Trying to decide secondary treatment

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oldflyingfarmer
Regular Member


Date Joined Jun 2009
Total Posts : 32
   Posted 8/4/2009 3:33 PM (GMT -6)   
Just thinking about options for the future.
I have mixed feelings for followup radiation. I had a psa of 31 and a Gleason score of 9. Had my RRP on 5/27/09. Lymph nodes were clear. My doc recommends radiation now. My psa at 6 weeks post op was <.05. I put off my decision for 3 months (next psa). Incontinence is pretty good, I wear 1 pad a day for safety. I think some days I could do w/o. My ED is not corrected. I am taking daily 5mg cialis and just started therapy on the pump. I feel I need a little more time to heal and correct myself before starting radiation. I am interested in the Proton radiation, side effects seem to be less but it will cost me a lot to go that route. My industry is in the worst shape that it has ever been in so money isn't growing on the trees.

What are most opinions, with my gleason and postop psa on doing the radiation?

I have a while but I need to be thinking.

Thanks all, this is a great site for all of us.

Ok, added your suggested title lol

Post Edited By Moderator (James C.) : 8/4/2009 3:11:35 PM (GMT-6)


oldflyingfarmer
Regular Member


Date Joined Jun 2009
Total Posts : 32
   Posted 8/4/2009 3:34 PM (GMT -6)   
sorry, forgot my topic. Maybe 'trying to decide secondary treatment'.
Age 55
Diabetic on insulin pump
PSA started rising in 2007
2 negative biopsiesthru 2008
2009 PSA 31, TURP found Gleason 9 cancer
Started holistic approach while waiting for surgery
RRP on May 27, 2009
Cath out 2 weeks after surgery
Very little drip, some pain
Had my 6 week post op doctor visit. PSA was <.05 so I am pleased.
Still some ED problems but seeing improvement. May try VED. Started on daily pills.


geezer99
Veteran Member


Date Joined Apr 2009
Total Posts : 990
   Posted 8/4/2009 4:21 PM (GMT -6)   
Well, your Gleason is high but your PSA is good. I think you need an opinion from a prostate oncologist to help sort out your options (especially with your diabetes as a factor.) My take is that immediate radiation, adjuvant treatment, has fallen somewhat out of favor compared to later treatment, salvage treatment. You don't list very complete post-surgical pathology, and at this point, that is important. If you don't have that report, get it from your surgeon.
Given that no new information seems to have emerged since your surgery (except the low PSA) I wonder why your doctor is recommending radiation. Did he tell you before surgery that he thought radiation should follow it? You need to know more before making a choice.
Age at diagnosis 66, PSA 5.5
Biopsy 12/08 12 cores, 8 positive
Gleason 3+4=7
CAT scan, Bone scan 1/09 both negative.

Robotic surgery 03/03/09 Catheter Out 03/08/09
Pathology: Lymph nodes & Seminal vesicles negative
Margins positive, Capsular penetration extensive Gleason 4+3=7
6 weeks: 1 pad/day, 1 pad/night -- mostly dry at night.
10 weeks: no pad at night -- slight leakage day/1 pad.
3 mo. PSA 0.0 - now light pads


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 8/4/2009 5:14 PM (GMT -6)   
My doctor is more a wait and see. Pre-surgery, he let me know that as a general rule, he wasn't for pre-emptive radiation after surgery. He's more of a salvage radiation guy if you truly have reaccurance, which is the situation I am in with my own post surgery PSA. He still thinks its right for me to slow down the Radiation Oncologists big rush to radiate me based on one quick visit. I still agree with that strategy. While I am waiting for my corrective surgery on the 18th, I am still going to have my 9 month post surgery PSA done on the 11th. I am anxious in a good way this time to see where the number is at. Until they can fix this blockage problem (persistent one I should say), can't really moved ahead with the secondary treatment even if I wanted to.

David in SC
Age 57, 56 at DX, PSA 7/7 5.8, 7/8 12.3,9/8 14.5
3rd Biopsy Sept 08: Positive 7 of 7 cores, 40-90%, Gleason 7, 4+3
Open RP surgery 11/14/8, Right nerves spared, 4 days hospital, staples out 11/24/8, 5th cath out on 1/19/9
 Pathlogy Report:Gleason 3+4=7, pT2c, 42 grm, tumor 20%, Contained in capsule, one post. margin, clear lymph nodes 
2009 PSA   2/9 .05, 5/9 .10, 6/9 .11, 8/11 ?
Lastest 7/13 met with Rad. Oncl, considering options, 7/20 Catheter #6 after complete blockage, scarring closed up bladder neck, corrective laser surgery scheduled for 8/18
 
 


Squirm
Veteran Member


Date Joined Sep 2008
Total Posts : 744
   Posted 8/4/2009 6:31 PM (GMT -6)   
Sounds like he (or she) wants to start radiation as a adjuvant treatment and not have to wait to use radiation as a salvage treatment.

