My head is spinning

AT a risk of boaring everyone, here are the highlights of my story that led to a situation I find myself in. Any thoughts or suggestions are highly appreciated.

Welcome to the fuzzy world of advanced disease cancer treatment. The hardest part of the entire process for me is what you are going through right now. There are not a lot of studies for advanced disease that show significant benefits. Until recently, as in this past year, there were really none that demonstrated a significant survival benefit of doing Salvage or adjuvant radiation if there was local spread or systemic involvement. Therefore, the more opinions you seek, the more opinions you will get.

Here is an attempt to answer some of your questions,

It is not too surprising MSK requested slides for their own report. I think most facilities do this and i know this was done in my father's case.
I believe the standard with Stage 3 is depending on the number of margins etc, wait for a PSA rise about a pre-set number (typcially .1 0r .2) and then move forward with treatment.
I can't speak for your MSK onc, but I believe that a lot of radiation oncologists have started adding HT to salvage recently. I don't think this has been the standard of care and has typically been used for systemic disease, however, recently, a number of guys that are being treated for local disease have had HT in addition to the radiation.

Lastly, my father had somewhat similar staging, as you can see from my signature. His PSA was undetectable by some standards following his RP, however, because of his lymph node involvement, HT was recommended and decided to have IMRT. He had one focally positive margin. At the time, there were not any studies that supported salavage radiation for stage 3/4 guys with local lymph node involvement, however, because his PSA was undetectable after RP and because the lymph node had a tiny portion that was positive and not engulfed with cancer, we decided to move forward with radiation and continue to hope and pray that if there was any remaining cancer, it was local and blasted by the radiation. He was a couple of shots left of his 2 year Lupron treatment and we will continue to hope and pray that his PSA will remain undetectable forever once stopping. The truth is, there are no absolutes with this beast. I truly feel you have to take all the medical opinions, research and your faith and make a decision that feels right and don't look back. Good luck and peace be with you in the decision process.

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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

Geebra,
The first thing is to confirm lymph node involvement. The best method to do this is with a Combidex MRI which is only done in Holland and is 96% accurrate. This will allow a decision to radiate the lymph nodes or not to radiate.
HT is recommended along with salvage radiation unless it can be positively acertained that the reoccurrrance is local.
Your Doctor is correct, a gleason 8 tumor should throw off a lot less psa than 30, so the psa must be coming from somewhere else. You may have micromets.
I would get a 2nd opinion from one of the top prostate oncologists even if I had to travel to see one.
Good luck.
JohnT

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64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DX BPH and continue to get biopsies yearly. Positive Biopsy in 10-08, 2 cores of 25, G6 less than 5%. Scheduled Surgery as recommended.

2nd Opinion from Dr Sholtz, an Oncologist said DX wrong, path shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G 4+3 approx 2.5cm diameter.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and burining urination. Daily activities resumed day after implants.

Scheduled for 5 weeks IMRT in July

JohnT

Hey John! Quick question out of curiousity, is the Combidex supposed to be able to pick up micro mets? It will be so nice once it is available in the US.

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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

The truth of PCa is that the doctors only can detect or know its where abouts in limited fashion. There are no guarantees with PCa, ever and even for low stats/risk patients it is not 100% guarantee of cure no matter how great the surgeon or method of treatment(s). It is a best guess scenario a s.w.a.g. estimate, using imperfect data, testings, scans and protocols, etc.

Now some docs could or will be honest enough to tell you such, some others will never admit such and sell the patient what they might like to hear.....yeah your salvage radiation will take care of it (or such)...it could do such is the real answer and it also could be done for nothing or very limited results. Just being a realist on what patients are facing, not the glass half full or empty, but more of is their a glass and where is it??? Some patients get taken advantage of in medical things and that is unfortunate and it is part of the culture of greed and profits, what a country. Tons of money wasted on scans, especially in low stats patients (see Dr. Strums data and books, an onco-doc of world class honesty on PCa issues).

