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Time to pull SRT trigger? Creeping PSA

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Posted 3/5/2019 11:26 PM (GMT 0)
Hi guys, I am facing my dilemma about SRT again. I was trying to postpone it but now I feel it maybe a time to pull the trigger...
I am 70 now. Had RALP 09/06/16 at the age of 68
Final path G3+4 , about 20% of prostate involved , no EPE, PNI + , no SV involvement, one positive anterior margin G 3+3 at the margin , LN dissection was not done. Staging T2c+
100% continent, however with ED after RALP. Had recent inguinal hernia repair surgery . Otherwise in good health and active ( swimming, biking, skiing) . Love being active and enjoy outdoors.

Here is my PSA trend from 2 labs ( my URO trusts uPSA, the second lab is Quest and done by PCP)
See below
-----------------------uPSA ( Architect, Abbott)
05.03.19 -0.074
08.29.18-0.043
05.21.18 – 0.033
05.21.18 – 0.033
11.10.17 – 0.022
06.16.17 – 0.009
-----------------------"Regular PSA "
01.24.19 – 0.15
06.29.18 - 0.05
10.26.17 -0.07
08.10.17 – 0.01
05.18.17 – 0.08
03.02.17 – 0.02
12.06.16 - 0.02
- -----------------------
It's interesting uPSA never crossed 0.1 but " regular" PSA did ( in addition " regular" was up and down, while uPSA showed steady rising trend)
of course my URO wants "just to watch" for now and take action at 0.2 but I am afraid it's time to pull the SRT trigger soon.
My questions:
1. I am afraid it's time to see RO, right ?
2. would you wait for about 2-3 month before starting SRT ? I just had hernia repair surgery and was told ideally should get about 2 month for recovery ...
3. for those who had SRT after RALP - whats the probability of incontinence? Did you have any? Any other side effects?
4. ADT + SRT or just SRT?
5. What tests are generally needed before SRT ? Would MRI and repeat bone scan show anything with PSA 0,074?

I know I am asking too many questions, would be grateful for any input!

Mos.

Post Edited (Mos_Ser) : 3/5/2019 7:07:51 PM (GMT-7)

Posted 3/6/2019 12:15 AM (GMT 0)
It's time to talk to the RO. At your PSA, scans are unlikely to show anything.

Hang in there and keep us updated on your progress.
Posted 3/6/2019 1:12 AM (GMT 0)
Done with the urologist, go see the radiation oncologist. They may want you on ADT for a month or two before starting SRT so you should see the RO soon.

How was your hernia surgery done? open, laparoscopic or robotic? Call your surgeon and get advice as to when SRT can start based on the hernia surgery recovery.
Posted 3/6/2019 2:06 AM (GMT 0)
Hernia was laparoscopic. My surgeon suggested ideally postponing SRT for 2-3 month.
Posted 3/6/2019 2:33 AM (GMT 0)
I agree with the others that you should see an RO soon. As for the side effects from SRT, I only had an increase in urination frequency. 4 months now since treatment ended and I still have no other side effects.
I also had 7 months of ADT based on my RO recommendation.
Posted 3/6/2019 2:43 AM (GMT 0)
Hard to say when to pull the trigger on SRT and whether to add ADT. There's no one-size-fits-all answer. Plus, if SRT, how many Grays? Prostate bed or whole pelvic? You need a first-rate RO experienced in treating PCa to evaluate your whole medical picture and advise you accordingly.

If you live in an area with more than one center/hospital that can do SRT on top-notch machines, I'd consult at both of them and compare the treatment plans they recommend.

Seems unlikely you're risking much by waiting a couple of months to start tx until you've healed from the hernia repair.

I've had no SEs from the radiation. No loss of continence. Of course, your mileage may vary. I don't know the statistics on probability of SEs, but certainly for some guys in the forum it ain't been a smooth ride.
Posted 3/6/2019 2:54 AM (GMT 0)
I agree with all the comments above. I was in a similar situation to yours. My surgeon was telling me to wait until .2. But I saw a rising trend that was very clear, and so I saw two top or RO’s. Both told me they recommend that I pull the trigger when I got to .06, saying that most recent studies have shown that once there was a clear trend upwards earlier is better. I started a SRT and ADT at .08

I’m three months past last treatment and last shot, no incontinence, but I do get up to to three times a night to PEE . Hopefully that will pass. I gained 10 pounds from the ADT, and still get occasional hot flashes but nothing that is not manageable. That was my experience

As far as ADT and your situation, which is very similar to mine, there is no clear protocol. Many are RO’s will say you don’t need ADT. Mine told me that he felt doing six months ADT would give me an additional 10% chance of success. But he left it up to me and I chose to go forward and do it

I hope my experience helps you make a decision, there’s no one decision that’s right for everybody in this situation. I guess it’s partly how lucky do you feel. Especially with G6 at the margin.

