Salvage treatments for failed radiation.

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John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4235
   Posted 1/24/2010 3:10 PM (GMT -6)   
There have been a lot of comments on this board that imply there are no good salvage treatments for failed radiation and a major reason for choosing surgery as a first line treatment is that you have a 2nd chance. Many urologists (surgeons) tell this to their patients on a regular basis.
The facts tell us that this is a misconception of uniformed doctors and patients.
The following article is devoted to salvage treatments available after a failed radiation:
 
 
To summarize the important points:
1. Only 26% of radiation failures are local. The vast majority are systemic failures. The same holds true for surgery.
 
2.. Salvage options:
 a. Cryosurgery
 b. HIFU
 c. low dose brachy
 d. High dose brachy
 e. radical surgery.
 
3. Results from High dose Brachy salvage:
Lee et al:  19 month follow up; 89% biochemical free.
Tharp et al: 58 month, 71% disease free
Gamie et al: 41% disease free at 41 months.
All of these results are better than the often quoted 30% disease free of salvage radiation after 1st line surgery.
The statements that there are no 2nd chances after failed 1st line radiation treatments are false.
Some of the salvage treatments, such as HDR Brachy, have better outcomes than SRT after a failed surgery.
The important thing to note that in all salvage treatment regardless of the 1st line treatment chosen, the reoccurrance must be local in order to be effective.
JohnT
 
 

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology 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. G7, 4+3, approx 16mmX18mm.

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. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 1/24/2010 3:16 PM (GMT -6)   
Your last sentence in your post is what it is all about. Is it local or not? The great unknown. I was not, and am not thrilled with the low expectations from my doctors for sucess at my recent SRT. I went through 2 months of hell to accomplish that, and it will only have been worth it to me if it stops the cancer. The SRT has done more direct home to my body and my head/attitude then even my big surgery and the corrective surgeries after. But that's just me.

A person should only have surgery, if their numbers and medical history show that it would be the best primary curative shot. Any other reason would be to satisfy the mindset of the patient, not necesarily what is in the patient's best long term interest.

David in SC
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Incontinence:  1 Month     ED:  Non issue at any point post surgery
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12
Latest: 7/9 met 2 rad. oncl, 7/9 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 out 38 days, 9/9 - met 3rd rad. oncl., mapped  9/9, 10/1 - 3rd corr. surgery - SP cath/hard dialation, 10/5 - 11/27 IMRT SRT 39 sess/72 gys ,cath #8 33 days, Cath #9 35 days, 12/7 - Cath #10 43 days, 1/10 - Corrective Surgery #4, and Caths #11 and #12 in at the same time


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 1/24/2010 5:26 PM (GMT -6)   
John you need to recheck those statistics on salvage radiation post prostatectomy. They are simply misleading. With bRFS post RP salvage EBRT shows near 70% success rates in restoring detectable PSA's post RP when salvage radiation is performed before the PSA reaches 2.0. This is reported by both RTOG studies and by multi-center RP studies. This is easily searched in the NCI/PubMed Database...

Here is the MSK Nomagrams showing performance of post RP salvage radiation. You can enter just about any Gleason and see that they have excellent history post RP.
www.mskcc.org/applications/nomograms/Prostate/SalvageRadiationTherapy.aspx

Tony
Prostate Cancer Forum Co-Moderator

Post Edited (TC-LasVegas) : 1/24/2010 3:30:06 PM (GMT-7)


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4235
   Posted 1/24/2010 5:48 PM (GMT -6)   
Tony,
Very useful tool. It depends on the numbers you put in. For a G8 with a psa of 10 and a .5 before salvage RT I get a 9% success rate. I plugged in my numbers and got 48% ( I had to guess on post surgery numbers)
The 30% success rate is the one I have often heard quoted as a average as this incluses both local and systemic reoccurrances. This tool is much more accurrate.
JT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology 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. G7, 4+3, approx 16mmX18mm.

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. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


don826
Veteran Member


Date Joined May 2008
Total Posts : 1010
   Posted 1/24/2010 5:56 PM (GMT -6)   
John,
Interesting article. As David stated the last observation is the key... the PCa must be localized to the prostate or adjacent area. This was something that I noted when I was making my decision on treatment. The prognosis was always better if the PCa could be verified as localized.