John T would know the most about Combidex, I think he would even say that micro mets could be missed by Combidex and it is missed often by all other scanning equipment that is available.
People put way to much faith in a given doctors verbage or opinion (he is the expert, yada...yada..yada) it is his opinion just like his opinion on politics or whatever, PCa is not a black and white perfected science or calculation type of thing. My guess and experiences lead me to believe that most surgeons do not even bother to learn things for PCa treatments outside their own specialization (sure they know of a few drugs or things, and so do you without a degree or schooling). So you will be given a sales pitch on their craft of perfection and they will be usually biased and they usually will not get emotional about your possible recurrence or problems after their modality is done on you. Understandable as they cannot get wrapped up in people personal lives, least they break down and become ineffective and unemployed perhaps.

My thoughts for PCa- get mulitple opinions, get mulitiple questions answered by other patients-internet-books-journal articles etc.-read anything even the controversial or negative stuff about treatments, learn something from any PCa patient (yananow mentors etc.), then weigh all that collective information and reach your own conclusions as best you can....then decide what you wish to consider doing, maybe in conjunction with your chosen doc. The other side of this is do whatever Doc-X says is best, which can be highly biased, highly profitable, full of return visits and perhaps in his best interests and if it happens to serve you well all the better. I could be wrong or biased, but based upon my own experiences and 8 opinions and years of internet boards and discussions, leads me to these conclusions. I am well served by getting those 8 opinions, that was a priceless education in the real world of PCa.

Dx-2002   total urinary blockage, bpsa 46.6  12/12 biopsies all 75-95% , gleasons 7,8,9's .  Got 2-surgeons opinions- one guaranteed a cure (wow-sales pitch)   second LRRP reknown surgeon-'I won't do surgery on you'   (I got 6 more opinions thereafter and plenty of education via searching)

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Post Edited (zufus) : 6/7/2009 5:20:26 AM (GMT-6)

Geebra,

Thanks for your post. I am a few months behind, but I had an EPE, which by definition is out side the capsule, but the surgeon apparently got enough other tissue out with it so that I had negative margins.

I am in the process of going to a well known Urology Oncologist to determine if I should do radiation of chemo now to make sure if any cells did escape, or if I had a micro met, before it starts to grow.

I kind of feel that chemo makes more sense at this stage, so that I can save the radiation as my last big gun if it does return. The VA is doing a clinical trial with chemo right now.

The other posts are right. This is a fuzzy world, with so many options, so many questions, and so few answers,

Thanks again for opening this thread. Please keep us in touch with your progress so that we can learn from the things you are learning from.

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Age 58

Thank you!

I plugged my numbers into the MSK salvage radiation calculator and it comes back with 72% biochemical recurrence free probability at 6 years. I guess this makes it almost as good as my numbers were at the surgery. So, this is a second chance? You dont get a lot of those in life. I want this one to count. Tomorrow is the MRI (both docs do not expect it to show anything, but want to be on the safe side). I will try to get in touch with all my docs next week and decide by next weekend. I doubt I will have any more info if I wait longer.

John - I had 16 lymph nodes removed as part of open surgery, all showed no involvement, so the pelvic radiation is a preventative measure. The thought is that some PCa may have escaped into that area. The treatment idea is then to be as aggressive as you can be, given that I am 47 and otherwise healthy and would have 30+ years of life expectancy.

Will be praying for guidance and good luck in the treatment.

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Previous 5 biopsies over 4 years negative

PSA going from 3.8 to 28

Father died from PCa @ 78 - normal PSA and DRE

Dx Nov 2007, age 46

PSA 29, Gleason 4+4=8

Decided to participate in clinical trial at Duke

6 rounds of chemo (Taxotere+Avastin)

1/8/2008	33.90
1/11/2008	29.50
1/31/2008	38.20
2/21/2008	32.00
3/13/2008	26.20
4/3/2008	26.60
4/24/2008	20.60

followed by RRP at Duke (Dr. Moul) on 6/16/2008

Gleason downgraded 4+3=7, T2c N0MX, one small positive margin

PSA undetectable for 8 months, then

2/6/2009	0.10
4/26/2009	0.17
5/22/2009	0.20

Geebra,
Zufus is correct. Combidex will only pick up PC in the lymp nodes, it won't pick up micro mets. Seeing a good oncologist is your best bet. There are a lot of tests now that may pick up micromets
JohnT

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64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DX BPH and continue to get biopsies yearly. Positive Biopsy in 10-08, 2 cores of 25, G6 less than 5%. Scheduled Surgery as recommended.

2nd Opinion from Dr Sholtz, an Oncologist said DX wrong, path shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G 4+3 approx 2.5cm diameter.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and burining urination. Daily activities resumed day after implants.

