adjuvant versus salvage radiation

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medved
Veteran Member


Date Joined Nov 2009
Total Posts : 1096
   Posted 5/22/2010 5:21 PM (GMT -6)   
I thought some of you might be interested in reading this article:
 
 
 
Age 46.  Father died of p ca. 
My psa starting age 40: 1.4, 1.3, 1.43, 1.74, 1.7, 1.5, 1.5
 


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 5/22/2010 5:24 PM (GMT -6)   
Excellent article, thanks for posting it. Lot of good info in it.
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, no problem post SRT
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, next one:  July
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, 1/19 - Corr Surgery #4,  Caths #11 and #12  same time, 2/8-Cath #11 out - 21 days, 3/2- Cath #12 out - 41 days, 3/2- Corr Surgery #5, 3/6 Cath #13 out - 4 days, Cath #14- 27 days, Cath #15 - 26 days, Cath #16 - 4/23 put in


60Michael
Veteran Member


Date Joined Jan 2009
Total Posts : 2229
   Posted 5/22/2010 7:08 PM (GMT -6)   
Very good article Medved. Will have to re-read it to soak up all the info.
Michael
Dx with PCA 12/08 2 out of 12 cores positive 4.5 psa
59 yo when diagnosed, 61 yo 2010
Robotic surgery 5/09 Atlanta, Ga
Catheter out after 10 days
Gleason upgraded to 3+5, volume less than 10%
2 pads per day, 1 depends but getting better,
 started ED tx 7/17, slow go
Post op dx of neuropathy
T2C left lateral and left posterior margins involved
3 months psa.01, 6 month psa.4, 6 1/2 month psa.5 on 11/28/10
Starting IMRT on 1/18/10, Completed 39 tx at 70 gys on 3/12/10
6 week Post IMRT PSA .44 a drop from .5 but maybe more
Great family and friends
Michael


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4235
   Posted 5/22/2010 7:39 PM (GMT -6)   
If 30% of Radical surgeries result in a reoccurrance and many are local and can be cured by salvage RT; I cant' help but think that if radiation can cure what's left behind then perhaps radiation should have been the primary treatment.
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


compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7211
   Posted 5/23/2010 1:47 AM (GMT -6)   

John T and Regal:

Your comments make no sense. 

The argument is that radiation is a good back-up.

As a primary treatment, one would have to figure in the morbidity of radiation and also backup tx. in case of failure.

 

Mel

63 years old . PSA-- 3/08--2.90; 8/09--4.01; 11/09--4.19 (Free PSA 24%),  after 45 days on cipro! DREs have always been normal. PCA-3 was about 75 (way above the 35 threshold). That led to:

Biopsy on 11/30/09. 5 out of 12 cores positive. Gleason 4+3. 2 cores were 3+3 (one 5% and the other 30%) on one side. On  other side:2 cores are 4+3 (5%)--1 core 3+4 (30%) no peri-neural invasion. prostate is 45 grams. Stage: T1C.  

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.  (Second opinion from Jon Epstein at Hopkins confirmed these results)

 Incontinence: joined that club-- definite leaks—1 pad/day. Night is dry, was  using 1 pad at night for security, but pretty much dispensed with that most nights. Update: no pads at night. No pads while at home, but still very uncomfortable. Use 1 pad for out-of-house activities. Suddenly got MUCH better on 3/10/10, almost overnight. Still some urgency but no pads about 90% of the time.  As of 3/12/10--completely continent! Uh...OH. As of about 3/16/10 problems with constant urgency although no pads needed--feels like an infection but none showing in urine.

Update: since late March all is well in that area. I would say 99.9% continent (a spurt here and there, maybe 5 spurts per week).

First post-op PSA on 3/10/10--DRUM ROLL: 0.01 Next PSA in mid-June.


compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7211
   Posted 5/23/2010 1:54 AM (GMT -6)   

This is an excellent article. I am going to save it as I have a feeling I'll need it.

Some salient points: the jury is still out regarding adj. vs. salvage.

It is very important to get on radiation quickly in case of a rising PSA.

