Questions about recurrence for family member

1. If he had a PSMA or Axumin Pet Scan, then that is the best technology available currently to determine if cancer has spread beyond the prostate bed and whether there is any point doing SRT.
2. MD Anderson is likely using the Lupron to sensitize the cancer to radiation before radiating. They are not using ADT as a long term measure.
3. There is evidence from the CHAARTED and STAMPEDE trials that Docetaxel before radiation improves outcomes in high risk cases, but it's unlikely in your relative's case because he is 74 and there is some risk to Docetaxel (about 1% death rate). I'm also not sure they would classify your relative as high risk from the info you have given. Here is a link https://www.ascopost.com/issues/june-25-2015/adjuvant-chemotherapy-proves-effective-in-localized-high-risk-prostate-cancer/

"1. With a PSA of 80 (clear Pet scan and MRI) how likely is it that local treatment (I.e. radiation) is enough? Is it likely that there is metastasis outside the prostate bed?"

it would be very unusual that the cancer is still contained in the prostate bed with a PSA of 80.

That's kind of what I thought about the PSA of 80...that it's likely out of the cage, and so I understand the Lupron but I guess I don't get the benefit of putting him through SRT (keep in mind that also means he's moving temporarily to Houston for 8 weeks because he lives in Ohio for the radiation therapy). It seems like local overkill and not enough systemic treatment, doesn't it?

This is why I asked about chemo. If the PSA is high enough to indicate that there's metastasis but the scans don't show it (I don't know what type of PET scan he had, but he told me he had one and that they couldn't see anything on it). Is it an option for him to skip the SRT and have chemo instead in hopes of wiping out unseen mets? What are the obvious options for him?

He's in otherwise good health, he's retired but still likes to play golf, is an active grandfather, etc.

WoP - I can only think of him getting another opinion, maybe Cleveland Clinic?, maybe not too far away?. Something doesn’t add up and I suspect that is because you are not getting the whole story, just his recollections of things happening. I am not sure why SRT is suggested either given 10+ years, really high PSA, and supposed negative scans. Considering that SRT is typically considered at a PSA > 0.2 after RP, a PSA of 80 seems like It would be something more than a local occurrence.

It could also be everything is under control, a good plan is in place, and he has just reported it in such a convoluted manner that nothing adds up. Hope for the best that the doctors at MDA are doing the right thing for him.

Sometimes I wonder (rightly or wrongly) just how serious many local gp's take prostate cancer.

I don't know anything about MDA and have heard nothing but good things about them. (they cured my sister of breast cancer 30 years ago). But sometimes I do wonder if, inside of center's of excellence, (the bubble of killing cancer at *all* cost...it's their job) may not blind them to other considerations.

I honestly do not know.

I suggest a second opinion at Cleveland Clinic, just to be safe. There are too many open issues at this point. Does he have someone to accompany him, and be a second set of ears? Hopefully he will give permission for you to receive his medical report. A Decipher genome test could help.

The CC radiation oncology dept. is first class.

Michael, me too.

I did confirm with him that the scan he had was the PETCT Fluciclovine- CAP, which is the same as the Axumin scan. And despite that high PSA, the scan was clean. His pelvic MRI also apparently didn't show anything obvious.

I'm really not sure why he waited until his PSA was so high to begin salvage treatment (I know it's easy to blame his local docs, and that could be appropriate but it may not...I just don't know).

To me, it seems unlikely that SRT is going to be curative for him, so why do it?

I told him that since he's starting Lupron now, and the SRT can't begin for another 2-3 months (He knew that, but he did not know that the reason for the delay in SRT was that the Lupron would make the cancer cells more radiosensitive...so I'm not sure if the docs aren't explaining this to him or if he's just not "getting it"), he has some time to ask some more questions without delaying anything.

I also confirmed that within the past 9 months his PSA has gone from 56 to 80. He had Gleason 7 (3+4), his surgery was in 2007, and he was below 0.04 for 5 years. From 2013 to 2017 quarterly PSAs were in the 0.2-0.4 range, and at that time his doc told him he either had slow growing cancer cells that weren't too concerning or that the higher PSA could be due to pet dander (never heard that one? seems like that should've been go time for SRT). Seems like there should've been more intervention then, and I'm honestly not sure why his docs didn't act more quickly at the time, but they told him then they'd let it get to 2.0 (which seems high for someone without a prostate)...when it started going into double digits, I don't know.

I suggested that he ask the docs about the possibility of doing hormone therapy and foregoing the radiation. He said he'd ask about that and seemed grateful for the suggestion of something else to ask about. I tried to gently tell him that while it's a good thing his scans are clean, it might be an indication that local treatment is NOT going to be curative and that it might make sense to consider hormone therapy on its own and spare his body the toxicity and trauma of SRT. I hope he understood and felt supported.

OMG AJMan. You know what? I didn't think of that because he told me multiple times verbally and in writing that it went from 56 to 80 and it didn't occur to me to clarify.

I just texted him and asked again is it 80 or 0.80? And he said he misspoke and it's actually 0.80.

Thank you for pointing that possibility out. That one little decimal point is a game changer, isn't it? Well, now I feel like the idiot who wasted everyone's time on here but thank you for talking it out!

Great to see this coming together! All the best for his upcoming treatments!

That's probably why the doc's in Ohio were not recommending any treatment at this time. There is still a lot of belief that BCR doesn't start until 2.

Larry

What a great detective story. My best for a good outcome for your Uncle!