Hormone treatment after IMRT and when PSA goes up

I would like to receive feedback from those who have had external beam radiation which later resulted in a rising PSA. I had IMRT about 42 months ago. My PSA was 10.5 before treatment. I had a Gleason 3+4=7, Stage T1c, with about a 3% involvement in one area, Left APEX.

My PSA went down to 1.8 after some months post treatment but never got to a nadir of less than 1.0. Over the past two years it has gone up to 2.1, 2.3, 2.6, and now 3.1. Recurrence is most likely. I only have a couple options which are Cryosurgy or hormone treatment. My radiation oncologist advises to postpone hormone treatment until the PSA rises further, possibly until it reaches 10.0. I haven't discussed this with my oncologist yet, but will do so on the 27th.

I would be interested to learn the experience of others who are in the same boat. When did you decide on hormone, what was the lowest you PSA went down to and how long after treatment and what was the PSA when you went on hormone treatment. Did you receive intermittent or steady hormone treatment? What was used? What was the effect?

Chuck

I can't answer your questions, but I am gonna welcome you to the Forum. Hate to see you here, thanks for coming. It would be helpful for people replying if you could put a concise version of your Journey in your signature so they can know your history. Again, Welcome

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James C. Age 61
Co-Moderator- Prostate Cancer Forum
4/07 PSA 7.6, referred to Urologist, recheck 6.7
7/07 Path report: 3 of 16 PCa, 5% involved, left lobe , GS 3/3:6.
9/07 Nerve sparing open Retropubic Radical Prostatectomy
9/07 Post-op Path Report: GS 3+3=6 Staging pT2c, 110gms, margins clear
16 mts: ED- 50 mg Viagra 3X week, pump daily,Trimix .35ml 2X week continues
PSA's: 3 mts-.04, 6 mts.-.04, 9 mts.-.04, 12 mts.-.02, 16mts.-?

If this were psa bump(bounce) from radiations it would have gone up some and went back down thereafter and more likely the bump starts within 18-20 months(avg.) and probably back down within months, although examples of longest psa bump for radiations are recorded at 60-84 months (fyi). Kind of like a radiation induced 'prostatitis' concept that causes this uniqe and bizarre event for radiation patients, with alot of anxiety attached (duh). I don't know much on the bump/bounce thing otherwise, it seems if bump was your case it should have gone back down by now (dropped back). So, my swag guess is it is not bump/bounce but psa rise due to PCa somehow or somewhere. I did say s.w.a.g.-ok.

In the past some docs concurred about the psa of 10 level before getting aggressive on resuming hormone treatments. The onco-docs like Dr. Strum et al, believe that doubling time is very significant in PCa and especially if it is in short duration months or 1 year, red flag. You are having psa velocity which is scary to anybody with PCa and also written about in his book. (A Primer on Prostate Cancer)

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Post Edited (zufus) : 1/17/2009 8:25:28 AM (GMT-7)

Welcome Marine, glad you found us, sorry you need us, but best on the net to hang in, wonderful group of people. There are others in here that have been through the radiation methods, so hopefully they can answer your questions. A signature would help us here access your situation. Glad you are here, brother.

David in SC

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Age 56, 56 at DX

How do I provide a signature with history info?  Thanks!

Have update profile with history.

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Age 73.  Health excellent (work out five days a week) except for prostate cancer and colon cancer, the latter was 12 years ago and seems to be fine as evidenced by continuing colonoscopies. 

 

Four biopsies.  Two positive and two negative.  Positive reflects involvement in one area (Left Apex 3%).  Gleason 3+4=7, T1c,  negative DRE.  Received 40 doses of IMRT delivered by Fox Chase affiliate.   PSA history below:

 

