yes, radiation is available as a salvage plan for failed surgery but there are also good backups for a failed radiation treatment. The options include HDR Brachy, LDR Brachy, cyrosurgery, HIFU, surgery and SBRT. Generally the surgeons seem to be not aware of these options so push the sales pitch of "having a backup plan for surgery" when, in fact, there are backup plans for both failed surgery and failed radiation. I suggest you discuss this with RO's as you do your rounds for original treatment.

In my simplistic way of thinking, I look at value propositions to evaluate options. Both surgery and radiation are likely to cure you equally and both have backup plans in case of failure. Surgery has the value propositions of immediate knowledge of your pathology and the psychological advantage of having "gotten it out of you" if that is important. Radiation has the value propositions of a better chance of avoiding the onerous side effects of incontinence and ED. You have to decide what is more important to you.

Good luck.

Jim
Posted 3/19/2017 3:36 PM (GMT 0)
Welcome to HW.

You don't want to go down any salvage plan. RT after surgery is doable, but not fun and has it's problems. Salvage after the various RT delivery methods is possible.

I would suggest not picking your primary treatment based on salvage options - go for the cure first and pick a treatment plan your comfortable with.

Andrew
Posted 3/19/2017 3:41 PM (GMT 0)
Hwy 19. . . (Oh, that was a song a while back. . . )

I'm about your age (will be 70 in November), and I chose SBRT radiation. My pathology is/was very similar to yours. One thing I took very seriously when choosing SBRT was the 9-year published oncological results. SBRT has been showing recurrence-free rates of over 90% at 9 years. Since we're closing in on 70 now, if we have 90+% chance of being recurrence-free at 80, how bad can it get after that? Most PCa (like our 3+4) is known to be slow-growing, so even if it did recur at age 80 or so, how bad could it get before something else gets us?

Personally, after open-heart surgery and several other significant surgical procedures, I wasn't interested in yet another surgery - especially if there was a non-surgical treatment with the same prognosis available. Just sayin'. . .
Posted 3/19/2017 3:50 PM (GMT 0)
Unless I missed it, I did not see you seeking a second opinion on your biopsy reports. My suggestion would be to read the "Sticky Notes" and get that second opinion from folks recommended that just do second opinions.

As far as you recurrence questions, I would totally agree with Tudpock18's well written thoughts.
Posted 3/19/2017 7:23 PM (GMT 0)
BTW, I meant to mention at the top how grateful I am to all on this forum. I've been lurking for over a month, learning and trying to become educated enough to even ask an intelligent question, and in particular one that hasn't been thoroughly wrung out before. There is a wealth of information from some obviously very caring brothers-in-kind here and I can tell you that it is much appreciated. Thanks to all.
Posted 3/19/2017 10:23 PM (GMT 0)
The best salvage treatment options after RT failure - the ones with the best SE profile- are salvage focal brachytherapy and salvage focal cryoablation. One of the more interesting options is salvage (whole gland) SBRT.

/pcnrv.blogspot.com/2016/08/salvage-sbrt-for-local-recurrence-after.html

In Florida, you have Gary Onik who is a specialist in focal ablation (he does several different kinds), or Stephen Scionti who specializes in focal HIFU.

I guess you could get focal brachy from John Sylvester in Florida.

More to the point is the fact that with your favorable intermediate risk prostate cancer, salvage therapy should not be a decisive factor in your deliberations. For example, in a recent clinical trial of SBRT, 5-yr biochemical recurrence-free survival for intermediate risk patients was 97%. And other research has shown that (unlike IMRT) most failures are not local - so the odds of a salvageable recurrence are about 1 in 100. Similarly good outcomes have been published for HDR brachytherapy.

/pcnrv.blogspot.com/2016/09/5-year-sbrt-trial-high-cancer-control.html
www.jurology.com/article/S0022-5347(11)04995-0/abstract
Posted 4/4/2017 3:58 PM (GMT 0)

Tall Allen said...
ore to the point is the fact that with your favorable intermediate risk prostate cancer, salvage therapy should not be a decisive factor in your deliberations. For example, in a recent clinical trial of SBRT, 5-yr biochemical recurrence-free survival for intermediate risk patients was 97%. And other research has shown that (unlike IMRT) most failures are not local - so the odds of a salvageable recurrence are about 1 in 100. Similarly good outcomes have been published for HDR brachytherapy.]


I'm totally confused about the above information. Are you saying that with IMRT that failures are more likely than with SBRT to be local and so you are more likely to have some sort of salvage therapy available than if the recurrence was after SBRT? And the biochemical recurrence of SBRT is extremely low, but when it does occur, the odds are about 1/100 that it will be salvageable? So, salvage therapy of some sort is more likely to be available after IMRT than SBRT, but basically with SBRT, the odds are very good that it will never be needed anyway?

