Adjuvant Therapy: How do I decide?

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hangin-in
Regular Member


Date Joined Sep 2008
Total Posts : 78
   Posted 11/10/2008 2:40 PM (GMT -6)   
It is now 10 weeks since my RP surgery. The pathology report indicates a positive apical margin. With Gleason 6 and no extra capsular extension, the Surgeon suggested that there is no need for further treatment as long as the PSA remains undetectable.
I didn't feel comfortable leaving it as is so I made an appt with a radiation oncologist. He thinks that there is a good reason to do preventative radiation now.
My gut feeling is to power up all the guns early and fire hard against this monster. However I have two concerns.
1. I might be inviting side effects (Incontinence and ED) unnecessarily. I do not have these problems now.
2. The radiation oncologist told me that I will have only one chance at radiation. It can not be used again if the PSA rises in the future.
 
So I have conflicting opinions and I don't know how to make this decision. On one hand I am scared of losing continence or potency but on the other hand, I would hate to have a rising PSA in the future and then kick myself for not doing radiation right after surgery.
Any advice? How does one make such a decision? HELP!!

Rising PSA 12/06=1.6 12/07=2.1 5/08=2.6
Biopsy 6/4/08 12 core 4 Positive 15%,15%,8%,3%
Diagnose @ Age 51 Gleason 3+3=6
Bone & Cat Scans Normal
Lapro Surgery 8/18/08 at Memorial Sloan Kettering
Pathology report stage T2c organ confined with positive apical margin Gleason 3+3 = 6 (with tertiary grade 4)
Catheter removed 8/26 - reinserted 8/29 - removed 9/2
No continence or potency problems from the get-go.
First post op PSA 10/2/08 < 0.05


LV-TX
Veteran Member


Date Joined Jul 2008
Total Posts : 966
   Posted 11/10/2008 2:53 PM (GMT -6)   
Well hangin...that's gonna be a tough choice. I am kinda in the same boat as you...but not really either. The location of your positive margin is the big difference. I don't have a concern with mine and so I am going to wait for a PSA rise (that's a big if by the way not a when)...and then depending on the doubling time what direction I will go if it does rise. I personally don't want radiation, however those that have been down this road will give you a good answer to the drawbacks (if any) with radiation after surgery. As much trouble as I have with the side effects from surgery...I don't want a repeat or extension of that and I am not willing to jump into more treatment as a result. Call it what you want...I say...don't fix what isn't broke.
Les
 
Age 58 at Diagnosis
Oct 2006 - PSA 2.6 - DRE Normal
May 2008 - PSA 4.6 - DRE Normal / TRUS normal-Gland 38 cc
July 2008 - Biopsy 4 of 12 Positive 5 - 30% Involved Bilateral (Perineural Invasion present at base)
Gleason (3+3) 6  Stage T1C
August 23 - Bone Scan - Hips, Spine and ribs marked uptake - X-Ray showed clear -Hooray
Sept 9 2nd DRE - questionable - TRUS...shadow in base - Gland now 41 cc
Robotic Surgery Sept 18, 2008
Pathology October 1,2008
Gleason 7 (4+3) Staged pT2c NO MX
Gland 50 cc
Seminal Vesicles and Lymph Nodes clear
Positive Margins Right Posterior Lobe
4 tumors in prostate - largest being 6 cm 
PSA Oct 08 <.05


Frank1205
Regular Member


Date Joined Feb 2008
Total Posts : 308
   Posted 11/10/2008 4:39 PM (GMT -6)   
Hangin,
 
I too am in a very similar position as you. My urologist is also an oncologist and recomended that I have a 50/50 chance of PSA coming back.  I  saw an Oncologist and he recomended radiation to increase my chances of no PSA return with the margin.  I saw a radiation oncologist and as soon as I told him what my urologist/oncologist said he quickly deferred to him.  Although he did seem to give the impression that the number and length of the margin(s) was a determining factor.
 
You dont describe your margin in your post.  Mine was a single .5MM I understand.  I asked how many cancer cells can live in something like that and he said maybe two to three. 
 
I am seven months post surgical and my PSA's are undetectable so far.  My Urologist states after my six month PSA that he would like to draw another one at the one year mark.  That to me ( 6 months) is not watching it closely.  I am going to request one every three months for a long while.  It is bothersome to not be sure if you got it all.  I often say if my PSA even blinks I want to do salvage radiation of the prostate bed.
 
You say your Doc stated that you can not radiate if your PSA comes back.  I hope that's wrong for I based my decision on that I can.  After a period of time after surgery they call it Salvage Radiation not adjuntive radiation and I understand the latter is more powerful when there is PSA detected so I would assume you have more chance of side effects if it comes back but thats a huge IF.
 
I have read some posts here where some of us change our minds for the pressure of PSA coming back and not doing all we can weighs heavy on ourminds and that alone effects quality of life.
 