Mel


63 years old . PSA-- 3/08--2.90; 8/09--4.01; 11/09--4.19 (Free PSA 24%),  after 45 days on cipro! DREs have always been normal. PCA-3 was about 75 (way above the 35 threshold). That led to:

Biopsy on 11/30/09. 5 out of 12 cores positive. Gleason 4+3. 2 cores were 3+3 (one 5% and the other 30%) on one side. On  other side:2 cores are 4+3 (5%)--1 core 3+4 (30%) no peri-neural invasion. prostate is 45 grams. Stage: T1C.  

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.  (Second opinion from Jon Epstein at Hopkins confirmed these results)

 Incontinence: joined that club-- definite leaks—1 pad/day. Night is dry, was  using 1 pad at night for security, but pretty much dispensed with that most nights. Update: no pads at night. No pads while at home, but still very uncomfortable. Use 1 pad for out-of-house activities. Suddenly got MUCH better on 3/10/10, almost overnight. Still some urgency but no pads about 90% of the time.  As of 3/12/10--completely continent! Uh...OH. As of about 3/16/10 problems with constant urgency although no pads needed--feels like an infection but none showing in urine.

Update: since late March all is well in that area. I would say 99.9% continent (a spurt here and there, maybe 5 spurts per week).

First post-op PSA on 3/10/10--DRUM ROLL: 0.01 Next PSA in mid-June.


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 5/23/2010 2:15 AM (GMT -6)   
Great post.

And if you look at my history below, you know that I am a proponent of surgery followed by adjuvant therapies if necessary. This group is simply showing excellent results. I had a very disappointing post prostatectomy pathology report, EPE, positive margins, and positive seminal bilateral vesicle invasion, but I am undetectable three years out.

I was very lucky to see reports back then that gave me the inclination to move forward with adjuvant therapies. Interestingly, this is a change of position for Patrick Walsh. His book "Guide to Surviving Prostate cancer" has several points to where he suggests waiting until PSA rises before commencing with radiation.

That fact is that it is beneficial to look ahead. If you have a high risk case after prostatectomy, then you should know about adjuvant radiation...

Again, great article and post...

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 47 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
LARP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 5/23/2010 2:24 AM (GMT -6)   
BTW,
The premonition that if surgery did not cure the disease on the front end and radiation would have is simply not a provable point and very likely untrue. It's the combination that worked in this study not added radiation alone. Many cases of prostate cancer recur after radiation in the local area because all of the prostate was not entirely ablated during the radiation procedure. Prostate cancer is multifocal. This is the problem with targeted therapies. Because a prostate is genetically inclined to produce cancer, it will likely be everywhere in the prostate that cancer can occur. So a radiation ablation may or may not solve the issue depending on how well the radiation hit the target, and whether the prostate survived the radiation. So you can't put this information to mean that radiation alone would have had the same effect. That is not at all provable since radiation alone stats do not match the surgery/radiation results of high risk patients in this study.

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 47 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
LARP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino

Post Edited (TC-LasVegas) : 5/23/2010 1:29:30 AM (GMT-6)


BB_Fan
Veteran Member


Date Joined Jan 2010
Total Posts : 1011
   Posted 5/23/2010 8:36 AM (GMT -6)   
MeVed, great artical. Revevant to decisions that I am facing right now. Thanks.
Dx with PC Dec 2008 at 56, PSA 3.4
 
Biopsy: T1c, Geason 7 (3+4) - 8 cores taken with 4 positive for PCa, 30% of all 4 cores.

Robotic Surgery March 2009 Hartford Hospital, Dr Wagner
Pathology Report: T2c, Geason 8, organ confined, negitive margins, lymph nodes negitive - tumor volume 9%
nerves spared, no negitive side effects of surgery

One night in hospital, back to work in 3 weeks

psa Jun 09 <.01
psa Oct 09 <.01
psa Jan 10 .07 re-test one week later .05
psa Mar 10 .28 re-test two weeks later .31

Aril 10 MRI and Bone Scan show lesion on lower spine, SRT on hold pending further testing.