The last line in the article was also very telling with the term "carefully selected patients". I read an article some time back that a couple of doctors in Germany were doing RP on previously radiated patients with some degree of success but only after careful selection. I suppose it comes back to the patient's individual characteristics and the skill of the physician.

Still it is nice to know that there is still some hope.

Don
Diagnosed 04/10/08 Age 58 at the time
Gleason 4 + 3
DRE palpable tumor on left side
100% of 12 cores positive for PCa range 35% to 85%
Bone scan clear and chest x ray clear
CT scan shows potential lymph node involvement in pelvic region
Started Casodex on May 2 and stopped on June 1, 2008
Lupron injection on May 15 and every four months for next two years
Started IMRT/IGRT on July 10, 2008. 45 treatments scheduled
First 25 to be full pelvic for a total dose of 45 Gray to lymph nodes.
Last 20 to prostate only. Total dose to prostate 81 Gray.
Completed IMRT/IGRT 09/11/08.
PSA 02/08 21.5 at diagnosis
PSA 07/08 .82 after 8 wks of hormones
PSA 10/08 .642 one month after completion of IMRT, 6 months hormone
PSA 03/09 .38 six months post radiation and nine months into hormones 
PSA 06/09 .36 or .30 depending on who did the test
PSA 09/09 .33 one year after IMRT and 16 months into hormone
 
 
 


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 1/24/2010 5:59 PM (GMT -6)   
One of the major advantages with surgery is that the PSA becomes a surrogate for disease progression instantly after RP. With ASTRO guidelines for bRFS (Nadir+2), a patient will more frequently be systemic by the time bRFS is determined.

I'm not sure how you entered the G8 but I show up to 80% bRFS at year 6 with salvage radiation. Remember that most guys will act on failure when their PSA reaches .1 to .2. Usually depending on which Assay is used and delay alloted for determining PSADT. Short PSADT's or bRFS withing the first year, may also include neo-adjuvant hormone therapy and the numbers look very strong with that option added...

These nomogram's at MSK are by far the most complete available. Here is the complete set:
www.mskcc.org/mskcc/html/10088.cfm

Tony
Prostate Cancer Forum Co-Moderator

Post Edited (TC-LasVegas) : 1/24/2010 10:41:09 PM (GMT-7)


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 1/24/2010 6:28 PM (GMT -6)   
I will repeat again what my uro/surgeon told me about salvage surgery after radiation as a primary treatment. He has almost 30 years of surgical experience. He said as a resident, he had to assist in two salvage surgeries, and that they were the most brutal and bloody surgeries he had to participate in. Both resulted in immense complications with the patients, including excessive bleeding, perm. incontinence and perm. ED, and both failed to stem the rise of the cancer. He said the meltdown in the prostate bed is so bad, that its virtually impossible to determine safe surgical lines to work with. Since then, he has refused 100% to do another, or even to assist in another salvage surgery.

Moral of the story, if you forgo surgery as a primary treatment and choose seeding and/or RT as your primary treatment, then would definitely rule out salvage radiation as a possibility for failure with the radiation. As JohnT has mentioned, and Tudpock, on various occasions, that there are suitable secondary treatments available for RT and Seeding, so its not like salvage surgery has to be condsidered.

David in SC
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Incontinence:  1 Month     ED:  Non issue at any point post surgery
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12
Latest: 7/9 met 2 rad. oncl, 7/9 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 out 38 days, 9/9 - met 3rd rad. oncl., mapped  9/9, 10/1 - 3rd corr. surgery - SP cath/hard dialation, 10/5 - 11/27 IMRT SRT 39 sess/72 gys ,cath #8 33 days, Cath #9 35 days, 12/7 - Cath #10 43 days, 1/10 - Corrective Surgery #4, and Caths #11 and #12 in at the same time


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4235
   Posted 1/24/2010 6:34 PM (GMT -6)   
Tony,
I certainly agree with you that SRT works well with localized reoccurrance and that reoccurrance can be identified faster after surgery. I don't think that time difference matters much in low Gleasons, but certainly is key in the higher Gleasons. I think we can agree that salvage treatments work for both surgery and radiation failures as long as the reoccurrance is local.
JT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology 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. G7, 4+3, approx 16mmX18mm.

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. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 1/24/2010 6:41 PM (GMT -6)   
First we need the test at dx, whether the PC is indolent or aggressive. If we had that alone, think of the billions of dollars that could be saved and the thousands of lives that wouldn't be suffering side effects because of treatments not needed.

