Timing of Post Surgery Radiation Treatment

At the reco of a friend/member of HW, I met today with the chair of RAd Onc at Cleveland Clinic in Florida. It was a long meeting, and very informative.
The short version is....
He recommends treating soon (to review, I was undetectable until the 2 year post op mark, then .02, .033, .046, 060, see signature below) he cited this study...

/jamanetwork.com/journals/jamaoncology/article-abstract/2670381?redirect=true

A multi institutional study with n=1566, it showed an advantage to treating below .1, vs treating .1 - .5.

The entire cohort was adverse pathology. While I had negative final margins, the RO felt that because my frozen section intraoperative margin was positive, and at the apex, my negative final margin was questionable, and he placed a high probability on the PSA coming from cells left in the prostate bed, thus a relatively high probability of a good result.

He said if I wanted to wait a few months he didn’t think it would put me at increased risk.

He didn’t put too much weight into my low Decipher score, saying I could be one of the 3% that has recurrence, nor did he put much weight in the oncoDx Grid report that predicted poor response to SRT, saying there was not enough data to validate it yet, too small a sample.

I also asked him what he thinks might happen if I decided to do nothing. His response, a 50% chance that 10 years from now I would be living a happy life with no issues related to PC. And a 50% chance that I’d have some serious problems in 10 years. I don’t like those odds.

He said with their machine, Varian Edge, I think, the chance of permanent side effects was less than 5% (but I should expect transient side effects)

I am meeting with Dr Zelefsky, RO at MSKCC, mid June. I will have one more PSA before that meeting.
I am inclined to look fir one more increased PSA after the Zelefsky meeting, then taking action, although that also depends on what the pre-Zelefsky PSA shows.

I’ve pretty much tossed aside my Surgeons advice to do nothing until/unless i get to .2.

I wish their was a black and white answer, but there apparently is not. So the beat goes on.

One thing I did not ask, is whether Medicare would approve early Salvage . Anybody know the answer from experience?

Nothing is ever easy is it. The trouble is with so many opinions and options what do you do? I personally would have a tough time doing nothing, so I fully understand you leaning towards pulling the trigger. I just started Medicare in March, so no help there. Good luck.
Tom

Pratoman said...
At the reco of a friend/member of HW, I met today with the chair of RAd Onc at Cleveland Clinic in Florida. It was a long meeting, and very informative.
The short version is....
He recommends treating soon (to review, I was undetectable until the 2 year post op mark, then .02, .033, .046, 060, see signature below) he cited this study...

/jamanetwork.com/journals/jamaoncology/article-abstract/2670381?redirect=true

A multi institutional study with n=1566, it showed an advantage to treating below .1, vs treating .1 - .5.

The entire cohort was adverse pathology. While I had negative final margins, the RO felt that because my frozen section intraoperative margin was positive, and at the apex, my negative final margin was questionable, and he placed a high probability on the PSA coming from cells left in the prostate bed, thus a relatively high probability of a good result.

He said if I wanted to wait a few months he didn’t think it would put me at increased risk.

He didn’t put too much weight into my low Decipher score, saying I could be one of the 3% that has recurrence, nor did he put much weight in the oncoDx Grid report that predicted poor response to SRT, saying there was not enough data to validate it yet, too small a sample.

I also asked him what he thinks might happen if I decided to do nothing. His response, a 50% chance that 10 years from now I would be living a happy life with no issues related to PC. And a 50% chance that I’d have some serious problems in 10 years. I don’t like those odds.

He said with their machine, Varian Edge, I think, the chance of permanent side effects was less than 5% (but I should expect transient side effects)

I am meeting with Dr Zelefsky, RO at MSKCC, mid June. I will have one more PSA before that meeting.
I am inclined to look fir one more increased PSA after the Zelefsky meeting, then taking action, although that also depends on what the pre-Zelefsky PSA shows.

I’ve pretty much tossed aside my Surgeons advice to do nothing until/unless i get to .2.

I wish their was a black and white answer, but there apparently is not. So the beat goes on.

One thing I did not ask, is whether Medicare would approve early Salvage . Anybody know the answer from experience?

Same thing the RO at JH said about mine...that it needed to be treated. He also recommended ADT with mine. (which drew considerable questioning here). But nomograms agree with his assessment....ADT gives me about a 15% greater chance of freedom from BCR in 10 years. He also said we didn't have to use it if I didn't want to.....(I'm concerned about DVT if we use ADT...something i got recovering from surgery)). He also said less than a 10% chance of aggravating my stricture. (I remain unconvinced of that)

I haven't had any issues with medicare. They approved probably a dozen consultations across the eastern seaboard without a peep.

Someone else needs to chime in on SRT before BCR. They've always been so good about paying it never would have occured to me to ask.

edit: I should add.....that RO's recommendation was based on my .05 PSA. He didn't have the lower reading of ..014 as I didn't get that confirmatory PSA check until I got back from Baltimore. (A local RO saw the latest .02 and said it would be cool to wait...fwiw)