There is an interesting article on Dr Catalona's site regarding this.
Here: http://www.drcatalona.com/quest/quest_winter08_2.htm

Radiation After a Radical Prostatectomy

This article is adapted by Cecilia Lacks, PhD, for Quest from two * journal articles on the topic of salvage radiotherapy vs. observation in men who have had a recurrence after a radical prostatectomy as indicated by a detectable and rising PSA. The studies upon which these articles are based, one sponsored by the Urological Research Foundation and one from Johns Hopkins, are preliminary findings with limited populations and more research is needed to confirm the results.

Despite the fact that early detection of prostate cancer is much improved since the era of PSA testing, a considerable number of patients have adverse findings in their final pathology reports on their prostatectomy specimens. Although adverse pathology findings clearly are associated with worse outcomes, the appropriate selection of patients for postoperative radiation therapy (RT) is an unresolved issue for treating doctors.


Randomized trials have shown an improvement in progression-free survival rates with adjuvant radiation therapy (ART). This treatment takes place soon, within 2 to 4 months, after a radical prostatectomy for patients with a high risk of cancer recurrence.

Less is known about the relative advantages and disadvantages of initial observation with delayed salvage radiation therapy (SRT). This treatment takes place some time after a radical prostatectomy but only when there is evidence from a rising or detectable PSA that indicates a recurrence. SRT is local radiation to the prostate bed alone (the area around where the prostate was located before surgery). SRT is sometimes combined with hormonal therapy, for example, in patients with a high Gleason-grade tumor.

Despite studies supporting the use of immediate adjuvant radiotherapy for men with unfavorable pathology in their RP specimens; the treatment may lead to additional side effects that can create treatment complications and affect quality of life. In addition, it’s possible that a proportion of men could be overtreated, for example, by receiving radiation treatment unnecessarily.

As a result, some physicians instead prefer initial observation with later salvage radiation therapy at the time when there is evidence of recurrence.

The purpose of these studies was to examine the results of initial observation followed by SRT in patients with adverse pathology and in patients with cancer recurrence as indicated by a detectable and rising PSA.

The appropriate management for men with adverse pathology at the time of RP is controversial. Some patients with minimal adverse pathology may have a low progression rate without additional treatment.

On the other end of the spectrum, some patients with high-risk features likely may have cancer that has already spread and will not benefit from additional local therapy.

The issue is to define the intermediate group of patients who will truly benefit from postoperative radiation and to know the best time for beginning treatment.

Study Connected to SM+ and ECE
The adverse pathology in radical prostatectomy patients from one study (Loeb 2008) falls into the following categories: Positive surgical margins (SM+), extracapsular tumor extension (ECE) and seminal vesicle invasion (SVI).

This study found that initial observation followed by delayed SRT at the time of PSA recurrence might be an effective strategy for select patients with positive surgical margins and extracapsular tumor extension.

Timing of SRT is an important factor in effective results. Those patients who began SRT when their PSA levels were less than 1 had much better results than those who waited until PSA levels were more than 1.

Some patients with seminal vesicle invasion may also benefit; however, additional studies are necessary to examine survival outcomes following SRT in these patients because the study found that patients with SVI had a significantly higher progression rate with observation alone.

Study Connected to PSA Doubling Time
Cancer recurrence after radical prostatectomy often results in a recommendation for salvage radiation. This study (Trock, 2008) examined whether salvage radiation confers a survival benefit compared with observation.

The research looked at survival statistics for men who were treated with salvage radiation after recurrence to see if some men had a significant increase in survival after treatment with salvage radiation and some men showed less or no effect.

What the study found is that men with a PSA doubling time of less than six months after recurrence benefited most from salvage radiation. In contrast, salvage radiotherapy has not yet been shown to be significantly associated with prostate cancer-specific survival among men with a PSA doubling time of 6 months or longer.