Second, if there is recurrance, then think what would happen if we knew up front if it were local or not.

That's why I was so hessitant about entering into the SRT I did, as with the exception of one positive margin, there was no way to know if I was going through all that radiation for nothing. I was never convinced one way or the other, but ended up doing it as a pro-active chance to do something that could be considered curative.

David in SC
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Incontinence:  1 Month     ED:  Non issue at any point post surgery
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12
Latest: 7/9 met 2 rad. oncl, 7/9 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 out 38 days, 9/9 - met 3rd rad. oncl., mapped  9/9, 10/1 - 3rd corr. surgery - SP cath/hard dialation, 10/5 - 11/27 IMRT SRT 39 sess/72 gys ,cath #8 33 days, Cath #9 35 days, 12/7 - Cath #10 43 days, 1/10 - Corrective Surgery #4, and Caths #11 and #12 in at the same time


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 1/24/2010 6:49 PM (GMT -6)   
I absolutely agree with that. And I also know that salvage therapies are near useless when it isn't at least regionally local. Exceptions lie in cases where pelvic nodes are positive. They can still be radiated. We went with this premise in my adjuvant therapies. Because my surgery gave us definitive information about the prostate, we decided to do ADT and WPRT based on the successes reported by Harvard and Stanford in their joint study on adjuvant treatment of stage 3 cases.

www.ncbi.nlm.nih.gov/pubmed/17459606

With this information, we are hoping for at least another 5 years in my case before advancing. With a little luck this will hold for me much longer without any more treatments added...

Tony
Prostate Cancer Forum Co-Moderator


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 1/24/2010 6:58 PM (GMT -6)   
Tony, with your journey, I hope and pray you get that 5 years extension plus a whole lot more. Yours has been an interesting and inspirational voyage for sure. Wanting only the best for you.

David in SC
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Incontinence:  1 Month     ED:  Non issue at any point post surgery
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12
Latest: 7/9 met 2 rad. oncl, 7/9 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 out 38 days, 9/9 - met 3rd rad. oncl., mapped  9/9, 10/1 - 3rd corr. surgery - SP cath/hard dialation, 10/5 - 11/27 IMRT SRT 39 sess/72 gys ,cath #8 33 days, Cath #9 35 days, 12/7 - Cath #10 43 days, 1/10 - Corrective Surgery #4, and Caths #11 and #12 in at the same time


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4235
   Posted 1/24/2010 7:07 PM (GMT -6)   
Tony,
The more I think about your 70% SRT success rate the harder it is to buy. This would mean that over 70% of all surgical failures are local; if so, this would be a very poor record for any 1st line treatment.. If 75% of radiation failures are systemic it would be hard not to believe that close to the same ratio would hold true for surgery patients as neither can cure systemic failures.
What am I missing? Is there a patient selection involved that excludes those patients with a high probablity of systemic disease?
I can buy that 70% of those who have a a high probabiity of a local reocccurance are cured by SRT, but I can't believe that 70% of all surgical reoccurrances can be cured with SRT. 30% overall makes a lot more sence.
JT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology 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. G7, 4+3, approx 16mmX18mm.

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. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


turner
Regular Member


Date Joined Jan 2010
Total Posts : 119
   Posted 1/24/2010 7:20 PM (GMT -6)   
 
 
  I have been reading with much interest the posts here recently about salvage therapy,mainly radation post RP. I find myself, David and some of the others here who have or are reluctantly doing radation for a "hail mary" chance at a cure. I have pluggd my numbers in the skm before however, it seems to make little difference what radation dosage i enter. Results are anywhere from 1 to 18 %. Now adding hormone threrapy bumps me up to 48% likelyhood of progresson free @6 yrs. Not real encouraging. Thats probably why my uro wants to start both this week. Iam struggling with my oncologist recomendation @ U o M to do radation first and when that fails then H/T. Would i be putting my success at risk by delaying H/T until (if) radation fails? Dont the most recent studies cite the best sucess rates combineing to two together. I meet with oncoligist tomorrow to go over my recent CT scans(still clear) and will see if she can give me some good data or reasons for delaying H/T.  I just am leary of a urologist being in charge of my H/T. Reguardless,the world as i know it will be changing...once again this week....turner
 
