The Other Active Surveillance

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Tudpock18
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Date Joined Sep 2008
Total Posts : 4156
   Posted 9/15/2010 11:58 AM (GMT -6)   

It seems that there is an impressive body of evidence that immediate adjuvant therapy is useful when the post-surgical pathology shows positive margins, seminal invasion or lymph node involvement.  Of course, like all things with PCa, this is controversial and there is no consensus among physicians (kinda like with AS).  What we frequently see on this forum are patients who have adverse pathology yet choose to “watch and wait” until their PSA reaches some predetermined level or they have some other indicator that it is time to move on to an additional treatment.

 

So, my question is this:  Why do so many folks want to criticize the “watching and waiting” associated with the traditional AS where the diagnosis is early stage cancer while I don’t seem to hear any criticism of what I call the “other” AS where the diagnosis is a much more advanced cancer yet patients are “watching and waiting” for some sign that indicates their need for more treatment?  Are these not similar situations but with the latter being potentially far more dangerous?

 

This whole area is (fortunately) well beyond my experience level and probably above my pay grade but I would seriously be interested in some perspective on this.

 

Tudpock (Jim)


Age 62 (64 now), G 3 + 4 = 7, T1C, PSA 4.2, 2/16 cancerous, 27cc. Brachytherapy 12/9/08. 73 Iodine-125 seeds. Procedure went great, catheter out before I went home, only minor discomfort. Everything continues to function normally as of 9/10/10. 6 month PSA 1.4, 1 year PSA at 1.0. My docs are "delighted"! My journey:
http://www.healingwell.com/community/default.aspx?f=35&m=1305643

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4227
   Posted 9/15/2010 12:45 PM (GMT -6)   
Tud,
It doesn't make any logical sense, but that's human nature. The basic premise is exactly the same; you wait for signs of progression before deciding to treat. It may be that that patients realize that the salvage treatments are only 30% effective whereas the primary treatment for low risk cancer is in the mid to high 90%. Also the psychological benefit of closure has been eliminated.
Recently both the NAAC and ICER have come out in favor of AS for low risk patients, so now major organizations instead of individual doctors are getting on board.
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


LV-TX
Veteran Member


Date Joined Jul 2008
Total Posts : 966
   Posted 9/15/2010 12:51 PM (GMT -6)   
Tud

My take on waiting after surgery for additional treatment is to allow as much time for healing before bombarding the prostate bed with radiation. Something to do with radiation stopping the progress in ED and incontinence. I would imagine most men (and doctors) would rather heal as much as possible before going to additional treatment. In some cases additional treatment may not even be needed. Even with adverse path reports, any remaing cancer cells often don't survive without the prostate.

As with anything PCa related...it all varies with the individual.

I would be interested in the number of men who are smokers that have a recurrence due to postive margins or EPE without lymph or seminal invasion. Smoking usually reduces blood supply in the prostate bed and would make survival for cancer cells pretty tough I would think. ( Another correlation with smoking and cancer?)
You are beating back cancer, so hold your head up with dignity
 
Les
 
Age 58 at Diagnosis
Oct 2006 - PSA 2.6 - DRE Normal
May 2008 - PSA 4.6 - DRE Normal / TRUS normal
July 2008 - Biopsy 4 of 12 Positive 5 - 30% Involved Bilateral w/PNI - Gleason (3+3)6 Stage T1C
Robotic Surgery Sept 18, 2008
Pathology October 1, 2008 - Gleason 7 (3+4) Staged pT2c NO MX - Gland 50 cc
Seminal Vesicles and Lymph Nodes clear
Positive Margins Right Posterior Lobe
PSA 5 week Oct 2008 <.05
                   3 month Jan 2009     .06
                   6 month Apr 2009     .06
                   9 month Jul  2009     .08
                 12 month Oct 2009     .09 
                 18 month April 2010   .19

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 9/15/2010 1:27 PM (GMT -6)   
Tud, in the surgical world of primary treatment for PC, there are two schools of though with the subject and value of adjuvant radiation. With bad pathology, in the past, adjuvant was pushed on often done, usually as soon as the patient was well enough to deal with it. From the radiation oncologists I spoke to a year ago, its seldom done that way anymore (at least in my area). Just because a guy has bad post surgery pathology, interestingly, doesn't always translate to recurrance, or at least recurrance in the short term. The new thinking is to wait and see if that final curative card of "radiation", either adjuvant or salvage is needed. Once that card is used, that's it for a hope of cure.

The current thinking also gives the patient a chance to get his incontinence issues under control, or as good as they are going to get, pre-surgery, as well as ED consideration.

I had pretty clean pathology, yet had recurrance in 9 months. Sonny had a great surgeon, and had immediate recurrance in a manner of speaking. We got guys that are Gleason 8/9, positive margins, etc, with no evidence of recurrance even 2 years out. Another fickled side to the wonderful world of PC.

Having been through 2 terrible radiation experiences in my life, who in their right mind would want to chance the perils of adjuvant or salvage radiation if they don't need it. And the odds of it working, are low, unfortunately. In my case, they were reduced to 20% being effective. If mine proves to fail, I definitely will not feel like it was worth the hell I have, and still going through. At the time, I was hoping to be in that 20% group that it could work.

If you want to call that, a form of AS, then use the term. Its really more a case of seeing if that card needs to be played.

David in sC
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 11/10 ?
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, on Catheter #21, will be having Ileal Conduit Surgery in Sept.

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 9/15/2010 1:30 PM (GMT -6)   
Les: funny you mention smoking. for all that men talk openly here about things pc, every time i have ever mentioned the role of smoking, it goes silent. does that mean we have a lot of smokers on board? I think that is a great topic for a new thread. I am always amused by people that job, exercise, eat "healthy", yet chain smoke. The damage from the smoking out trumps all their other healthy traits ten fold in my opinion.
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 11/10 ?
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, on Catheter #21, will be having Ileal Conduit Surgery in Sept.
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