Possibly, the men with slower doubling times have less aggressive cancers with less need for salvage radiation. But it is also possible, and even likely, that with longer follow-up, men with slower PSA doubling times will be shown to receive a survival advantage from SRT as well.

In their article, researchers said, "This study provides provocative evidence that even men with adverse prognostic features such as rapid PSA doubling time or high Gleason score may benefit from salvage radiotherapy".

Before this study, the prevailing theory was that recurrence was evidence the cancer had metastasized in some other place or places in the body. This finding, they said, "If true, has somewhat surprising implications for the prevalence of local recurrence as a source of PSA relapse".

Additional findings suggested that men for whom salvage radiotherapy is most beneficial are those with a PSA doubling time of less than 6 months, who also undergo treatment within 2 years of an increase in PSA level and before the PSA reaches 2.

More Research Will Help Make Decisions
The findings in these studies are preliminary. Clearly, additional studies with more detailed information on pathologic features would be helpful to further evaluate the effectiveness of treatment for a patient who has adverse findings on his final pathology report from his radical prostatectomy specimen.

Options now include:

Doing nothing other than monitoring PSA and having salvage radiation or hormonal therapy if the PSA rises.
Having adjuvant radiation (with or without hormones).
Having adjuvant hormonal therapy alone.
Having experimental chemotherapy (with or without hormonal therapy).

For most patients, the decision (if they are having radiotherapy) is adjuvant vs. delayed salvage radiation. But, in some instances, the other options are recommended.

"Based upon these studies, it cannot be said that salvage radiation is as good as adjuvant, and it can’t be said that some patients with other adverse features might not also benefit from salvage, if the follow-up were longer," Dr. William J. Catalona said.

He explained further, "What can be said is that salvage RT has a survival benefit for some patients and, that at the present time, those with the most aggressive features seem to benefit the most".

If doctors knew which patients with adverse pathology could safely be observed after their RRP, rather than treated soon after with ART or with SRT upon recurrence, the side effects of radiation – which can create quality of life issues and possible future medical concerns – could be minimized.

Post Edited (Squirm) : 8/4/2009 5:38:04 PM (GMT-6)


goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2691
   Posted 8/4/2009 10:52 PM (GMT -6)   
farner,

Yoiu and I are in same leaky boat. Gleason 9 makes all the doctors nervous. (How do they think I feel )

I considered Chemo for a while, and decided that radiation is the best second option if we need it. Found some studies that showed a significant change in reocceurence rates for those who did adjuvant radiation within 4 months of surgery.

My radiatio guy says maybe a 5% decrease in reoccurence. Oh abd by the way there is a 1 to 2% chance of radiation tumors, along with the other potental nasty side effects.

If 5 % is all I gain on what I feel is a 64 % chance of no reoccurence, I say radiation now is nit worth the potential side effects, including permanent incontinence and permanent ED.

I am also on a wait and see regimen. PSA's every 3 months. If see a rise, then I'll probably pull the trigger.

Let's keep in touch and if you find anythng promising, let me know !
Age 58, PSA 4.47 Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09   Nerves spared
0/23 lymph nodes involved  pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks due to anatomical issues with location of ureters with respect to bladder neck.  Try 3 tubes where no tubes are supposed to be for 2 weeks !
Neg Margins, bladder neck negative
Living the Good Life, cancer free  6 week PSA  <.03
3 month PSA <.01 (different lab)


oldflyingfarmer
Regular Member


Date Joined Jun 2009
Total Posts : 32
   Posted 8/5/2009 4:58 AM (GMT -6)   
Thanks for all the input guys. As usual, there is always decisions to be made. I have a while until I go back to the doctor, so I am trying to get as educated as I can. At least then, maybe I will sound like I am not stupid. I will keep reading and talking and trying to educate myself until I go back.
I appreciate all the info and wish all the same result that I am seeking. To beat this cancer. Good luck to all.
Age 55
Diabetic on insulin pump
PSA started rising in 2007
2 negative biopsiesthru 2008
2009 PSA 31, TURP found Gleason 9 cancer
Started holistic approach while waiting for surgery
RRP on May 27, 2009
Cath out 2 weeks after surgery
Very little drip, some pain
Had my 6 week post op doctor visit. PSA was <.05 so I am pleased.
Still some ED problems but seeing improvement. May try VED. Started on daily pills.