PSA Tests	PSA	FreePSA	Change
05/97	4.2
09/97	4.7		+0.5
01/98	4.5		-0.2
08/98	4.3		+0.2
03/99	4.5	7.1	+0.2
10/99	4.0		-0.5
03/00	4.1		+0.1
10/00	5.2		+1.1	Biopsy
02/01	3.8		-1.4
03/01	4.4		+0.6	Biopsy
07/01	5.9	6.6	+1.5
11/01	6.8		+0.9
03/02	6.8	9.2	0.0	Biopsy
10/02	6.9		+0.1
05/03	5.9		-1.0
11/03	5.9		0.0
06/04	6.3		+0.4
11/04	9.0		+2.7
12/04	10.5		+1.5	Biopsy
07/05	6.4		-4.1	After IMRT (8 wks)
11/05	3.1		-3.3	After IMRT (6 months)
03/06	2.3		-0.8	After IMRT (10 months)
07/06	2.3		0.0	After IMRT (14 months)
11/06	1.8		-0.5	After IMRT (18 months)
05/07	2.1		+0.3	After IMRT	(24 months)
09/07	2.3		+0.2	After IMRT (28 months)
01/08	2.0		-0.3	After IMRT (32 months)
05/08	2.1		+0.1	After IMRT (36 months)
09/08	2.6		+0.5	After IMRT (40 months)
01/09	3.1		+0.5	After IMRT (44 months)

 

Go to Control Panel at the top of the page, then Edit Profile, then go down to Signature, then save it. I believe that is the correct sequence

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Age 56, 56 at DX

Looks there are 2 issues here---cryosurgury (or some other form of salvage surgery) or hormone treatment.   ANd then, IF hormone treatment, when?

My history is different than yours, but keep in mind hormone therapy is GERNALLAY not thought to be curative --- more of a progression delying therapy (although it CAN be curative in some instances, and the delay might be for decades).  The cryosurgery is curative ONLY if the recurrence is thought to be localized in the pelvic area.   Problem is, no one can tell for sure.

I'd say get your best guess if the disease is local or systemic, then bet on the treatment.  If local, get salvage treatment of some sort (they also do salvage prostectomies in some cases after failed radiation therapy as an alternative to cryro surgery)).   If you think its sytemic, then hormone therapy --- letting it run up to some higher number (sounds like they told you 10)......seems to be the norm.  Look into intermittent hormone therapy with diet changes (Charles "Snuffy" Myers is the guru on this approach....“Beating Prostate Cancer: Hormonal Therapy and Diet” is THE book to get on the subject).

Hope this helps...good luck!

 

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Sterd82

Hi Chuck,

Welcome to the site. My situation is slightly different than your own but I would like to make a suggestion to you. There is another PCa support site prostatepointers.org that has a patient to physician (P2P) group where the questions are answered by a Dr. Strum (I think he is the same Dr. Strum that you see mentioned here so often). You will need to put a data sheet together similar to you signature. The form is on the site.
There is also an EBRT group at this site where you can post questions. As I recall there are a few with problems similar to yours. I have recieved some good information and support there as well as at this site. It never hurts to have more than one reference point. The EBRT group is mostly guys who had radiation as primary and some who had it as secondary.

Chuck, best of luck to you.
Don

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Diagnosed 04/10/08

My father had a RP and the path showed local lymph node involvement after his RP, his PSA dropped to .05 at 8 or 10 weeks out, however, because there was a node involved, the team recommended 2 years of HT immediately and we opted for IMRT.
I have not seen the theory or support behind waiting until your PSA reaches 10. I would understand if you were already on HT and taking a HT vacation and then waiting until it reaches 10 to start again, but why wouldn't you start it immediately?
Welcome to HW and please keep us posted in your journey! All the best!

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Father's Age 62 (now 63)
Original Gleason 3+4=7, Post-Op Gleason- 4+3=7,
DaVinci Surgery Aug 31, 2007
Focally Positive Right Margin, One positive node. T3a N1 M0.
Bone Scan/CT Negative (Sept. 10, 2007)
Oct. 17 PSA 0.07
Nov. 13 PSA 0.05
Casodex adm. Nov 07, Lupron beg. Dec 03, 2007 2 yrs
Radiation March 03-April 22, 2008- 8 weeks 5x a week
July 2, 08 PSA <.02
Oct. 10, 08 PSA <.02
Praying for a cured dad.

Co-Moderator Prostate Cancer Forum

Hi Marine man!
Welcome to HealingWell. You are obviously a veteran already and have done well for quite some time. Each case is different but I can see where your radiologist is coming from. But I would probably start the HT sooner. Just my mind set. I have tolerated it well, and I have had good results. Great job on the PSA post. I really tells a story. Let me know if you need anything as all. Otherwise welcome to ethe best place, I think, on the web for caring and compassionate support.