Keep us posted and good luck
Posted 3/6/2019 3:23 AM (GMT 0)
thanks a lot for your replies! I'll try to stay calm and zap it all with RT .
Booked an appointment with RO in 3 weeks.
Will keep you posted!

Post Edited (Mos_Ser) : 3/5/2019 8:27:06 PM (GMT-7)

Posted 3/6/2019 4:37 AM (GMT 0)
Mos_Ser, It depends on your age. Do you want to jump into more SE's. I was in the same boat. .05 then .08. Thought I would wait and see. 3 months later .07 . Time to line up RO,s,, Maybe. Take your time to find your doubling time line.
Posted 3/6/2019 5:16 AM (GMT 0)
read this, interesting!! askdrmeyers.wordpress.com/2012/12/19/when-recurrent-psa-isnt-cancer/ Links back to healing well but dr Meyers perspective is interesting. Sorry I don't know how to link.
Posted 3/6/2019 6:55 AM (GMT 0)

oldbeek said...
read this, interesting!! https://askdrmeyers.wordpress.com/2012/12/19/when-recurrent-psa-isnt-cancer/ Links back to healing well but dr Meyers perspective is interesting. Sorry I don't know how to link.

Well, I tried hyperlinking for you, but the url doesn't work.

Post Edited (Saipan Paradise) : 3/5/2019 11:58:33 PM (GMT-7)

Posted 3/6/2019 10:09 AM (GMT 0)
Both my urologist and RO said time to pull the trigger at .06. Both felt SRT was all I needed to do at GS 7 (3+4). I am 42 months out, no problems all psa have been <.006.
Praise God! Go find best RO around you and follow their recommendation.
Posted 3/6/2019 4:21 PM (GMT 0)
Octorobo , thanks for your reply !

Looks like you had SRT alone and did just fine!
Posted 6/10/2019 3:07 AM (GMT 0)
My recent update. My first laparoscopic hernia repair failed, I had hernia recurrence in 2 month post op and underwent open hernioplasty 03/19/19 , meanwhile my PSA was rising and I hit 0,1 mark recently

My RALP was 09/06/16, final path G3+4 , about 20% of prostate involved , no EPE, PNI + , no SV involvement, one positive anterior margin G 3+3 at the margin , LN dissection was not done

Date uPSA architect Abbot
5/24/19 0.101
5/06/19 0.096
3/05/19 0.074
08/25/18 0.043
05/21/18 0.033
02/21/18 0.033
11/10/17 0.022
06/16/17 0.009

So as soon as my general surgeon told me it's ok to start RT, I had my treatment plan outlined
It was truly hard decision , but I opted for ADT and RT . Had my Lupron shot about 1 month ago and starting RT tomorrow.
Fingers crossed.
Will keep you posted ....
Posted 6/10/2019 4:34 AM (GMT 0)
sorry you have to go through all that.

Do keep us updated on your progress.

Andrew
Posted 6/10/2019 10:21 AM (GMT 0)
That sucks, Mos. When it rains...
So, have you been to an RO now? What’s your plan?
Posted 6/10/2019 10:43 AM (GMT 0)
We had our prostates yanked at just about the same time. My psa started rising sooner than yours, however. I started SRT when psa reached .05, after 2 consecutive increases. My uro and I both thought that represented a trend. I visited two ROs, one local and one a hour away at a major medical center. The major medical center people gave no reason not to use the local guy, which I did. Neither suggested ADT. I've been 18 months without recurrence, so far. I was completely continent 10 months post-surgery, but the radiation caused new leaking, nearly all in the evening. Most days I don't need a pad but sometimes I do. If I were more diligent with kegels, it might dry up completely. Also, alcohol causes much more leaking, so I've reduced alcohol consumption about 95%, which has other benefits.
Posted 6/10/2019 11:30 AM (GMT 0)
Mos, FWIW I think you made a wise decision. The trend was clear.
As I mentioned in my previous post, our pathology and trends are very similar, as is our action point now.
I’ve got no long lasting side effects from SRT so far. Still waiting for ADT effects to wear off

Good luck, you’ll be fine
Posted 6/10/2019 12:59 PM (GMT 0)
Thank you guys for all support!