 diag 2/09 @ 3 wks before 50th
 
 psa 4.5
 
 t2b
 
 5 of 6 cores pos....5,20,50,25,5 %
 
 gleason 3+4
 
 N/S RALRP 4-20-09
 Path: lymph node -
          seminal ves -
          margins -
          EPE -
          preineural inv-
          gleason 3+4
          stage pt2c
          tumor vol 40
Continence- 99%- @3-4 months post op
ED-gradual work in progress w/meds
         
 
 psa 7/22/09  0.1
      10/23/09  0.3
       11/23/09 0.5
       01/05/10 1.1
 Met with raidioligst 12-28
 Meeting prostate oncologist @Uof M 1-11
 Not like'n where this heading.  Surgery was and still is a walk in the park compared to what lies ahead :(
 
 
 
 


skeener
Regular Member


Date Joined Dec 2009
Total Posts : 214
   Posted 1/24/2010 7:34 PM (GMT -6)   
Turner -- So sorry to read your posting.  Your journey certainly has become more difficult.  Hope you get definitive answers to your questions tomorrow.
Skeener
Age:  63 
Biopsy: May 09 showed 2 of 12 cores positive for prostate cancer -- 1 at 5% and 1 at 25%.  Cancer indicated as non aggressive.  Gleason Score: 3+3.
RRP on Oct 23/09 in London, Ontario.  Excellent surgeon. 
7 Weeks Post Op -  The fears I had about bad things about the operation and recovery did not materialise except of course ED!!.  Otherwise, everything went very smoothly.  Incontinence not a problem.  Wear a pad when out just in case. Pain was never a problem.
Pathology:  Unremarkable 
First followup PSA and Visit: Feb 07/10.      


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 1/24/2010 7:44 PM (GMT -6)   
Not sure where that 70% number is coming from either. Of all the radiation oncologists I met, including the one I work with, the best they gave was 30%, the lowest was 20%, and the prevailing attitude was that it was a long shot, but at least a pro-active curative possibility.

Even as a surgical guy, and not 2nd guessing my original decision (based on my numbers), I am starting to be concerned even among our small group (compared to the entire country) of men who have had surgical failure pretty early on. And this includes the men that were able to go to the top hospitals in the country with some of the top surgeons doing the job.

What is that really saying about surgical options? I can't prove the next statement out of my mouth, but looking at my own journey, I am starting to believe I was fighting a losing battle from the day of my official PC dx. And I am starting to believe more and more about how devestating PSA velocity and doubling times really means in this fight. A bit doom/gloomy perhaps, but its hard not to think that way under the circumstances. As a patient, and a fellow brother here, I feel I have done what I could do, with the exception of not using HT at this time. I am only 14 months out of surgery, and I have basically used up all my curative cards.

David in SC
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Incontinence:  1 Month     ED:  Non issue at any point post surgery
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12
Latest: 7/9 met 2 rad. oncl, 7/9 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 out 38 days, 9/9 - met 3rd rad. oncl., mapped  9/9, 10/1 - 3rd corr. surgery - SP cath/hard dialation, 10/5 - 11/27 IMRT SRT 39 sess/72 gys ,cath #8 33 days, Cath #9 35 days, 12/7 - Cath #10 43 days, 1/10 - Corrective Surgery #4, and Caths #11 and #12 in at the same time


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 1/24/2010 7:49 PM (GMT -6)   
Turner, yours is a very good question. Some studies do show a benefit about combing HT with Salvage Radiation, and some show differently. It makes it really hard to know as a layman and as a patient what to do. That was the dilemna I had at that very same juncture. Who do I believe? In the end, I went with the majority opinion of the 3 radiation oncologists I met with, that in my case, with my numbers, the best shot was high dose gys. of IMRT to the prostate bed only, without mixing in HT at this time. This is what I went with, but in reality, how do I really know? Obviously, if the SRT ultimately works, great, if it doesn't, then it could be said that I tried.

Good luck in your own situation. Its very hard at best, please keep us posted.

David in SC
'
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Incontinence:  1 Month     ED:  Non issue at any point post surgery
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12
Latest: 7/9 met 2 rad. oncl, 7/9 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 out 38 days, 9/9 - met 3rd rad. oncl., mapped  9/9, 10/1 - 3rd corr. surgery - SP cath/hard dialation, 10/5 - 11/27 IMRT SRT 39 sess/72 gys ,cath #8 33 days, Cath #9 35 days, 12/7 - Cath #10 43 days, 1/10 - Corrective Surgery #4, and Caths #11 and #12 in at the same time


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 1/24/2010 8:08 PM (GMT -6)   
John,
Define what you are calling local... You might be comparing apples and oranges...