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 5/23/2010 9:51 AM (GMT -6)   
Regal

There is another side to this coin. When surgery failed to keep me at the "zero" PSA mark, I had to go through SRT late last fall. The rad. oncologist estimated that the remaining PC in my prostate bed was approx. 1/1600 th the side of the original size of the cancer prior to surgery. I was given a heavy dose of IMRT for salvage at 72 gys, an amount that is often given to me who still have a prostate in place. In some ways might have been overkill, but that was the plan.

So they normally use a lot of salvage radiation to go after what is assumed to be a tiny bit of cancer. Many doctors know like to wait to see recurrance before doing salvage. In a couple of years ago, the use of adjuvant was a more common approach. All 3 rad. oncologists I met with felt the same way, as did my uro/surgeon But, that still comes down to each man's case and their own medical team to decide.

If one uses surgery as their primary curative treatment, then salvage radiation becomes the natual second and last curative treatment attempt available. If radiation or seeding fails as a primary treatment, then you have to go to other means to get that "second" chance. In most case, salvage surgery is not done or recomended..


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, no problem post SRT
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, next one:  July
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, 1/19 - Corr Surgery #4,  Caths #11 and #12  same time, 2/8-Cath #11 out - 21 days, 3/2- Cath #12 out - 41 days, 3/2- Corr Surgery #5, 3/6 Cath #13 out - 4 days, Cath #14- 27 days, Cath #15 - 26 days, Cath #16 - 4/23 put in


142
Forum Moderator


Date Joined Jan 2010
Total Posts : 6980
   Posted 5/23/2010 10:35 AM (GMT -6)   
Good article.

Tony, I saw the same difference in Walsh's position.

This gives a base of statistical support to the decision I made (at my surgeon's advice) to go straight into IGRT. Good to see that it was not just off-the-cuff.

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4235
   Posted 5/23/2010 11:21 AM (GMT -6)   
Tony,
Radiation and surgical local failures are caused by different things. In a surgical failure it is becase prostate tissue is left behind, there is a positive margin somewhere, most likely at the Apex or that some cells are left in other structures such as the nerves or seminal vesicles.
Radiation does a much better job as a primary treatment in hitting these areas.
Radiation failures are caused by too low a dose, A very large tumor that can't be overwhelmed by the radiation, or dead spots that the radiation may have missed. Surgery would have eliminated these.
Of course the combination of surgery and radiation would much better than any one treatment alone, as it gets what the other would have missed, except that one has to live with the morbidity of two treatments.
Mel, it does make sense. Tumor location and evidence of minor extracapsular extension would make radiation a better primary treatment as these are primary causes of surgical reoccurrance. I think you go with the best primary treatment possible for your individual case and don't worry about a backup as this is like the tail wagging the dog. There are also backups for failed radiation like low and high dose brachy, cryosurgery and HIFU that have the same success rate as salvage radiation after failed surgery.
Any combination treatment, sugery and radiation, radiation and Brachytherapy, HT and surgery and HT with radiation are all more effective than a primary treatment alone, but all come with a high price.
I think it is prudent, and the PCRI also recommends combination treatments for all high risk patients.
All combination treatments have more morbidity, so pick the primary treatment that has the best chance of getting your particular PC, depending on it's volume, location and grade with the least amount of side affects to you.

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


compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7211
   Posted 5/23/2010 11:36 AM (GMT -6)   

John:

I understand your second post. Your first post implied that the article suggests radiation as THE primary treatment.

As you said, it depends on your individual situation.

Overall, the article seems more hopeful regarding SRT.

In my case, it is a close call. The doctors at Ford suggested I forego adjunct and do the SRT if needed. Their point is I have a good chance of not needing any further treatment, so hopefully I can avoid the radiation morbidity.

Still, I suspect I will need SRT down the road. If so, I hope it is a few years away!