All I can say is do your research and take action based on who you are and what you feel is right.
 
I wish you the best in your decision.
 
Frank 
 
 
 
 
Diagnosed @ 53 years old now54
DRE normal , 2004 Biospy negative - 2008 Biopsy positive (01-08-08)
10 cores, 1 positive and at 1% of that one core
PSA @ surgery 6 
Bone and Ct scans negative
clinicaly Staged at T1C - Gleason 3+3 = 6
Robotic Da Vinci performed March 27th, 2008
University of Chicago,Hospital stay 30 hours -
Catheter out in 7 days 
normaly expected leakage
Post Pathology T2C, Gleason 7, 10 % of both portions of prostate
Seminal vessels clear, fat tissue clear
single positve margin measureing less than 1/2mm 
Six week PSA < 0.1 , 4 month PSA <.05 Gen II test. 6 month PSA  <0.01
Urologist recomends to hold off on Radiation and watch PSA closely. Oncologist and Radiation Oncologist seem to lean to doing pre-emptive radiation.Uroligist says 50/50 chance of PSA re-occurence.  
I have decided to hold off and see in 3 months lets see in 9 months.
Next PSA January 2009.
11-08-08 (7months) starting to go without day pads, 100 mg Viagra seeing good results
 
 
 
 


hangin-in
Regular Member


Date Joined Sep 2008
Total Posts : 78
   Posted 11/10/2008 5:50 PM (GMT -6)   
Thanks for your reponses.
Frank - My pathology report did not describe the margins other than to say positive apical margin. Do you think I should push for more detail? Also, I am sorry if I wasnt't clear. What I meant to say was that my Radiation Dr said that if he does radiation now, then I would lose the option of doing radiation again in the future if the PSA begins to rise. In other words we have only one opportunity for radiation.
I agree with you about the three-month checks. I would definitely not wait any longer than that. The anxiety would kill me.
Les - What is the difference in the location of the positive margin? Is apical margin better?
 
Thanks again so much for your responses. You guys are great.
 
I wonder if anyone here did / or did not decide on radiation and later regretted / or was happy with the decision?
Mmmmmm.....

Rising PSA 12/06=1.6 12/07=2.1 5/08=2.6
Biopsy 6/4/08 12 core 4 Positive 15%,15%,8%,3%
Diagnose @ Age 51 Gleason 3+3=6
Bone & Cat Scans Normal
Lapro Surgery 8/18/08 at Memorial Sloan Kettering
Pathology report stage T2c organ confined with positive apical margin Gleason 3+3 = 6 (with tertiary grade 4)
Catheter removed 8/26 - reinserted 8/29 - removed 9/2
No continence or potency problems from the get-go.
First post op PSA 10/2/08 < 0.05


Ken S
Regular Member


Date Joined Nov 2006
Total Posts : 120
   Posted 11/10/2008 5:56 PM (GMT -6)   
Hangin-In,

My pathology is a mirror image of yours. My urologist stongly suggested that I see a radiologist and an oncologist - all three thought it would be a good idea to be aggressive so I opted to have adjuvant therapy.

Before the radiation treatments I stopped using pads but part way through I had to start wearing them again and I still do 17 months after treatments ended. I wear one pad a day and I leak just enough for it to be embarrassing if I don't, at the end of the day I usually have a spot about the size of 2 half dollars.

ED problems have not changed at all since my surgery. I get maybe a 50% erection without the use of any aids, chemical or otherwise.

I'm sure the radiation effected my incontinence, my ED problems - I have no way of knowing.

May I suggest that you go to http://www.urotoday.com/ sign up, become a member and do a search for positive margins and adjuvant therapy.

One thing for all of us to keep in mind is the inroads that are being made every year in fighting this monster and if there is a recurrence down the road we'll have options that are unknown today.

Ken
Age 54 (2006)
PSA: 2005 - 3.2, 2006 - 3.7
Biopsy 8/06, Gleason 6 (3+3), T1c
Radical Retropubic Prostatectomy 11/3/06
Memorial Hospital, Pawtucket, RI
Post-Op Biopsy, still Gleason 6 (3+3),
T2c, right apical margin positive
CT Scan 1/07, tumor discovered on right
kidney (unrelated to PCa)
Partial Nephrectomy 3/9/07
R.I. Hospital, Providence, RI
IMRT (37 Treatments) 4/23/07 - 6/14/07
PSA: 7/08 - 0.02


LV-TX
Veteran Member


Date Joined Jul 2008
Total Posts : 966
   Posted 11/10/2008 6:23 PM (GMT -6)   
Hangin...from what I read from some articles...the location is a factor, however the amount or size of the positive margin is even a greater factor. I believe if memory serves me, anything greater than 3 cm is going to be the biggest factor, next followed by the location and number of positive margins. The two locations of greatest concerns are those located nearest the bladder neck and the apex (apical), but that doesn't matter much if the margin was fairly large. Again I would see if your surgeon has this info if available, it might help you in your decision process.