I am not referring to prostate capsule contained cases. Local is defined post RP as prostate bed or regional lymph nodes. With high risk cases brachytherapy alone is out performed by surgical intervention but there is higher failure rates for both options. With prostate contained disease RP has a 94% success rate at year 10. Read the nomograms that are using actual cases comparing the two options in high risk cases which most SRT cases are.

Seeds alone have a high failure rate in prostate cancer that has regionally spread. That is why RO's combine it with EBRT and HT in the first place in high risk cases. They already know that seeds alone will likely fail. Else why do it? With surgery you select the appropriate action after RP only if that option fails at all or if an unfavorable pathology is revealed, you can option to have adjuvant therapies. There is plenty of debate as to whether SRT is equal to ART but that is being studied at Stanford/Harvard with favorable results for ART.

Tony
Prostate Cancer Forum Co-Moderator

Post Edited (TC-LasVegas) : 1/24/2010 9:17:06 PM (GMT-7)


JoeyG
Regular Member


Date Joined Jul 2009
Total Posts : 162
   Posted 1/25/2010 7:30 AM (GMT -6)   
TC-LasVegas said...
With ASTRO guidelines for bRFS (Nadir+2), a patient will more frequently be systemic by the time bRFS is determined.

Many cryosurgeons use the Astro guidelines for failure. Unfortunetely it is up to the patient to decide SOONER whether he wants to throw in the towel. My own failure marker will be a 1.2 psa, not the nadir +2 (or 2.2 in my case). I get my next psa test in two weeks.
 
As to salvage for radiation, cryo is slowly becoming the standard. Second doses of radiation can cause a lot of unwanted side effects and totally make radiation unavailable if one were to get another cancer that would normally be treated with radiation.
Age -57; Diagnosed 10/05 PSA 13.4 GS 9 Organ confined (T2B)
Cryoablation 4/06 Allegheny Hosp-Dr Ralph Miller (Cohen/Miller)
Post Cryo Nadir 8/06 0.2
Rising steadily to 0.7 4/09 :-(
Steady at 0.7 (7/09) (Pomegranate???)
Looking to take next steps soon
Hoping to qualify for salvage cryo or radiation


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4235
   Posted 1/25/2010 11:52 AM (GMT -6)   
Tuner,
Yours is a difficult decision. I think that most oncologists would agree that the most agressive treatment done as early as possible will result in a better outcome. Tony chose this and it seems to be working for him. I'm personally of the opinion that with agressive PC you hit it hard with everything you have early on and take the hit on side affects. Good luck, whatevery you decide.
JT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology 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. G7, 4+3, approx 16mmX18mm.

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. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 1/25/2010 1:10 PM (GMT -6)   
Tuner,
You had that meet with the oncologist, what is his thinking? A stint on HT does look likely and it does not appear that SRT will do enough to be effective. I would not doubt that your oncologist suggests HT with RT after two months. He may also suggest a study that is going on with early Taxotere (sanofi-Aventis), I passed on it...

John is right, I threw in the kitchen sink at advanced disease. Too young to trust the nomograms and studies alone ~ of course there were no studies that applied to me because for some reason the medical community felt it unnecessary to track guys at age 44.

I took proactive approaches everywhere it made sense:

Age at Dx 44, 47 now
4 of 8 positive cores up to 80%
Ciry of Hope for RALP (Dr. Tim Wilson)
Surgery, pT3b, N0, Mx, G4+3=7, (SVI+, PM+, EPE+, PNI+, 10 nodes -)
Oncology and Hematology with Dr. Nicholas Vogelzang
5 weeks after surgery PSA was <0.1, plumbing is fine (great surgeon)
2.5 years of adjuvant ADT (Lupron and Casodex)
Radiation oncology with Dr. David Pomerantz
38 hits with adjuvant RT (IMRT) (68gy. with pelvic lymphatic system included)
Coming up on year three in remission. (Bayer Assay <0.1), plumbing is still fine...
T levels climbing from a low of 21 to presently 128, PSA holding so far...

Sigh...

Tony
Prostate Cancer Forum Co-Moderator

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