watching it rise

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Im_Patient
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Date Joined Aug 2009
Total Posts : 670
   Posted 6/2/2010 12:54 PM (GMT -6)   
Well, it's been a few months now of monitoring the PSA monthly. I was hopeful that it had stabilized when I went onto the sensitive test and had 2 consecutive 0.17 readings. The last couple of readings has me rethinking. I am not planning to rush into anything, and my doctor is closely watching this with me. I have told myself if it hits 0.5, I will start SRT. I am convinced that it makes more sense to fight a known cancer, even at the risk of the potential cure causing unknown cancers down the road. Not sure when to go talk to an oncologist. Praying.

Sure would like to be part of a Provenge trial for early stage cases... if anyone knows how to get onto that bus, let me know.
Jeff
Gleason, 3+4; PSA, 7.9
Robotic Prostatectomy, March 2008 (Age 48 then), nerves both sides spared, post surgery analysis confirmed 3+4 Gleason,
pT2c, prostate 60.2g, margins: negative; perineural invasion: present; lymphatic invasion: present; 3 lymph nodes removed, clear; seminal vesicle invasion: absent; Gleason 4 comprises 5-10% of carcinoma
PSA consistently <0.1 since surgery until Oct 09: 0.1; retested Oct 09, <0.1,
Jan 10, 0.2
retest Feb 1 confirmed 0.2
CT scan, bone scan Feb 10 both clear
PSA after, 2010: March, 0.17; April, 0.17; May, 0.24; June, 0.31


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 6/2/2010 1:01 PM (GMT -6)   
Jeff, with all your PSA readings just in 2010 alone so far, most radiation oncologisits would reccomend starting salvage radiation, at least the 3 I had conversations with. They would probably agree that you do have recurrance in place, and that it would make no sense to let it climb to .50 to begin the radiation. The lower the reading when you start, works in your favor many times. Unless insurance, finances in general, or if you are still dealing with incontinence issues, in my opinion, I would already be meeting with the radiation folks. At face value, and I am no crystal ball reader, it would appear that there is no reason to think that any future PSA readings will be going down, instead of up. Just my take.

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 - 31 days, 5/24 put in Cath #17


Im_Patient
Veteran Member


Date Joined Aug 2009
Total Posts : 670
   Posted 6/2/2010 1:16 PM (GMT -6)   
David, no offense, but I have followed your case for awhile, and it is one of the reasons that I am taking my time choosing radiation. I know we all have our own situations and likelihoods of outcome, but I don't think you can blame me for being reluctant to follow you down that rabbit hole. I'm probably going to give it just a little more time before I call it inevitable.
Jeff
Gleason, 3+4; PSA, 7.9
Robotic Prostatectomy, March 2008 (Age 48 then), nerves both sides spared, post surgery analysis confirmed 3+4 Gleason,
pT2c, prostate 60.2g, margins: negative; perineural invasion: present; lymphatic invasion: present; 3 lymph nodes removed, clear; seminal vesicle invasion: absent; Gleason 4 comprises 5-10% of carcinoma
PSA consistently <0.1 since surgery until Oct 09: 0.1; retested Oct 09, <0.1,
Jan 10, 0.2
retest Feb 1 confirmed 0.2
CT scan, bone scan Feb 10 both clear
PSA after, 2010: March, 0.17; April, 0.17; May, 0.24; June, 0.31


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 6/2/2010 1:28 PM (GMT -6)   
Jeff, no offense taken. My negative reacation and experience with radiation for the 2nd time in my life is unusual and not the norm. Salvage Radiation isn't a rabbit hole, after surgery, its the best and final curative means to try to beat the cancer, even though the percentages are less then some people realize. I respect your own personal choice, as well as what you and your doctor(s) are comfortable with. There are no guarantees either way, so its never an easy choice. My consent to SRT was tough, and it ended up being the negative experience I was afraid it would be. But if the SRT keeps my PC in remission at this point, then all the troubles that went along with doing it, will be worth it, at least to me and my family. At 57, I am not quite ready to "write" my life away. But it was a tough choice. Good luck in your decision.

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 - 31 days, 5/24 put in Cath #17


142
Forum Moderator


Date Joined Jan 2010
Total Posts : 7084
   Posted 6/2/2010 1:40 PM (GMT -6)   
Jeff,

Although it has more to do with being a Gleason 4+5 and out of the margins than anything, I decided/agreed to start the IGRT radiation with a still non-detectable PSA. I agree with David, and my doctor - kill it before it gets big enough to not be killed by the tools we have.

I have that same fear of radiation, but mets scare me more.