Peace,

Tony

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Age 46 (44 when Dx)

Thanks to all for the information provided.

From it I gather there is some thought either way regarding when to get the hormone started. Waiting or until PSA goes up to say 10.0.

I would also like to know what hormone treatment (brand I guess) was used and how it affect the people on it.

I was aware hormone is not curitive but just a way to manage PSA for some time until it no longer is effective since some cells reject hormone therapy and continue to grow. I was also aware there are some, I believe Pittsburgh is one of them, that does salvage protectomy. My urologist told me about that but does not do it himself. He also told me he would do the operation but suggested IMRT might be the best for me considering quality of life.

Thanks again to all.

Chuck

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Age 73.  Health excellent (work out five days a week) except for prostate cancer and colon cancer, the latter was 12 years ago and seems to be fine as evidenced by continuing colonoscopies. 

 

Four biopsies.  Two positive and two negative.  Positive reflects involvement in one area (Left Apex 3%).  Gleason 3+4=7, T1c,  negative DRE.  Received 40 doses of IMRT delivered by Fox Chase affiliate.   PSA history below:

 

PSA Tests	PSA	FreePSA	Change
05/97	4.2
09/97	4.7		+0.5
01/98	4.5		-0.2
08/98	4.3		+0.2
03/99	4.5	7.1	+0.2
10/99	4.0		-0.5
03/00	4.1		+0.1
10/00	5.2		+1.1	Biopsy
02/01	3.8		-1.4
03/01	4.4		+0.6	Biopsy
07/01	5.9	6.6	+1.5
11/01	6.8		+0.9
03/02	6.8	9.2	0.0	Biopsy
10/02	6.9		+0.1
05/03	5.9		-1.0
11/03	5.9		0.0
06/04	6.3		+0.4
11/04	9.0		+2.7
12/04	10.5		+1.5	Biopsy
07/05	6.4		-4.1	After IMRT (8 wks)
11/05	3.1		-3.3	After IMRT (6 months)
03/06	2.3		-0.8	After IMRT (10 months)
07/06	2.3		0.0	After IMRT (14 months)
11/06	1.8		-0.5	After IMRT (18 months)
05/07	2.1		+0.3	After IMRT	(24 months)
09/07	2.3		+0.2	After IMRT (28 months)
01/08	2.0		-0.3	After IMRT (32 months)
05/08	2.1		+0.1	After IMRT (36 months)
09/08	2.6		+0.5	After IMRT (40 months)
01/09	3.1		+0.5	After IMRT (44 months)

 

I'm confused. Your urologist wasn't suggesting IMRT again was he? Also, did your previous IMRT include the pelvic area or just the prostate?

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Father's Age 62 (now 63)
Original Gleason 3+4=7, Post-Op Gleason- 4+3=7,
DaVinci Surgery Aug 31, 2007
Focally Positive Right Margin, One positive node. T3a N1 M0.
Bone Scan/CT Negative (Sept. 10, 2007)
Oct. 17 PSA 0.07
Nov. 13 PSA 0.05
Casodex adm. Nov 07, Lupron beg. Dec 03, 2007 2 yrs
Radiation March 03-April 22, 2008- 8 weeks 5x a week
July 2, 08 PSA <.02
Oct. 10, 08 PSA <.02
Praying for a cured dad.

Co-Moderator Prostate Cancer Forum

Welcome to the forum my friend. I am certainly no expert nor do I claim to be however based on your previous experience I think going ahead and attacking with HT would be a good protocol. There may be something to waiting to see how long it takes to double but I still think firing the weapons are the best course.

peace to you
Dale

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My PSA at diagnosis was 16.3

Thanks for continuing discussion and information.

Doting Daughter: sorry for the confusion but in my 1:16pm but I was referring to treatment options going in and not after decision and treatment. I guess I didn't make that clear but my urologist said he would do the operation if I decided on it (he is a very well thought of an experienced doctor in South Central PA) but thought IMRT would be a better choice since he thought based on PSA history and percent of involvement (only 3% in one area) IMRT would suit me better. The IMRT was delivered after the radiation oncologist reviewed the results of the biopsy. previous biopsies, bone scan, and C-Scan. He mapped out the region but I believe it was confined to prostate.