 

Mel

 


63 years old . PSA-- 3/08--2.90; 8/09--4.01; 11/09--4.19 (Free PSA 24%),  after 45 days on cipro! DREs have always been normal. PCA-3 was about 75 (way above the 35 threshold). That led to:

Biopsy on 11/30/09. 5 out of 12 cores positive. Gleason 4+3. 2 cores were 3+3 (one 5% and the other 30%) on one side. On  other side:2 cores are 4+3 (5%)--1 core 3+4 (30%) no peri-neural invasion. prostate is 45 grams. Stage: T1C.  

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.  (Second opinion from Jon Epstein at Hopkins confirmed these results)

 Incontinence: joined that club-- definite leaks—1 pad/day. Night is dry, was  using 1 pad at night for security, but pretty much dispensed with that most nights. Update: no pads at night. No pads while at home, but still very uncomfortable. Use 1 pad for out-of-house activities. Suddenly got MUCH better on 3/10/10, almost overnight. Still some urgency but no pads about 90% of the time.  As of 3/12/10--completely continent! Uh...OH. As of about 3/16/10 problems with constant urgency although no pads needed--feels like an infection but none showing in urine.

Update: since late March all is well in that area. I would say 99.9% continent (a spurt here and there, maybe 5 spurts per week).

First post-op PSA on 3/10/10--DRUM ROLL: 0.01 Next PSA in mid-June.


Ed C. (Old67)
Veteran Member


Date Joined Jan 2009
Total Posts : 2458
   Posted 5/23/2010 12:38 PM (GMT -6)   
The article seems to indicate that adjuvant radiation is recommended for those with adverse pathological results such as EPE, positive margins,... however, as is my case and Mel's case we both are in that category and yet we have undetectable PSA (mine is 14 months). I will certainly go the salvage route at the first sign of a rising PSA, at least I would have had a period of normalcy before I fight the second battle.
Age: 67 at Dx on 12/30/08
PSA 9/05 1.15; 8/06 1.45; 12/07 2.41; 8/08 3.9; 11/08 3.5 free PSA 11%
2 cores out of 12 were positive Gleason (4+4) and (4+5)
Negative CT scan and bone scan done on 1/16
Robotic surgery performed 2/9/09 Dr Fagin, Austin TX
Pathology report:
Prostate weighed 57 grams size:5.2 x 5.0 x 4.9 cm
Posterior lateral lesions measuring 1.5 x 1.4 x 1.0 cm showing focal capsular penetration over a distance of 3mm in circumference.
Prostatic adenocarciroma accounts for approx. 10-20% of the hemisphere.
Gleason 4+4
both nerve bundles removed,
pT3a Nx Mx, Negative margins
seminal vesicles clean, lymph nodes: not dissected
continent after 5 months
2 months PSA test 4/7/09 result <0.1
5 months PSA test 7/9/09 result <0.1
8 months PSA test 10/9/09 result <0.1
11 months PSA test 1/21/10 result 0.004
14 months PSA test 4/19/10 result 0.005


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 5/23/2010 12:51 PM (GMT -6)   
Ed,
By definition adjuvant therapy is treatment used with another primary treatment to prevent a relapse. Statistics are showing that adjuvant therapies are working better than salvage. John's second post is well written and on target. It is always a difficult decision to add a therapy when you don't see an immediate reason, but by reason of this article, certain men are higher risk than others.

My stage after surgery was the farthest it go before declaring it stage 4. Nomograms had my probability of relapse by year 10 at near 90%. It was an easier decision for me than for other stage 3 guys...

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 47 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
LARP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino


Ed C. (Old67)
Veteran Member


Date Joined Jan 2009
Total Posts : 2458
   Posted 5/23/2010 2:04 PM (GMT -6)   
Tony,
I certainly understand your situation. I'm just saying that in my case, my decision to do salve if needed, instead of adjuvant has worked for me so far. I hope that I don't regret that decision.
Age: 67 at Dx on 12/30/08
PSA 9/05 1.15; 8/06 1.45; 12/07 2.41; 8/08 3.9; 11/08 3.5 free PSA 11%
2 cores out of 12 were positive Gleason (4+4) and (4+5)
Negative CT scan and bone scan done on 1/16
Robotic surgery performed 2/9/09 Dr Fagin, Austin TX
Pathology report:
Prostate weighed 57 grams size:5.2 x 5.0 x 4.9 cm
Posterior lateral lesions measuring 1.5 x 1.4 x 1.0 cm showing focal capsular penetration over a distance of 3mm in circumference.
Prostatic adenocarciroma accounts for approx. 10-20% of the hemisphere.
Gleason 4+4
both nerve bundles removed,
pT3a Nx Mx, Negative margins
seminal vesicles clean, lymph nodes: not dissected
continent after 5 months
2 months PSA test 4/7/09 result <0.1
5 months PSA test 7/9/09 result <0.1
8 months PSA test 10/9/09 result <0.1
11 months PSA test 1/21/10 result 0.004
14 months PSA test 4/19/10 result 0.005