I would have that talk with the oncologist sooner than later. At least then the decision you make will be based on up-to-date information.

My best wishes for you.

Im_Patient
Veteran Member


Date Joined Aug 2009
Total Posts : 670
   Posted 6/2/2010 1:58 PM (GMT -6)   
David, your vote for SRT after what you've been through counts as a pretty strong vote. I recognize it as my only shot at a cure at this point (although I am still hoping that the vaccine approach that is in the works gives us another option). Thanks for your input.
Jeff
Gleason, 3+4; PSA, 7.9
Robotic Prostatectomy, March 2008 (Age 48 then), nerves both sides spared, post surgery analysis confirmed 3+4 Gleason,
pT2c, prostate 60.2g, margins: negative; perineural invasion: present; lymphatic invasion: present; 3 lymph nodes removed, clear; seminal vesicle invasion: absent; Gleason 4 comprises 5-10% of carcinoma
PSA consistently <0.1 since surgery until Oct 09: 0.1; retested Oct 09, <0.1,
Jan 10, 0.2
retest Feb 1 confirmed 0.2
CT scan, bone scan Feb 10 both clear
PSA after, 2010: March, 0.17; April, 0.17; May, 0.24; June, 0.31


medved
Veteran Member


Date Joined Nov 2009
Total Posts : 1100
   Posted 6/2/2010 2:45 PM (GMT -6)   
I posted links to a couple of articles not too long ago, on another thread about adjuvant and salvage radiation. One was by Dr. Walsh and others and the other by Dr. Choo at Mayo. They discuss, in part, the relationship between cure rates and the psa level at which post-surgery radiation is initiated. As you consider when to begin, it might be worth your time to read those articles. Best wishes, Medved
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 : 25393
   Posted 6/2/2010 3:35 PM (GMT -6)   
Jeff, I can see what your PSA was at, at time of your dx, but what was your PSA record like the last 2 or 3 years before surgery? Did you have much of a PSA velocity issue going on pre-treatment?

Yes, it was a tough, tough decision for me to make, and most of the time, I was 90% against SRT, it was my own uro that kept encouraging me to do it, despite the fears and reservations and potential for it to be problematic. Even as a surgeon, he said with my numbers and velocity issues, he would do it in a heartbeat. That's why each guy here, despite the best advices and encouragements for treatments or secondary treatments, has to make tough choices in the end for their own journey. Never gets any easier.

You got my support for whatever you choose to do or not to do.

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 - 31 days, 5/24 put in Cath #17


Galileo
Veteran Member


Date Joined Nov 2008
Total Posts : 697
   Posted 6/2/2010 4:25 PM (GMT -6)   
I would not wait long.

In my case, my uro had me wait 4 months and in that time my PSA went from 0.2 to 0.6. I scrambled to get appointments, consultations, scans, etc. and by the time my radiation started my PSA was 0.7.

Usually with prostate cancer, time isn't that crucial. But time is of the essence when considering salvage radiation, as others have indicated. More than one researcher has shown the importance of the pre-SRT PSA in predicting the outcome. Here are some snippets from recent studies.

"The 6-year response to SRT among patients treated at PSA levels of 0.50 ng/mL or less appears to be durable because only two progression events were observed after 6 years among 32 patients at risk at 6 years (median follow-up, 90 months)." Stephenson, et al., "Predicting the Outcome of Salvage Radiation Therapy for Recurrent Prostate Cancer After Radical Prostatectomy" http://jco.ascopubs.org/cgi/content/full/25/15/2035

"The 3-year biochemical control rate was 93% in patients whose preradiation PSA was 0.5‚ÄČng/ml or less and 29% in patients whose preradiation PSA was more than 0.5‚ÄČng/ml." Wadasaki, et al., "Treatment results of adjuvant radiotherapy and salvage radiotherapy after radical prostatectomy for prostate cancer" http://www.springerlink.com/content/4372314q7p766308/

"The greatest 5-year rate of biochemical control (69%) was obtained in patients with a pre-EBRT PSA level of 0.5 ng/mL or less." MacDonald, et al., "Salvage radiotherapy for men with isolated rising PSA or locally palpable recurrence after radical prostatectomy" http://www.ncbi.nlm.nih.gov/pubmed/15491716

"In our series, initiation of salvage RT before PSA rose above 0.5 ng/mL resulted in improved bRFS. A cut point of 0.5 ng/mL resulted in a 4-year bRFS of 63%, versus 55% with a cut point of 1.0 or 2.0 ng/mL." Reuther, et al., "Improved Biochemical Relapse-Free Survival With Early Salvage Radiation Therapy After Prostatectomy"

Best wishes.
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


Im_Patient
Veteran Member


Date Joined Aug 2009
Total Posts : 670
   Posted 6/2/2010 4:44 PM (GMT -6)   
David, I didn't get my PSA numbers for any significant time before my diagnosis. I can get them from my GP, whatever they may be, the next time I see him. Like most, at the time of dx, I hardly knew what PSA was, and I was pretty overwhelmed when I was told. What I know is that my GP considered my PSA to have increased from normal levels 2 years earlier to the reading in July, 8 months before my surgery. That reading was comparable to the 7.9 that I had just prior to surgery in March of 2008, although I don't have a record of what it was. I believe that for the 8 months prior to surgery, my PSA did not change significantly.