Scheduled for 5 weeks IMRT in July

JohnT

Just spoke to my Medical Oncologist and he agreed with Radiation Onc's suggestion for two months of ADT prior to radiation, two months during and six months afterwards. He does feel the six months afterwards may be a bit of an overkill. Now I have to wait for the results of my MRI (done two days ago) and get started...

Read this,

http://www.forbes.com/feeds/hscout/2009/06/10/hscout627941.html

Interesting, but I am not sure applicable in my case. These are the studies for radiation as a primary treatment. However, it would be logical that if it helps in primary treatment it would also help in salvage treatment.

My Onc mentioned that most of the existing sdudies for salvage radiation do not show benefit of hormonal therapy, however, he still recomends the HT+SRT, because of larger studies for use of this protocol as a primary treatment showed significant benefit.

The radiation doc said the latest (small) studies have shown benefit, so either way, I am going for it.

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Previous 5 biopsies over 4 years negative

PSA going from 3.8 to 28

Father died from PCa @ 78 - normal PSA and DRE

Dx Nov 2007, age 46

PSA 29, Gleason 4+4=8

Decided to participate in clinical trial at Duke

6 rounds of chemo (Taxotere+Avastin)

1/8/2008	33.90
1/11/2008	29.50
1/31/2008	38.20
2/21/2008	32.00
3/13/2008	26.20
4/3/2008	26.60
4/24/2008	20.60

followed by RRP at Duke (Dr. Moul) on 6/16/2008

Gleason downgraded 4+3=7, T2c N0MX, one small positive margin

PSA undetectable for 8 months, then

2/6/2009	0.10
4/26/2009	0.17
5/22/2009	0.20

Good Luck Geebra....I know it was a tough decision to make. If I was your age I would do exactly what you are doing and not take any chances of not putting this disease into long term remission. Good luck again and keep us posted to the progress and the effects of your treatment plans. It will be very valuable information to others that may go down that path you are traveling.

Stay tough mentally and emotionally.

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You are beating back cancer, so hold your head up with dignity

Best wishes Geebra,

You've done your research, now go beat the beast! 

DS

As a fan of Who Wants to be a Millionaire? I've noticed that an easy question is one that I happen to know the answer.  For chosen ones who have had PC the "correct" treatment is the one that worked for them.  I've been as guilty as anyone in preaching about the best choice of treatment. I can only suggest that anyone considering radiation of any type do their research into the side effects.  I can say that being one of the lucky ones who have not required any post-surgery treatments of any kind.  Another thing that I've noticed is that many people will say that they would never do chemo or whatever, but when the doc says this may save your life you will probably do whatever is recommended.

Geebra:

To your question about ED with ADT: I had a Lupron Depot shot as part of a botched initial treatment protocol. This was before my Da Vinci RP (after I found a different urologist). I had no erectile difficulty AT ALL, but absolutely NO INTEREST in sex. My wife would get exasperated and say "Am I going to finally get laid, or what?" Talk about the shoe on the other foot! Once we began I had no problem whatsoever achieving a normal erection and completing the process. Orgasm was normal. This cycle would then repeat.

As the Lupron effect slowly wore off, I suffered a lot of the associated and documented side effects of low testosterone. Hot flashes, memory loss, night sweats, depression. It was miserable. Initially, I didn't seem to be bothered by the Lupron, just when my body tried to re-start the testosterone production. I had a 4 month depot shot in June 2008 and finally got the T replacement in Jan 2009.

After my first PSA came back .01 my GP agreed to Testosterone replacement. Urologist wanted to wait another 6 months. I used the Androderm patch. It took about two weeks and all the symptoms disappeared. I continued for two months, and quit.

Now it's "Will you give up on that? It's not going to happen" from my wife.


These posts show two things: we need to find the cancer earlier, and we need a better detection method or methods. They keep talking about testing for the gene expression of the more aggressive form of the cancer, to identify those pre-disposed to an agressive PCa, but I don't see it happening anywhere.

Thank you, KeyWestPirate. This is very useful.

Took my first Casodex today. Lupron is scheduled for 6/18. One month shot first, then a 3-months one. Total six months (as opposed to 10 as I originally thought). 2 months before, 2 months during and 2 months after the radiation.