when to do post surgery SRT

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compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7270
   Posted 2/7/2010 1:32 PM (GMT -6)   
I was told the magic number was 0.20 (with a confirming follow-up PSA test 4 weeks after that).
 
But, looking at various signatures, many of you started SRT well before then as your PSA started rising. So, I don't think I have the complete story.
 
Say my PSA scores were .01, .02, .03, .04. These numbers look great when compared to 0.2. So, is this zero club numbers? It seems to me we have a short doubling time here.
 
Please comment. This mathematician is confused!
 
Mel
63 years old
PSA-- 3/08--2.90;  8/09--4.01; 11/09--4.19 (Free PSA 24%), this after 45 days on cipro! DREs have always been normal.  
History of BPH/prostatitis. PCA-3 test: 75.9 (bad news, guaranteeing I have to do....): Biopsy on 11/30/09. Result of biopsy:

5 out of 12 cores positive. Gleason 4+3. More specifically: 2 cores were 3+3 (one 5% and the other 30%) on one side. On the other side:2 cores are 4+3 (5%)--1 core 3+4 (30%) no peri-neural invasion. prostate is 45 grams. Stage: T1C

REVISED BIOPSY REPORT: The previous was read by Umich. Slides were then sent to Dr. Menon at Ford Hospital. Here is their report (much better) -- changes in bold print below:

5 out of 12 cores positive. Gleason 3+4. More specifically: 2 cores were 3+3 (one 5% and the other 20%) on one side. On the other side, 3 cores were 3+4 (5%, 5%, 20%)

 Surgery with Dr. Menon at Ford Hospital,  1/26/10. He says all looked good. Spared nerves. Awaiting pathology report, set for 2/2/10.

Pathology Report: G 4+3 (65%-35%). Cancer in 15% of gland.

Lymph Nodes: Clear

Perineural Invasion: yes. Seminal Vessical Involvement: No

Extraprostatic Extension: yes

Positive Margin: Yes-- focal-- 1 spot .5mm

Final Weight is 52.7 gms

Incontinence: just joined that club-- definite leaks-- my guess is 1 pad during the day -- at night??? First night tonight!

 

 

 


Galileo
Veteran Member


Date Joined Nov 2008
Total Posts : 697
   Posted 2/7/2010 2:41 PM (GMT -6)   
I think 0.2 has been the traditional point where most doctors would declare a recurrence, but there is no universal standard.

Dr. Andrew Stephenson and other researchers have identified 0.5 or lower as a "best" point to start SRT.

According to Stephenson (et al): "An estimated 48% of patients who received SRT alone at PSA levels of 0.50 ng/mL or less were free of progression at 6 years, compared with 26% for those treated at higher PSA levels."
Source: Journal of Clinical Oncology, Vol 25, No 15 (May 20), 2007: pp. 2035-2041
Predicting the Outcome of Salvage Radiation Therapy for Recurrent Prostate Cancer After Radical Prostatectomy
Andrew J. Stephenson, Peter T. Scardino, Michael W. Kattan, Thomas M. Pisansky, Kevin M. Slawin, Eric A. Klein, Mitchell S. Anscher, Jeff M. Michalski, Howard M. Sandler, Daniel W. Lin, Jeffrey D. Forman, Michael J. Zelefsky, Larry L. Kestin, Claus G. Roehrborn, Charles N. Catton, Theodore L. DeWeese, Stanley L. Liauw, Richard K. Valicenti, Deborah A. Kuban, Alan Pollack
Full text: http://jco.ascopubs.org/cgi/content/full/25/15/2035

I think you're right. Your hypothetical numbers would be fine, *except for the trend*. A clear upward trend over time is enough for many patients and their doctors to start a secondary treatment before PSA reaches the 0.2 threshold. I think there are some on this board who started around 0.1.

In my case, I was being monitored with the standard, non-ultrasensitive test. My was less than 0.1 at 90 days after surgery, then 0.2 at 6 months (at which point my uro SHOULD have rung the bell and referred me to oncologists, or at least have retested fairly soon, but he didn't) then 0.6 at 9 months. At that point, I scrambled to get going with SRT as quickly as possible, consulting with both a radiation oncologist and medical oncologist. By the time I started SRT, I was at 0.7.
Galileo

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T2c, NX MX, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 and thereafter <0.1
http://pcabefore50.blogspot.com


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 2/7/2010 3:33 PM (GMT -6)   
The .2 is just a common line in the sand that some go by. I have read .5 and I have read 1.0. Studies show that the sooner you start, once you have recurrance for sure, the better the chances are that SRT can be efffective. But even then, it depends on your pre-surgery psa velocity, and post surgery psa's as well. You would also have to factor in your Gleason/Stage into the mix.

All 3 radiation oncologists I met with agreed that SRT is definitely not too effective if you let it rise to or above 1.0.