Thanks for the links, guys
I may just ask my doc for a referral sooner than later.
Gleason, 3+4; PSA, 7.9
Robotic Prostatectomy, March 2008 (Age 48 then), nerves both sides spared, post surgery analysis confirmed 3+4 Gleason,
pT2c, prostate 60.2g, margins: negative; perineural invasion: present; lymphatic invasion: present; 3 lymph nodes removed, clear; seminal vesicle invasion: absent; Gleason 4 comprises 5-10% of carcinoma
PSA consistently <0.1 since surgery until Oct 09: 0.1; retested Oct 09, <0.1,
Jan 10, 0.2
retest Feb 1 confirmed 0.2
CT scan, bone scan Feb 10 both clear
PSA after, 2010: March, 0.17; April, 0.17; May, 0.24; June, 0.31


dsmc
Regular Member


Date Joined Jul 2008
Total Posts : 150
   Posted 6/3/2010 7:03 AM (GMT -6)   
Jeff,
I agree with Galileo 110% on this. My Doc and I agreed that earlier was better. I had 4 consecutive rises to .1 and had IGRT at that point. I had no problems with my treatments and it went straight to undetectable. Good luck with your decision and health.

David
Age 55
Pre-op PSA 4.3
Surgery Feb. 17 2005
Post-op Path : Gleason 3+3=6
Right pelvic lymph nodes: negative for metastatic carcinoma
Left pelvic lymph nodes: negative for metastatic carcinoma
extent: right lobe 40% left lobe 10%
capsular penetration: Absent
Seminal vesicles and vasa differentia: Uninvolved
Prostate: 26 grams
Post-op PSA's <0.04 for 3 years
Feb. 08: 0.07, March 08: 0.08, June 08: 0.09 and Sept. 08: 0.1
IGRT scheduled.....November 17th....
FINISHED 01/14/09
05/14/09
1st PSA after SRT <0.04
12/03/09
2nd PSA after SRT <0.04


Im_Patient
Veteran Member


Date Joined Aug 2009
Total Posts : 670
   Posted 6/12/2010 2:49 PM (GMT -6)   
Well, after a sleepless night, I saw the rad oncologist yesterday, very sharp guy. I was surprised by a few things:
First, in spite of my negative margins, the working assumption for radiation therapy is that the margin was actually positive instead, and it just wasn't picked up in the pathology. He said this is much more common that you might expect. So, instead of what I expected, which is that the radiation was going primarily target lymph nodes, the IGRT is directed at the prostate bed. There are some lymph nodes that get hit, but my impression was that they are more as a matter of course. This is actually a good thing, in that they can do a better job of avoiding the rectum and other organs that we would prefer not to irradiate. I am particularly concerned about this, since I have colitis and am concerned about a flare-up.
Second, it was my impression that the 70-72 grays planned would be the lifetime dose for my body, and therefore radiation for any other reason in the future would not be an option. He said that the radiation is only a lifetime dosage for the organs/tissue hit, and therefore, if lymph nodes or bone are found to be involved in the future, and they have not yet been hit, they can be irradiated. I also found this as good news.
Third, their planned treatment, regarding filling the bladder, is different from what I have heard on the forum here. He said that they were having so much trouble getting guys to have and keep a full bladder for the treatment, that they have adopted a different strategy. They want you to have a half-full bladder: empty 1 hour before treatment, and immediately drink 8 oz of water, and then do not urinate before treatment. I suppose as long as this procedure is repeatable, it is effective.
Sooo... in spite of the odds being only 40-50%, and the potential and likely side effects, I have opted to start IGRT treatments beginning in early August. I am much more closely following each of your journeys that are now the same as mine, to get a better idea what to expect, with some trepidation. I am grateful for the information and support that is always present on this forum.
Gleason, 3+4; PSA, 7.9
Robotic Prostatectomy, March 2008 (Age 48 then), nerves both sides spared, post surgery analysis confirmed 3+4 Gleason,
pT2c, prostate 60.2g, margins: negative; perineural invasion: present; lymphatic invasion: present; 3 lymph nodes removed, clear; seminal vesicle invasion: absent; Gleason 4 comprises 5-10% of carcinoma
PSA consistently <0.1 since surgery until Oct 09: 0.1; retested Oct 09, <0.1,
Jan 10, 0.2
retest Feb 1 confirmed 0.2
CT scan, bone scan Feb 10 both clear
PSA after, 2010: March, 0.17; April, 0.17; May, 0.24; June, 0.31


