How do you process differing opinions?

Well crap, we met with the RO and he recommended RT without a doubt as DH's PSA has not been detectable. He believed starting earlier rather than waiting for over .2 is necessary based on his G8 and apical margin tumor. He questioned why the surgeon didn't take any LN. He ordered a bone scan and is trying to get us approved for the Axiom scan. He also recommended a consult with an oncologist.

We met for the 3 month check up with the surgeon. He sat down and commented on the PSA still hanging around. He thinks that he can still wait until the PSA gets ago above .2. I think he even said as long as it is not doubling quickly. I told him I've heard about the PSA DT but I'm concerned that my husband has never been non-detectable. When speaking about RT he said it doesn't always make sense to jump to radiating the prostate bed if it is cancer and it isn't there. I brought up several studies about getting better results when you start RT after RALP when PSA is below .2. He discounted every one of them. I know he is a very smart guy who does lots of research. We did not tell him we had met with a RT as we wanted to hear what his recommendation was. He thinks the recovery is going well in terms of his continence and ED. He said to test in another month and then as long as he stays on an even plateau he is ok. If and when he has a significant rise then he can gt additional treatment. We left there bewildered and confused. How an drs. have such opposing opinions? What is a patient to do? Keep getting opinions for a tiebreaker.

DH had the bone scan last week and as luck would have it the dr went on vacation. We hoped he would have called us today with the results but we were not so lucky. I gave him a day to get back to work but tomorrow we will push for results. The Axiom scan was denied by our insurance. Is there another scan that might show any cancer in soft tissue?

We met with a cardiologist who is a friend of the family on Fri based on something seen at the pre op. He checked out fine but we had an interesting conversation with him about prostate cancer. He told us that he had prostate cancer 20 something years ago. Same G8 and same positive margin as DH. He said that while he is an expert on hearts and not prostates he thought DH should consider RT. He had gone up to Loma Linda for 3 weeks and then did some other RT therapy after. He has no horse in the race. He was just offering up his opinion based on everything we told him and his experience.

We meet with the oncologist tomorrow. I'm so scared to hear what he is going to say. Is he going say DH should hit ADT immediately and then RT? Do we get another couple opinions? What the hell are patients to do when the drs don't agree on treatment. We are paying them the big bucks to direct us. It seems the standard of care has a wide berth.

When doctors disagree it is a real problem for the patient. If I were in your husband's position, I would opt for RT right away, provided bone scans come back clean. The American Urological Association issued a report in which they recommend ART in cases with adverse pathology.

http://www.auanet.org/guidelines/radiation-after-prostatectomy-(astro/aua-guideline-2013)

In addition, there is evidence that beginning SRT sooner rather than later is beneficial.

https://prostatecancerinfolink.net/2016/09/21/very-early-salvage-radiation-has-up-to-fourfold-better-outcomes-and-saves-lives/

In my opinion you sort out the general path that is most likely and you start to focus on the specialists that appear to be the next step.

In my opinion, the urologist job is becoming history as it appears the surgery may not have been curative. Thus I would progress along that line and get ready for the next steps on a pro-active basis. Obviously you have started that by speaking with a radiation oncologist as SRT is a distinct probability. Please make sure you are meeting with a well experienced radiation oncologist that does a lot of prostate work. You may even want to meet with more than one ro. I do think it is early for the medical oncologist as their role is really after the attempt to cure has failed, and I don't think your are there. The medical oncologist may end up adding to the confusion at the present time.

One thing you must accept by doing the research and seeking multiple opinions for different specialists, is that you now must be the filter and decision maker. Hopefully the people on this board can assist you based on their experience.

I would say his PSA is detectable since after 4 tests it has never gotten below .17. I had heard that after a RALP there could be a few cells that could produce some PSA and then they kind of die out. I asked if this could be the case and was told no. But where is the PSA coming from?????

There are always some benign cells left behind, but in a successful surgery these are not enough to express a detectable PSA, certainly not as much as you are experiencing. And the prostate does not grow back. The delayed reaction you refer to is applicable to radiation treatment but not surgery. It takes as long as a few years for the radiation treatment to kill some of the cells.

It is very reliable after surgery that an increasing PSA indicates growing cancer. Also not reaching an undetectable PSA after surgery is usually a sign that there was cancer that the surgeon could not remove.


So the indication is that there is some cancer that was left behind. With the extent of the positive margins, it could be that the cancer is still in the prostate bed. This would indicate SRT as the next step. Eventually, if not already, the cells will migrate outside the radiation area and then radiation won't be effective.

It looks like it is a matter of when you start ADT and SRT, not whether you do. I would accelerate the meetings with the radiation oncologists and determine a course of action.

As I understand it, in the case of a known +SM and persistent detectable PSA the preferred path would be to begin neoadjuvant ADT and plan on ART within the first year post-op. But then I do not see where you list any of his post-op PSA's "after 4 tests it has never gotten below .17"... I only see pre-op. But you speak of his PSA as never being undetectable. I'm guessing that his double digit pre-op PSA plus the +SM is sufficiently adverse pathology (despite his T2c stage indicating an organ confined tumor) to proceed with adjuvant therapy rather than waiting until his PSA begins to rise and then initiate salvage therapy. Just IMO... it is easier to keep the horse in the barn than try to chase them down once they've escaped.