I am retired and my thoughts are mostly about fishing and sex........ I thought I had retired from all this cognitive stuff.....LOL.....I think my hair is on fire.......good grief!!!!! smilewinkgrin

Posted 4/4/2017 4:15 PM (GMT 0)
Obviously, I am an idiot when it comes to using the "quote" command. I'll figure it out but I think it's clear where my question starts.....
Posted 4/4/2017 6:19 PM (GMT 0)
I'll take a shot at this one. I read some of the same research prior to selecting SBRT for my therapy. I think TA is quoting one study that shows the 5-year biochemical recurrence free survival rate for SBRT monotherapy to be about 97%. With this high success rate, he raises the question of "Why worry about plan B when plan A has such a high success rate? There's only a 3% chance you would need a plan B."

The other study, if I interpret it correctly, shows that SBRT is so effective at control of local disease that if you do suffer recurrence, it is most likely NOT local to the prostate, so local salvage therapy would not be an effective option at all. With IMRT, though, more of the post-treatment recurrences are local. Assuming this, after IMRT there is more of a chance that a recurrence may be local and thus treatable with another focal therapy.

Get a good grip on your head. If it spins too much, you may lose it completely. . .
Posted 4/4/2017 6:49 PM (GMT 0)
Thanks, Paxton. That was pretty much what I was trying to get across, but u did it better. I appreciate that and all ur other responses to my sometimes not so well articulated questions. I'm meeting with Dr Debra Freeman in Tampa Thursday to discuss SBRT and although I'm sure she will answer all my questions, I just want to be as prepared as possible so the answers will make make more sense to me.
Posted 4/4/2017 9:39 PM (GMT 0)
"Are you saying that with IMRT that failures are more likely than with SBRT to be local and so you are more likely to have some sort of salvage therapy available than if the recurrence was after SBRT?"

Yes. about half of IMRT failures are local only. about 20% of SBRT failures are local only.

"And the biochemical recurrence of SBRT is extremely low, but when it does occur, the odds are about 1/100 that it will be salvageable?"

No. From the start (the place you're in now), if you select SBRT, the odds of a salvageable recurrence are about 1/00. If there is a recurrence, the odds that it is salvageable are about 1/5. In other words, with 97% recurrence-free survival, that leaves 3% who would expect recurrence. Among that 3%, 1/5 will be salvageable. So 3%x1/5=0.6% (which I rounded up to 1/100)

"So, salvage therapy of some sort is more likely to be available after IMRT than SBRT, but basically with SBRT, the odds are very good that it will never be needed anyway? "

Yes. This is why I'm saying that it is not wise to use salvage prospects as a factor in your decision-making, It's a very minor consideration for you.
Posted 4/5/2017 4:32 AM (GMT 0)
Ok. Now that I see the math specifically, I get it. I presume the 1/5 that is salvageable of the 3% is from some documented study. The only reason I mention the 1/5 is because I didn't see anything that specified that number. TA, I can't thank you enough. I know you mentioned before that with my risk factor at favorable intermediate, salvage therapy should not be a part of the decision-making process with SBRT. And I understand that better now, however, it is my nature, particularly with an issue like this to "beat it to death".....or at least that what my bride says I do... smilewinkgrin

I appreciate all the helpful and encouraging comments that I have read and received on this forum. I almost feel like I need to ask you all for a bill for your services.....especially TA. But I know from the spirit and remarkable courage of the folks that I have been listening to and reading about every day for the last couple months, it's all about sharing and being there for each other. As I progress through this process wherever it takes me, I hope to be able to chronicle it well enough that it will be of interest and assistance to others as they unfortunately have to look forward to a similar journey. May we all have a better tomorrow and lend a helping hand to those less fortunate.
Posted 4/5/2017 8:16 AM (GMT 0)
The numbers are derived from Katz and an unpublished multi-institutional presentation at the last ASTRO meeting. Katz reports that after 6 years, there were 14 biochemical failures among all his intermediate risk patients, but only 3 of those were local, so 3/14=21%.

journal.frontiersin.org/article/10.3389/fonc.2014.00240/full
/pcnrv.blogspot.com/2016/09/5-year-sbrt-trial-high-cancer-control.html
Posted 4/5/2017 11:07 AM (GMT 0)

19tarpon47 said...
I almost feel like I need to ask you all for a bill for your services.....especially TA..

Actually it is traditional for members to buy each of us a round of "virtual drinks" as you get favorable post treatment results. We expect many years of such beverages from you...

Jim yeah
Posted 4/5/2017 2:09 PM (GMT 0)
Favorable outcomes not required by me, virtual drinks are on me today, a bottle of Petrus for the Tall One.
Posted 4/5/2017 6:40 PM (GMT 0)
Well, obviously I would hope for a favorable outcome, but that's just something that once the "big decision" is made, I don't have alot of control over. However, all the folks who post and respond here deserve a real drink for all that u do for others. I know what I'll do...... I'll toast each and every one of u individually after treatment. Guess I'll have to stock up with a couple cases to make sure I don't run out...... smilewinkgrin
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