Just keep in mind that because you have had a positive margin, you still have a greater chance on remaining cancer free. Somewhere along the lines of having an 80% probability of being cancer free at the 10 year mark. However...I am pretty sure you didn't have surgery for those kinds of odds...you wanted them to be 95% or better.

All of this is going to be a tough decision, so I would continue your research for what YOU want to do.

For me...I am going to role the dice that I am in the 80%. If not...then I will do what I need to do at that time.

I don't really know if it makes any difference to have radiation before or after PSA rise in the grand scheme of things and I don't know if the dose is higher in one vs. the other either.

I am sure there are differences...but it all depends on who you talk to. The biggest thing is...if you have treatment adjuvantly and no PSA rise...did the radiation do it's job...or was it because you were already in the 80% bracket in the first place. Also, I don't know of any that had adjuvant therapy and still had a subsequent rise in PSA. I do know some that some have failed with salvage...so maybe there is some merit to doing it before.

Tough decision that is for sure.
Les
 
Age 58 at Diagnosis
Oct 2006 - PSA 2.6 - DRE Normal
May 2008 - PSA 4.6 - DRE Normal / TRUS normal-Gland 38 cc
July 2008 - Biopsy 4 of 12 Positive 5 - 30% Involved Bilateral (Perineural Invasion present at base)
Gleason (3+3) 6  Stage T1C
August 23 - Bone Scan - Hips, Spine and ribs marked uptake - X-Ray showed clear -Hooray
Sept 9 2nd DRE - questionable - TRUS...shadow in base - Gland now 41 cc
Robotic Surgery Sept 18, 2008
Pathology October 1,2008
Gleason 7 (4+3) Staged pT2c NO MX
Gland 50 cc
Seminal Vesicles and Lymph Nodes clear
Positive Margins Right Posterior Lobe
4 tumors in prostate - largest being 6 cm 
PSA Oct 08 <.05


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 11/10/2008 8:21 PM (GMT -6)   

This stage is the most contraversial there is.  But at least my doctors have been forthright with that facts.   I think the stage pT2c guys have a tougher choice than I did.  I was the last staging designation before stage IV.  (Note you guys with "pT3c" are the same as me just a different older table).  For me with seminal vesical invasion (SVI), extraprostatic extention (EPE), and multiple positive margins, the blitz was on.  But make no bones about it, I could have stoppedthe undetectable after the surgery.

So why didn't I?  Well age for one.  I was just 44 at the time, and all the reading, and nomagrams showed me some pretty poor numbers in 5 years past surgery.  Still do but the nomagrams don't take into account my treatment options I selected.  In 7 years I had a 22% chance of being free of this disease in seven years.  My doctors sais 10% in anything after that.  I listed that nomagram below.  You pT2c guys with positive margins have better numbers there.  But it is still a tough call and adjuvant therapy does show improved numbers in later years.

SKM Nomagrams! For Post Prostatectomy!

Tony



Age 46 (44 when Dx)
Pre-op PSA was 19.8
Surgery on Feb 16, 2007 @ The City of Hope
Post-Op Pathology: Gleason 4+3=7, positive margins, Extra Prostatic Extension (EPE)
Bilateral seminal vesicle invasion (SVI); Stage pT3b, N0, Mx
HT began in May, '07 with Lupron and Casodex 50mg (2 Year ADT)
IMRT radiation for 38 Treatments ending August 3, '07
Current PSA (September 17 '08): <0.1 ~ Undetectable!
 
You can visit my Journey at:
 
STAY POSITIVE!
 
 

Post Edited (TC-LasVegas) : 11/10/2008 6:26:12 PM (GMT-7)


hangin-in
Regular Member


Date Joined Sep 2008
Total Posts : 78
   Posted 11/11/2008 3:49 PM (GMT -6)   

Thanks for your responses.

I went to http://www.urotoday.com/ and it has a wealth of information. Thanks Ken.

I read so much that I am on overload right now. I think I need to take a step back for a day or two and let it all sink in.

Thanks for your help.


Rising PSA 12/06=1.6 12/07=2.1 5/08=2.6
Biopsy 6/4/08 12 core 4 Positive 15%,15%,8%,3%
Diagnose @ Age 51 Gleason 3+3=6
Bone & Cat Scans Normal
Lapro Surgery 8/18/08 at Memorial Sloan Kettering
Pathology report stage T2c organ confined with positive apical margin Gleason 3+3 = 6 (with tertiary grade 4)
Catheter removed 8/26 - reinserted 8/29 - removed 9/2
No continence or potency problems from the get-go.
First post op PSA 10/2/08 < 0.05

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