Carlos
Regular Member


Date Joined Nov 2009
Total Posts : 486
   Posted 6/12/2010 3:25 PM (GMT -6)   
Jeff,  I have been following your post with a great deal of interest (just in case I need to do the same as you).   I am curious about your thoughts about HT along with SRT.  I notice that some HW posters chose to use HT and others do not.  Did your rad onc have anyting to say about HT?   Good luck going forward.
 
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.


Jakester
Regular Member


Date Joined Aug 2009
Total Posts : 288
   Posted 6/12/2010 3:29 PM (GMT -6)   
Im_patient,

My situation seems similar where my margins were also deemed negative but still had a rising psa afterward. I saw my radiation oncologist once the psa hit .3 and agreed to start SRT about a month later this past January. He added that negative margins were not conclusive. As you can see from my stats, I had a psa test 5 weeks into the SRT and it had risen to .4 but the oncologist didn't seem to be concerned (offering the explanation that it may have been that level at the beginning of SRT).

Last week I got my first post SRT psa after 10 weeks and it came in at .2 (not undetectable yet but going in the right direction). He also said the radiation can take up to a year.

The radiation oncologist is a big believer in taking D3 and fish oil (I'm taking 4000 IU D3 and 3000 fish oil) to help minimize bowel problems. I had/have tolerable side effects. The most noticeable was fatigue (I was very functional but hit the hay early and the walk upstairs was long some nights).

I feel that the SRT was worth the shot.

Our best to you and the others,
Jake
Diagnosed 8/2008 Pre-op psa 4.2, Age 60 at dx
7 of 12 biopsies positive 3+3
DaVinci LRP 11/08
Post Op pathology clear margins, confined to prostate, absent extraprostatic extension, vascular or perineural. Gleason 3+4=7, 5-10% of 4 and location in right mid-gland.
3 month psa .1 2/09, 6 month .1 5/09, 9 month .2 8/09
broke ankle bones 6/09
9/21/09 Bone scan clear, psa still .2
11/12/09 chest xray was clear, psa however up to .3,
01/05/10 psa still .3, radiation setup done with tats, 01/19/10 started 39 sessions 70.2gy, psa at 6th week salvage IMRT up to .4
Post SRT psa at 10 weeks (5/31/2010) down to .2


Im_Patient
Veteran Member


Date Joined Aug 2009
Total Posts : 670
   Posted 6/12/2010 4:02 PM (GMT -6)   
Carlos, I am not convinced that the hormones do anything other than reduce the PSA - but I am sure that this is a very controversial point of view. That said, I have some limited amount of "natural" hormone therapy going on, in that my testosterone levels have been low since I first was diagnosed with PCa. My latest T reading this past month was 130, which is low enough to make sex seem not particularly interesting, although I expect from an HT perspective, it is not considered low. There are some recent research results that argue that HT with radiation helps. I talked with the oncologist about his opinion, and the bottom line was that he felt for my case it was not merited. I expect that this is something best reviewed on a case-by-case basis, and I am sure Gleason score and other things go into consideration.

Jake, thanks for the D3 and fish oil tip -- I am looking for whatever can proactively help in the bowel department. I had not heard that rad PSA results can take up to a year - I had heard that you have to wait for awhile after the end of treatments before you can expect the PSA to fully drop.
Gleason, 3+4; PSA, 7.9
Robotic Prostatectomy, March 2008 (Age 48 then), nerves both sides spared, post surgery analysis confirmed 3+4 Gleason,
pT2c, prostate 60.2g, margins: negative; perineural invasion: present; lymphatic invasion: present; 3 lymph nodes removed, clear; seminal vesicle invasion: absent; Gleason 4 comprises 5-10% of carcinoma
PSA consistently <0.1 since surgery until Oct 09: 0.1; retested Oct 09, <0.1,
Jan 10, 0.2
retest Feb 1 confirmed 0.2
CT scan, bone scan Feb 10 both clear
PSA after, 2010: March, 0.17; April, 0.17; May, 0.24; June, 0.31
Starting salvage IGRT in beginning August

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