PCA Recurrence - What to Do Next???

Hi Italatinate-

The first thing to do is to get in talks with a radiation oncologist. If UCLA is an option for you, I would recommend my RO, Chris King. Urologists have an annoying habit of waiting until it's too late:

/pcnrv.blogspot.com/2017/03/conflicting-messages-after-surgery-for.html

A PSA of 0.3 is already in a riskier category than if you had salvage radiation while it was still under 0.2:

/pcnrv.blogspot.com/2016/09/very-early-salvage-radiation-has-up-to.html

There is no question that you are right that your treatment field must include the pelvic LNs, since you know that at least one LN was positive. If there's one, there's almost assuredly more - they're just too small to be detected on even the best PET scans.

Adjuvant hormone therapy is probably a good idea. Just how much is a subject of controversy, but with N1 and T3a, it can really increase your odds of a cure.

/pcnrv.blogspot.com/2016/08/combining-androgen-deprivation-therapy.html

Thank you Allen.

Since I last posted, I have consulted with two RO's, one a VERY well known Los Angeles RO and co-author of the RTOG 9601 study, who by the way wrote in his study that his personal PSA threshold for "no" ADT with SRT is 0.5, (my PSA is now .355) and the second, another well known RO who has specialized in PCA for years at a highly regarded cancer treatment center in Pasadena. I was given two very different opinions.

After hearing that I was very concerned about the side effects of ADT, the first RO recommended 4 months of Casodex plus Avodart with the SRT. After reading later that his study had proven that treatment with two years of bicalutimide improved SRT outcomes, I wondered why he recommended only 4 months in my case. The other RO recommended no ADT with SRT due to my low PSADT and PSA velocity of 15 mos and .01 ng/mo. He also stated that the ADT would mask the results of the SRT. Both ROs highly recommended that my pelvic lymph nodes be radiated as well as the prostate bed.

I have found nothing in the more recent literature that I have read to indicate that Casodex is any better than Lupron for SRT, nor of it is even being used instead of Lupron along with SRT. I did find one member here who posted in his signature that he had 3 months of Casodex during his SRT. However, he also wrote that his SRT subsequently failed.

After meeting with my MO and RO at City of Hope recently I am planning on scheduling the SRT at City of Hope as soon as possible. I am leaning towards taking the 4 months of Casodex. Although my MO and RO are agreeing my sense is that they are doing so reluctantly. After reading all the horror stories about Lupron I want to avoid it if at all possible. However, I am also concerned that if I do decide on the Casodex, it may not be enough to improve the SRT outcome.

All of this is making my decision much more difficult to reach regarding which ADT if any, to undergo. The delay in my next appointment to July 5 to finalize everything is also not helping with my current state of anxiety.

Any additional comments or recommendations you may have will be greatly appreciated.

Post Edited (Italatin8) : 6/9/2017 11:25:09 PM (GMT-6)

Italitin,

My experience with Lupron wasn't that hurrendous honestly. Yeah, loss of labito and menopausal symptoms including hot flashes, mood swings and breast enlargement are hard to digest for a guy when pondering ADT (I'm half Italian myself and in case you are Italian and sensitive over loss of machismo... which I understand...please think more about long term survival than the short term loss of the use of your catso. Haha!)
After years of not being on ADT I wouldn't know I was ever on it other than some bone loss. Make sure you practice proper bone loss management with Prolia, etc.
The idea of being back on ADT is depressing for me but if it increases survival odds, I'll do it. I'll be dragging my feet but I'll do it.

Michael said...
Allen, what do you feel about ADT following lymph node dissection? Do you think the same benefit exists for salvage surgery as it does with salvage radiation?

There hasn't been any evidence of benefit of ADT before or after surgery.

You have to wait 2 months before starting SRT. The whole point of the HT is to sensitize/weaken the cancer so that it is more easily killed by the radiation. That takes some time.

erbob-

This thread has nothing whatever to do with your situation. PSA after prostatectomy should be undetectable for there to be no evidence of disease. After radiation, on the other hand, PSA gets low but seldom gets undetectable, and PSA bounces and rises are usually causes for concern.

Update on my Casodex and Avodart hormone therapy and SRT.

I met with my MO today and my PSA plummeted from .406 to .112 in the last thirty-five days after 50 mg of Casodex and .5 mg of Avodart daily. I did not expect this much of a reduction in such a short period of time. However, my testosterone shot up from the mid 400's to 703. The next best part is that my side effects have been minimal. An occasional bit of fatigue and stomach upset the first few days, a very light few minute hot flash maybe once a week or so and that has been it.

On a not so good note, I was scheduled for SRT simulation last Friday and to begin my first treatment on August 24. However, my RO called me at 8:45 PM last Thursday to tell me that my insurance company had denied coverage of the SRT. I am at a loss on this one as my insurance company benefits document clearly states that radiation therapy is a covered procedure. There has to be a peer to peer review to hopefully get the SRT approved.

Has anyone experienced an SRT denial by their insurance company before and had a good outcome? Although my RO said he could "definitely get the SRT approved" there will be a week or so delay in moving forward with treatment.

Post Edited (Italatin8) : 8/14/2017 4:26:37 PM (GMT-6)

Italitin8,

Sometimes when procedures get denied it's because some underpaid person in an office somewhere messed up a code. This happens more than people realize- and in the meantime you're stressing out.

Hopefully that's all it is.