Dale: considering your Gleason and percent of involvement in several areas it appears you are doing quite well with the IMRT and hormone. I imagine they used the hormone going in to IMRT, correct? When did you receive the IMRT?

I understand based on information I have read: Some doctors think that hormone therapy works better if it is started as soon as possible if the cancer has reached an advanced stage (for example, when it has spread to lymph nodes), if it is large (T3) or has a high Gleason score, or if the PSA starts rising after initial therapy, even though the patient feels well. Some studies have shown that hormone treatment may slow down the disease and perhaps even lengthen patient survival. But not all doctors agree with this approach. Some are waiting for more evidence of benefit. They feel that because of the likely side effects and the chance that the cancer could become resistant to therapy sooner, treatment should not be started until symptoms from the disease appear.

One thing for sure is nothing is certain or guaranteed. My goal now is to learn more about hormone treatment and other options for a rising PSA post-IMRT.

My best to all.

Chuck

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Age 73.  Health excellent (work out five days a week) except for prostate cancer and colon cancer, the latter was 12 years ago and seems to be fine as evidenced by continuing colonoscopies. 

 

Four biopsies.  Two positive and two negative.  Positive reflects involvement in one area (Left Apex 3%).  Gleason 3+4=7, T1c,  negative DRE.  Received 40 doses of IMRT delivered by Fox Chase affiliate.   PSA history below:

 

PSA Tests	PSA	FreePSA	Change
05/97	4.2
09/97	4.7		+0.5
01/98	4.5		-0.2
08/98	4.3		+0.2
03/99	4.5	7.1	+0.2
10/99	4.0		-0.5
03/00	4.1		+0.1
10/00	5.2		+1.1	Biopsy
02/01	3.8		-1.4
03/01	4.4		+0.6	Biopsy
07/01	5.9	6.6	+1.5
11/01	6.8		+0.9
03/02	6.8	9.2	0.0	Biopsy
10/02	6.9		+0.1
05/03	5.9		-1.0
11/03	5.9		0.0
06/04	6.3		+0.4
11/04	9.0		+2.7
12/04	10.5		+1.5	Biopsy
07/05	6.4		-4.1	After IMRT (8 wks)
11/05	3.1		-3.3	After IMRT (6 months)
03/06	2.3		-0.8	After IMRT (10 months)
07/06	2.3		0.0	After IMRT (14 months)
11/06	1.8		-0.5	After IMRT (18 months)
05/07	2.1		+0.3	After IMRT	(24 months)
09/07	2.3		+0.2	After IMRT (28 months)
01/08	2.0		-0.3	After IMRT (32 months)
05/08	2.1		+0.1	After IMRT (36 months)
09/08	2.6		+0.5	After IMRT (40 months)
01/09	3.1		+0.5	After IMRT (44 months)

 

Hello Chuck, First of all let me thank you for serving our country....!!

My husband, Pete had external radiation and seed implant plus hormone treatment eight years ago. After four years his PSA began to rise..... We received mixed information at that time (2 1/2 years ago) ..Our primary urologist suggested HT, and not salvage prostectomy. He said it would be too difficult after radiation... (He was right) We also saw two Pca oncologists...One recommended intermittent HT and one recommended salvage surgery with a caviat: There MAY be side effects, Well, that was an understatement. And this was from the Sloan Kettering group that is supposedly one of the best salvage surgeons in the country....It has been a nightmare of horrible side effects. The radiation damage that was there caused a fistula..after the surgery....(a connection between the rectum and the bladder), and catheter in for ONE YEAR, more surgery to fix that, plus total incontinence... How I wish we would have done the HT....probably intermittently....The quality of life would have been so much better for Pete. So whatever salvage (I hate that word) you decide, I would definitely forgo the surgery one. Good luck to you... Diane

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Husband Pete
dx Jan 2001 gleason 4 + 3 PSA 16.5
Seed implant and conformal radiation and Lupron from Jan 2001 to Jan2002
2005 Dec PSA began to rise from .5 to 8 within 6 months
Salvage surgery at MSK 9/06 Dr. Eastham
Fistula operation 2/07 MSK Dr. Wong
Many cystoscopies and ER visits with strictures
Catheter for one year....Catheter taken out Sept 07..
Total Incontinence since then....
PSA .52 3/08
AUS Operation at MSK Sept 8 2008 Dr. Sandhu
Activated Oct 28th Dr. Sandhu..MSK
Some difficulty with AUS arising Nov 10 2008
Meeting with Dr. Sandhu to discuss AUS problems and new PSA test Dec 11, 2008
PSA .6 12/08
AUS improving..only 2 pads a day and one at night
Complete hip replacement surgery Dr. Waters Gainesville, FL 1/9/09
Forging ahead to health!