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 5/23/2010 3:00 PM (GMT -6)   
I think you will do great either way. Part of my decision was based on being 44 at the time. it was a small window to look through but I still believed in the possibility of total eradication so I went for it.

All the best to you...

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 47 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
LARP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino


pasayten
Regular Member


Date Joined Mar 2007
Total Posts : 439
   Posted 5/23/2010 8:06 PM (GMT -6)   
Great article and great followup posts...
 
I initiated SRT when PSA increased to 0.13 some 32 months postop...  Finished my SRT in 2nd week of March 2010...  Will get first new PSA result 1st week of June.    SRT side effects negligible.  
 
Looking forward to rejoining the "zero" club and will keep forum posted...
 
Praying that we can all be in the "zero" club...
 
pasayten
After 3-4 years of annual PSA 4-6, biopsy recommended
3/13/2007 - 12 point biopsy - Left 0/6  Right 1/6 Gleason 3+3 T1c
4/24/2007 - DaVinci performed at Virginia Mason hospital in Seattle
5/2/2007 - Catheter Out! Final pathology of Gleason 6  T2c Nx Mx, approx 20% of prostate involved, positive margin, but only at 2 focal points.  
6/28/2007 9 weeks incontinance... Overnite, went from 4-6 soaked pads a day from prev 8 weeks to 2 barely wet pads a day.
7/12/2007 11 weeks post-op  Minimal leakage...  one small pad a day
7/18/2007 First Post-Op PSA...  0.01 !!! 
9/10/2007 Pad free and ED at 75% with 100mg Viagra generic
6/26/2008 2nd Post-OP PSA at 14 months...  0.02 
12/2/2008 3rd Post-OP PSA at 20 months...   0.03
10/30/2009 4th Post-OP PSA at 31 months...   0.13 (moved and diff lab)
11/3/2009 Retest at my original lab...  0.11  (followup with Doc sched 11/10)
11/10/2009 Discussion indicated biochemical reccurrence and need for salvage radiation treatment. 
1/21/2010 Another PSA test at 34 months...  0.14
1/26/2010 IMRT Salvage Radiation Treatment started
                  32 sessions for 64 gys total.
3/12/2010 Finished 32 sessions...  No side effects to date except a little
tiredness.  Slight changes in bowel movements the last week...  
4/8/2010  Some rectal prostitis, but no change in urgency.  No urinary effects at all.  Now just waiting for the upcoming PSA test in June.
 


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 5/23/2010 9:36 PM (GMT -6)   
Below is a recent study completed at the multifaceted Memorial Sloan Kettering center posted in the Journal of Clinical Oncology that shows RP outperforming IMRT in mortality. Now keep in mind these numbers indicate a 5 in 100 improvement in mortality. Additionally, men choosing to use IMRT were slightly older and with higher PSA's. Stage was from T1C to T3B.

tinyurl.com/27o65xs

There is some points here to note that relate to this post.
1> IMRT patients received salvage therapy much later than surgery patients. This is a known issue for radiation patients that can be tied to how relapse is determined. Surgery patients received salvage therapy within 13 month versus over 5 years for an IMRT patient
2> IMRT patients went straight to hormone therapy as it likely was determined that at the time the need for salvage therapy, a metastatic disease was present.
3> 8 year numbers of metastatic free disease after RP was 97%. That certainly is not 30% failure.
4> Surgery outperformed IMRT in low risk, intermediate risk, and high risk cases alike. The highest degree of improvement was in late stage/high risk cases...
5> Kaplan-Meier determined that overall death rate of surgery patients was 3.8% and overall death rate for IMRT was 9.5%.

