You asked the question on where I got the idea that most PC reoccurrances are systemic and not local. It was in one or more of Dr Leibowitz's publications.
Your question really got me thinking because you are one of the most informed persons I know and you never heard of it; and I just took it for granted. That question kept me up most of the night and led to a bunch more questions.
I took it for granted when I 1st heard it because I've had experience with breast cancer because my wife was treated 5 years ago and as everyone knows it has a high reocurrance rate. Breast Ca is always treated as systemic even though the tumor is local. Surgery and radiation are adjuncts to the primary chemo treatment. So Im used to thinking of cancer as being systemic.
Reocurrance being systemic makes sence when you think about it.
The local treatments, surgery, radiations ect, are exactly the same for gleason 5 and 6 as they are for gleason 8 and 9. But we know that 5 and 6 reoccurances are unlikely whereas 8 and 9 are very likely. If there is no difference in the treatment then the only variable is the cancer grade. If the prostate is completely removed during surgery then it can only mean that cancer has excaped and entered the blood stream before the prostate and all the cancer cells in it were removed.
We know that millions of cancer cells are elswhere in the body of PC patients but that only a few of them will develop into tumors.
Maybe G 8 and 9 cells are the ones that eventually develop into tumors and g 5 and 6 stay indolant.
I'm way over my head going down this road because I have absolutely no training, but I have an idea of how PC cancer works. It goes through the blood stream and usually settles in the pelvic lymph nodes , the prostate bed or the pelvic bones. For some reason it doesn't like organs. Most of the PC cells don't grow but some of them do and it could take years. I suspect that the same conditions that made it grow in the prostate will make it grow again down the road. Diet could influence the future growth rates.
If you have a reoccurance you have to assume that it came from cells that are already inside your body, unless the surgery was botched and some prostate tissue was left. If your treat this locally you are not killing all the other cells that are elsewhere just waiting to grow.
The other thing that bothers me is that recurrances usually have a much faster psa doubling time than the original tumor.The original tumor usually has a 2-3 year psa doubling time and reoccourances usualy have a much faster doubling time, a year or months, Something's happening here that I don't understand. You can come to a bunch of conclusions about this, but I don't think there is any evidence to support any of them.
Reoccurance in high PSA patients is fairly strateforward, no matter what the gleason score is. You can easily calculate the size of the prostate gland and determine the psa it will generate. If you know the tumor size and grade, which should be known, you can calculate the psa that it is putting out. If the psa is higher, then it must be coming from somewhere else, most likely from small tumors in the lymph nodes. Transition zone tumors are different as they create lots of psa for their size, but agressive gleason 8 and 9s create low psa. I don't know why more doctors don't use this easy psa calculation on their high psa patients to better stage their PC. I know my uros never used it.
I hope I've given you some things to think about. I don't know why more research isn't done in this area. I think it's because most PC doctors are urologists and concentrate on surgery and surgical solutions even though there is a lot of evidence that PC behaves a lot like most other cancers and spreads through the bloodstream.