Diane:  Thank you for your input and advice.  I am so sorry to learn of your husbands experience but from what I have learned over the years, an operation after radiation is very risky.  I do not believe I would chose it.  I will go with the hormone treatment but am trying to determine when is best.  If intermittent or continuing is best.  What to use? 

Chuck, another option for a recurrence of localized PCa following Radiation is HIFU. It has been available in Australia for several years now, however I do not know of any studies of it's efficacy following EBRT. Might be worth a look on Pub Med.

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Diagnosed March 2007, Age 57
Positive DRE, 12 Core Biopsy, 6 cores positive PCa,
Gleason 7 (4+3), Stage T2B
Rx 9 months LHRH ADT Lucrin, Neo Adjuvant,
Gold Seed implants 2 weeks prior to EBRT
70gy 3D Conformal EBRT
PSA: Nov 2006 = 6.0 ng/ml, May 2007 = 5.6 ng/ml * 1st Lucrin IMI
Aug 2007 = 0.85 ng/ml* 2nd Lucrin IMI
Nov 2007 = 0.45 ng/ml * 3rd Lucrin IMI
Jan 2008 = 0.29 ng/ml * 8 weeks EBRT and TURP in May
June 2008 = 0.12 ng/ml, Sept 2008 = 0.14 ng/ml, Dec 2008 = 0.1 ng/ml

Chuck

zdy, welcome to the forum and thanks for sharing your story. I hope some effective treatment plans are available to select from. I wanted to welcome you, and to point out that you have replied to a 7 months old thread, so the previous participants may not respond back to you, if they have moved on or for whatever other reason.

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James C. Age 62
Co-Moderator- Prostate Cancer Forum
4/07 PSA 7.6, referred to Urologist, recheck 6.7
7/07 Biopsy: 3 of 16 PCa, 5% involved, left lobe, GS 3/3=6
9/07 Nerve sparing open RRP 110gms.- Path Report: GS 3+3=6 Stg. pT2c, 110gms, margins clear
21 mts: ED- 50 mg Viagra 3X week, pump daily,Trimix .35ml 2X week continues
PSA's: .04 each 3 months

zdy:  I hope your husband finds effective treatment.  Every day we hang in there we are a winner. 

Hi Chuck,

Thought I would comment on the ADT since I began Lupron Apr. 21, 2009.  Had seed implants Jan 08, first PSA's promising, then rising PSA's (see my signature).  Docs didn't waste any time putting me on Lupron.  I didn't ask, but believe that my cancer is/was somewhat aggressive despite the Gleason 6.  Hot flashes are the main side effect, very tolerable, whole body gets hot, but no big deal for me.  Waiting for next PSA around Aug. 10.  Will know then how effective the Lupron is.  I guess individual docs have their own protocols as to when to initiate various treatments.  So, if you trusts your docs, it seems sensible to follow their advice.  All the best to you.

Gene in Md

Chuck,

welcome to the site from an ex grunt. From everything I have read about reoccurrances, psa doubling time is the most important factor. If it is over three years, which yours seems to be then it is very controllable for a long time and you will probably die from something else.

The best protocol is ADT3, which is Lupron, Casodex and Proscar. You may want to ask your oncologist about Casodex as a mono therapy as your psa is not rising fast and the side affects are about 20% of Lupron. The best thing is to get a good prostate oncologist even if you have to travel to see one. His recommended treatments can be done locally so you may have to travel only once per year for followups if at all. My neighbor has been on Lupron since 1996 and is doing fine.

Good luck,

JT

Thanks for the posts and advice yesterday.  I get the next round of PSA & urologist visit in September.  Then I will question the wait or treatment regarding rising PSA depending on results.  Having so far survived both colon and prostate cancer and now facing a back problem termed a "remarkable back" by my Otho doc, treatment of which begins with epidural shots, I understand the need to take control of one's health and not just sit back and swallow everything the doc's say.