This study is about surgery versus IMRT as primary treatments and their salvage options as they relate to metastatic progression and mortality and not bFRS through PSA control. It was key that salvage IMRT was used for the surgery patient as opposed to salvage ADT for the IMRT patient. Next I will post study material that shows adjuvant IMRT even improves those numbers for the stage 3 surgically operated patient.

While seemingly small these are significant differences.

Tony's biased opinion coming: I believe that as we start to see studies age with less mature treatments modalities, that the pendulum will swing back to RP as the gold standard it has been for decades.

Hehe...Boy am I asking for it....

Disclaimer: I still believe that IMRT can be an excellent choice for certain patients. Surgery is not for everybody

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 47 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
LARP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino

Post Edited (TC-LasVegas) : 5/24/2010 1:17:59 AM (GMT-6)


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 5/23/2010 9:41 PM (GMT -6)   
Tony, I agree, the "Gold Standard" will still be there long after the dust settles. There's very good logic in Surgery first, then mop up with radiation if needed. Still, every man's choice. Radiation including seeding can still be an effective primary treatment despite saying this.
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, no problem post SRT
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, next one:  July
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, 1/19 - Corr Surgery #4,  Caths #11 and #12  same time, 2/8-Cath #11 out - 21 days, 3/2- Cath #12 out - 41 days, 3/2- Corr Surgery #5, 3/6 Cath #13 out - 4 days, Cath #14- 27 days, Cath #15 - 26 days, Cath #16 - 4/23 put in


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 5/23/2010 10:35 PM (GMT -6)   
Who should do adjuvant versus salvage radiation:
tinyurl.com/27jh5j3

Clearly there is a positive impact with adjuvant local radiation in advanced stages. And when you compare surgery/adjuvant IMRT with sans the ADT to combination radiation sans ADT, it's certainly an interesting result ~ study pending. ADT certainly masks combination radiation therapy results with PSA control, but the key question is does it improve mortality? I know ART does...

Stay tuned...

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 47 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
LARP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino

Post Edited (TC-LasVegas) : 5/24/2010 1:19:12 AM (GMT-6)


medved
Veteran Member


Date Joined Nov 2009
Total Posts : 1096
   Posted 5/27/2010 2:21 PM (GMT -6)   
Another very recent article on this subject, by Dr. Choo at Mayo Clinic:

http://cancerresearchandtreatment.org/Synapse/Data/PDFData/0036CRT/crt-42-1.pdf
Age 46.  Father died of p ca. 
My psa starting age 40: 1.4, 1.3, 1.43, 1.74, 1.7, 1.5, 1.5
 


Carlos
Regular Member


Date Joined Nov 2009
Total Posts : 486
   Posted 5/27/2010 2:56 PM (GMT -6)   
medved,  Thanks for posting the link to Dr. Choo's article.   It is not very encouraging is it?  SRT just doesn't work very often and if one considers morbidity, the decision can be very difficult.  Your post is timely since my next PSA is a few weeks away.
 
Carlos

Diagnosed 2/2008 at age 71, Gleason score 5+3=8, stage T1c, PSA 9.1. 
Robotic surgery 5/2008, nerves spared, stg. pT2c, N0, MX, R0, Gleason 5+3=8 
PSA <0.1 at 20 months and each test since surgery.


Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 5/27/2010 3:08 PM (GMT -6)   
medved said...
Another very recent article on this subject, by Dr. Choo at Mayo Clinic:

http://cancerresearchandtreatment.org/Synapse/Data/PDFData/0036CRT/crt-42-1.pdf

This Choo paper has been mined for common sense approach to using ultra-sensitive PSA testing after RP. 
 
It quotes the European Consensus Group as saying that the "ultrasensitive PSA assay could be used for monitoring patients, but not for management decision-making." [italics & underline added by me for clarity & emphasis]
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