CPA
Veteran Member


Date Joined Feb 2008
Total Posts : 655
   Posted 8/5/2009 7:12 AM (GMT -6)   

Greetings, farmer.  You (and others) are probably correct that the Gleason 9 is what prompts him to want to look at additional treatments.  However, I have always heard - mainly from this group - that you watch your post op PSA's to see where they are tracking and once it gets above .1 (like it has recently for our friend David in S.C.) you watch it very closely until it gets to .2 and then you look at radiation.  Like someone else said, I would think a visit to a good oncologist who specializes in prostate cancer would be in order. 

It sounds as if you are doing well and we are grateful for that.  Best wishes for continued great reports.  David


Diagnosed Dec 2007 during annual routine physical at age 55
PSA doubled from previous year from 1.5 to 3.2
12 biopsies - 2 pos; 2 marginal
Gleason 3+3; upgraded to 4+3 post surgery
RRP 4 Feb 08; both nerves spared
Good pathology - no margins - all encapsulated
Catheter out Feb 13 - pad free Feb 16
PSA every 90 days - ZERO's everytime!
Great wife and family who take very good care of me


Squirm
Veteran Member


Date Joined Sep 2008
Total Posts : 744
   Posted 8/5/2009 10:18 AM (GMT -6)   
goodlife,
There are some reports of decreased chance of secondary cancers using proton therapy instead of photon.

goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2691
   Posted 8/5/2009 1:35 PM (GMT -6)   
Squirm,

I have also heard that, but proton is less accessbile. My real point is tho, is a 5 % increase in odds, even with no secondary cancers worth the risk of perm ED, incontinence, rectal / anal issues etc. ?

Tell me 25 % then maybe I will say that is a worthwhile risk.
Age 58, PSA 4.47 Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09   Nerves spared
0/23 lymph nodes involved  pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks due to anatomical issues with location of ureters with respect to bladder neck.  Try 3 tubes where no tubes are supposed to be for 2 weeks !
Neg Margins, bladder neck negative
Living the Good Life, cancer free  6 week PSA  <.03
3 month PSA <.01 (different lab)


55 and healthy in NJ
Regular Member


Date Joined Apr 2009
Total Posts : 58
   Posted 8/5/2009 3:48 PM (GMT -6)   
I agree with geezer99.  The missing piece of information here is the post-surgical pathology report.
 
Greg

Age 55
PSA history: 2.9 (Oct 04), 3.7 (Dec 05), 2.79 (Nov 07), 4.54 (Jan 09), 4.9 (Feb 09)
05/18/2009 - Robot-assisted (daVinci) laparoscopic radical prostatectomy by Michael Esposito, M.D. and Vincent Lanteri, M.D. http://www.roboticurology.com/ both nerve bundles spared
Surgical Pathology: Prostate gland 51.8 grams; Gleason score 3+3=6; Pathologic stage T2c, N0, Mx; Left/Right Pelvic lymph nodes clear (no tumor present); No presence of extra-capsular invasion;  No margin involvement
05/26/2009 - Catheter and incision staples removed
05/30/2009 - Started Viagra 25mg 3x/week
07/06/2009 - 1st post-surgery PSA <0.1


Squirm
Veteran Member


Date Joined Sep 2008
Total Posts : 744
   Posted 8/5/2009 6:03 PM (GMT -6)   

goodlife,

From my numbers it does equal to 25% chance of secondary radiation therapy working for a 5% increase in overall progression free survival.

Again, we have what's called a parallel system of reliability. Meaning that if both treatments fail then the outcome is failure, but only if both fail.

The math works out like this. R=1-(1-R1)(1-R2)

Replace R with .85 (The overall probability outcome of one of the treatment options is successful). Replace R1 with .8 (reliability of surgery working). Now find R2. After the math you find radiation will have a 25% (1 in 4) chance of success to gain a 5% chance in overall probability. Something to consider.


Post Edited (Squirm) : 8/5/2009 10:29:23 PM (GMT-6)


goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2691
   Posted 8/6/2009 9:16 PM (GMT -6)   
Squirm,

Nifty little calc. The question is, if r-2 is what they call salvage radiation at a later date, instead of adjuvant ( pre-PSA rise) does the calculation remain the same ?
Age 58, PSA 4.47 Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09   Nerves spared
0/23 lymph nodes involved  pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks due to anatomical issues with location of ureters with respect to bladder neck.  Try 3 tubes where no tubes are supposed to be for 2 weeks !
Neg Margins, bladder neck negative
Living the Good Life, cancer free  6 week PSA  <.03
3 month PSA <.01 (different lab)

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