Prato, special thanks to you, when I was debating about ADT I knew what to expect and what difficulties I'd face. I was prepared.
How long was your ADT? How soon after your last shot you started feeling that side effects improve? And how many fractions of RT did you have?
So far, hot flushes are frequent but tolerable, but it's only beginning. Trying to be optimistic and think positively!

Mos

Post Edited (Mos_Ser) : 6/10/2019 7:11:36 AM (GMT-6)

Posted 6/10/2019 5:27 PM (GMT 0)
Mos,

Probably a very good move to have gone the route you have. I may be in not too far after you.

Have not read the following too closely yet, but it seems that you will be way ahead of the game, judging from the outcomes of others.

https://www.urotoday.com/conference-highlights/asco-2019-annual-meeting/asco-2019-prostate-cancer/112927-asco-2019-outcomes-of-men-with-recurrent-m0-prostate-cancer-who-defer-androgen-deprivation-therapy-until-metastasis-medical-oncologist-perspective.html?tmpl=component&print=1

Good luck. Will be interested in your progress if you will be so kind as to update sometimes.

Robert
Posted 6/10/2019 7:55 PM (GMT 0)
Thanks, Robert!
Will keep you posted about my progress!
Here is another link applicable to me I guess

https://www.urotoday.com/conference-highlights/esou18/esou18-prostate-cancer/101562-esou18-salvage-radiotherapy-for-prostate-cancer.html

Post Edited (Mos_Ser) : 6/10/2019 2:05:31 PM (GMT-6)

Posted 6/10/2019 8:18 PM (GMT 0)
I just wanted to wish you good luck with your SRT. In all likelihood, you'll breeze through it--but the ADT sure is bothersome. Good luck to you!
Posted 6/10/2019 9:41 PM (GMT 0)

Mos_Ser said...
Thank you guys for all support!

Prato, special thanks to you, when I was debating about ADT I knew what to expect and what difficulties I'd face. I was prepared.
How long was your ADT? How soon after your last shot you started feeling that side effects improve? And how many fractions of RT did you have?
So far, hot flushes are frequent but tolerable, but it's only beginning. Trying to be optimistic and think positively!

Mos

Mos,
To answer your q's...
My ADT was 6 months. My last shot of Lupron was in November, it was a 3 month shot. So it supposedly ran its course mid February. As of April 1st, my T was still in the cellar at 7 :-(. But when i tested two weeks ago, it was 48, so still in the cellar but starting to rise. My Hot Flashes persist, but seem to be diminishing in intensity, just a bit. Not sure if its my imagination. I am still fighting weigh issues, hard to lose. But no fatigue whatsoever.
Everyone is different. So your experience may be better, or not
Posted 6/10/2019 10:08 PM (GMT 0)
Mos,

The usual duration of ADT depends on your risk category. For low risk they don't usually bother with ADT at all. For intermediate low-risk cases (like yours, I think) it seems like six months is a popular duration. For high-intermediate and high risk cases it can be as little as one year up to three years with 18 months being fairly common. It is, of course, between you and your RO but if you want to know what to sort-of expect, six months is a good guess.

Most guys bounce back pretty quick after a six month period of ADT with most of the side effects better after three or four months and feeling mostly normal after six. Once you get past a year of ADT the time to recover gets longer on average and the chances you won't fully recover go up (to about one in ten).

Good luck with your RT. Most guys find it fairly tolerable. Be sure to complain to your RO about any symptoms. If, for instance, you find that the radiation makes your hemorrrhoids act up (a fairly common side effect of prostate RT) he can hook you up with something that will help.

If possible, use the buddy system to watch whodunits on TV while you are being treated. Have your buddy write down who the perpetrator was and how s(he) was caught. The most common side effect of radiation is a tendency to fall asleep when you sit down in your comfy chair in the evening and turn on the television.
Posted 6/10/2019 11:09 PM (GMT 0)

PeterDisAbelard. said...
The most common side effect of radiation is a tendency to fall asleep when you sit down in your comfy chair in the evening and turn on the television.

You've got that right. Also, while on ADT I not only lost any interest in sex, I also lost interest in most TV dramas and just stuck with Modern Family and such.
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