And Mel, most of the experts agree that you need 3 consecutives rises above .10 to validate recurrance. So all the numbers below .10 are within the range of normal testing tolerances, and there can be up and down movements in that range that mean nothing at all.

In my own case, they made a lot of fuss about how quickly I got to .16, which by some people's thinking isn't all that high,, but they factored in the high PSA velocity I had pre-surgery as being very darning to my case, even post surgery.

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


Sephie
Veteran Member


Date Joined Jun 2008
Total Posts : 1804
   Posted 2/7/2010 5:10 PM (GMT -6)   
From Mel: Say my PSA scores were .01, .02, .03, .04. These numbers look great when compared to 0.2. So, is this zero club numbers? It seems to me we have a short doubling time here.

Mel, the difference between .01 and .04 or .05 is so minute that many doctors won't even pay attention to it. PSA, like your weight, will fluctuate from day to day. When your post-surgery PSA hits 0.1 or higher, then its time to pay attention. Generally, any PSA reading that starts with 0.0 is considered undetectable and earns you membership in the zero club.

Hope your recuperation is proceeding smoothly.
Husband diagnosed in 2/2008 at age 57 with stage T1c. Robotic surgery performed 3/2008. Stage upgraded to T3a (single small EPE in posterior left). Perineural tumor infiltration present. Apex margin, bladder neck and SV negative. Final Gleason 3+4. PSA: 0.0 til July 2009. August 2009- 0.1, September 0.3, October back to 0.0, December 0.0. Thank you God!


goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2692
   Posted 2/7/2010 5:36 PM (GMT -6)   
The studies say the sooner you can do the radiation, the higher the success, probably because those little buggers stay put in their beds.

The other factor is continence. If possible, you want to have the continence under control before starting SRT.
Goodlife
 
Age 58, PSA 4.47 Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09   Nerves spared, but carved up a little.
0/23 lymph nodes involved  pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks .
Neg Margins, bladder neck negative
Living the Good Life, cancer free  6 week PSA  <.03
3 month PSA <.01 (different lab)
5 month PSA <.03 (undetectable)
6 Month PSA <.01
1 pad a day, no progress on ED.  Trimix injection
No pads, 1/1/10,  9 month PSA < .01


geezer99
Veteran Member


Date Joined Apr 2009
Total Posts : 990
   Posted 2/7/2010 6:29 PM (GMT -6)   
Let's try a thought experiment. Suppose that your lab is unable to reliably determine such low PSA values. Let's imagine that they "fake" it by having a hat with four balls numbered .01, .02, .03, .04. To give your test results they just reach into the bag, pull out a ball, and report that number. Thus the chances of any particular sequence of four numbers on four sequential tests is 1/4 * 1/4 * 1/4 * 1/4 = 0.004. Unfortunately that makes .01, .02, .03, .04 a pretty rare event although one should also remember that .01, .01, .01, .01 is equally rare.
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
6 mo. PSA 0.00 -- 1 light pad/day
9 mo. PSA 0.00 -- 1 light pad/day ED remains


compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7270
   Posted 2/7/2010 7:51 PM (GMT -6)   

Geezer:

 

I'm sure somewhere you have a point in your post -- I just fail to see it.

PSA results are not random

Mel


63 years old . PSA-- 3/08--2.90; 8/09--4.01; 11/09--4.19 (Free PSA 24%), this after 45 days on cipro! DREs have always been normal. History of BPH/prostatitis. PCA-3 test: 75.9 (bad news, guaranteeing I have to do....): Biopsy on 11/30/09. Result of biopsy: 5 out of 12 cores positive. Gleason 4+3. More specifically: 2 cores were 3+3 (one 5% and the other 30%) on one side. On the other side:2 cores are 4+3 (5%)--1 core 3+4 (30%) no peri-neural invasion. prostate is 45 grams. Stage: T1C.   REVISED BIOPSY REPORT: The previous was read by Umich. Slides were then sent to Dr. Menon at Ford Hospital. Here is their report (much better) -- changes in bold print:  5 out of 12 cores positive. Gleason 3+4. More specifically: 2 cores were 3+3 (one 5% and the other 20%) on one side. On the other side, 3 cores were 3+4 (5%, 5%, 20%)

Surgery with Dr. Menon at Ford Hospital, 1/26/10. He says all looked good. Spared nerves. Unfortunately: Pathology Report: G 4+3 (65%-35%). Cancer in 15% of gland. Lymph Nodes: Clear.  Perineural Invasion: yes. Seminal Vessical Involvement: No.  Extraprostatic Extension: yes.  Positive Margin: Yes-- focal-- 1 spot .5mm. Final Weight is 52.7 gms.  Incontinence: joined that club-- definite leaks—1 pad/day. Night is dry but using 1 pad at night for security.

Next Event: First post-op PSA on 3/1/10

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