When should SRT begin?

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reachout
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Date Joined May 2009
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   Posted 5/8/2011 9:01 AM (GMT -6)   
I'm sure this has been answered, but I've had a hard time finding a good answer. I've seen everything from "the earlier the better" to "not later than PSA of 1 or 2." I know that .1 is the red flag used by many docs to monitor more closely, and .2 is either the definition of BCR or the start of SRT but can't recall which.

So, is there a concensus or at least a most frequent PSA point at which to start SRT?

Galileo
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Date Joined Nov 2008
Total Posts : 697
   Posted 5/8/2011 10:11 AM (GMT -6)   
Andrew Stephenson, from Cleveland Clinic, a major researcher on the topic of SRT, along with Scardino and other leading lights, have shown that it's preferable to start SRT before PSA reaches 1.0, and optimally before it reaches 0.5.
Source: jco.ascopubs.org/content/25/15/2035.full , plus you can find this echoed by other researchers in various articles.

As to the definition of recurrence, this seems to be a matter of some debate as to exactly when the declaration is made. But generally it's 0.2. I think the debate is whether it's 0.2, or 0.2 and rising as confirmed by the next test. Here's what Judd Moul, of Duke University says:

Recently, the American Urological Association published guidelines that establish the consensus definition of PSA recurrence after RP to be greater than 0.2 ng/mL and rising, as confirmed on a repeat test. This definition is to establish recurrence for outcomes reporting; however, it may not be the appropriate cutpoint to initiate therapy.

Indeed, it is our practice in a patient with a consistent and clearly rising PSA, often based on ultrasensitive values, to occasionally begin salvage radiotherapy when the PSA is between 0.1 and 0.2 ng/mL. Because microscopic or focal benign prostate tissue can sometimes be left behind after RP and may produce some small amounts of PSA, it is clinically important to recognize that a PSA of 0.2 ng/mL may not always represent cancer recurrence. Therefore, in the majority of patients, we do wait until the PSA is > 0.2 ng/mL before beginning salvage treatments.
Source: "Rising PSA in Nonmetastatic Prostate Cancer" www.cancernetwork.com/prostate-cancer/content/article/10165/63133 (free article, but registration is required.)

When my PSA hit 0.6, my uro finally was concerned enough to refer me to radiation and medical oncology (I consulted both but went with salvage radiation alone). I moved as quickly as I could, and the day before I started SRT, my PSA hit 0.7. Although so far things look good, in retrospect I wish I had been more proactive, knowing what I do now about the importance of pre-RT PSA. It's far from the only factor, but it stands out as important.

You might want to take a look at my "knol", a Google document where I have summarized what I learned as an SRT patient on one page of Q&A, with references if you need more: knol.google.com/k/salvage-radiation-for-prostate-cancer .

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) Jan-Mar 2007
PSA 9/2007 and thereafter <0.1
pcabefore50.blogspot.com

James C.
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Date Joined Aug 2007
Total Posts : 4462
   Posted 5/8/2011 12:45 PM (GMT -6)   
I'm waiting for some definite results stating that mine has reoccurred. I'm right now in the .08-.09 range and holding, so it could be benign tissue left behind, or it could be very slow growing cancer cells. In any case, I have already visited and discussed the situation with a radiation oncologist. Their standards is the .2 and rising before starting treatment. For the same reasoning as given in Galileo's post.
James C., Age 64, Kingsport, E. TN
Gonna Make Myself A Better Man tinyurl.com/28e8qcg
4/07: PSA 7.6, 7/07 Biopsy: 3 of 16 PCa, 5% involved, left lobe, GS6
9/07: Nerve Sparing open RP, Path: pT2c, 110 gms., clear except:
Probable microscopic involvement-left apical margin -GS6
3 Years: PSA's .04 each test until 04/10-.06, 09/10-.09, 12/10-.09, 02/11-.08
ED-total-Bimix 30cc

zufus
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Date Joined Dec 2008
Total Posts : 3149
   Posted 5/8/2011 1:04 PM (GMT -6)   
James have you ever thought of considering not jumping into SRT so quick even if psa reaches .1 to .2+ or near that??? Who says you cannot try casodex, or other drug choices for short duration and test to see longer term...how well did that work for you???
It could be a choice that might be very impressive to some. Then later decide I am going for SRT or not or some newer therapy that just hit the scene.

The SRT is still a big gamble no matter what, they used to say in books it was less than 50/50 chance of working. So it is illegal to gamble on hitting those PCa cells with drug therapy and getting Psa tests to monitor closely??? Some docs might say do consider such a choice, plenty of others especially if getting money by doing SRT or a referral would be all about you gotta get SRT. There is a 100% chance of it being profittable when using SRT, this is known. Hey, I am not saying I know...I am saying we should question everything and always.

Years ago alot of patients were no so much advised to get SRT, just go to hormone therapies. So, is it the science that is much more superior today vs. 2002 or is it revenue enhancement has esculated just like drug prices???? I don't know? I see the science defining perhaps a lower psa threshold...but is that the only thing and how well is that working for everyone??? I am a curious s.o.b. aren't I.

James C.
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Date Joined Aug 2007
Total Posts : 4462
   Posted 5/8/2011 1:13 PM (GMT -6)   
zufus, you know, I have been turning that exact idea over in my mind. I am wondering if there is a period that something fairly mild, such as DES, would/could suffice for years to come. I imagine that careful psa monitoring would allow the use of drugs before radiation. I had already made up my mind that if I did show a real chance of BCR that I would be right off to consult with a medical oncologist just to discuss this possibility. The only worry I would have is any possible 'masking effect' of the drugs, and ending up with a much higher psa count and cancer cell count that if I had went straight to SRT. I will admit, the more I learn about SRT, the less enthused I am at taking it. Thanks for bringing that up.

What say the rest of you experienced BCR guys?
James C., Age 64, Kingsport, E. TN
Gonna Make Myself A Better Man tinyurl.com/28e8qcg
4/07: PSA 7.6, 7/07 Biopsy: 3 of 16 PCa, 5% involved, left lobe, GS6
9/07: Nerve Sparing open RP, Path: pT2c, 110 gms., clear except:
Probable microscopic involvement-left apical margin -GS6
3 Years: PSA's .04 each test until 04/10-.06, 09/10-.09, 12/10-.09, 02/11-.08
ED-total-Bimix 30cc

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 5/8/2011 1:36 PM (GMT -6)   
James, zufus brings up an interesting point, with a potential delay of SRT. Your point about the possibility of "masking" would concern me to in your situation. If that is the case, you would buy time delaying SRT, but might, and I only say might, increase the risk factor with the delay, and possibly lessen the effectiveness of the SRT if you had to do it later.

I am glad that you have some negative feelings about SRT, I think all men with BCR or approaching BCR should carefully consider the entire option. Depending your individual case and numbers and agressiveness, the positive odds range from the 20% that I was told for me, to about 40% on a good day. A few push that number to 50%. Not the greatest odds in the world, but still a curative hope in it. That's why many go ahead and bite the bullet. I knew what I was facing with low odds, and with my past negative radiation experiences, I still went for it. In my case, it was for naught, and I got slammed with perm. damage.

The problem with SRT scenerios in my opinion, is that if your surgery fails, the radiation oncologists absolutely do not know where any remaining cancer cells or clusters are located. It's an educated guess at best. My radiation oncologist in the planning phase, made a 3-D image on a computer recreating the size of my prostate and where it was formerly located, and based on the surgical and pathology notes, tried to place the spot where my positive margin was located.

The general rule is the prostate bed, naturally. But with additional problems with PNI, the theory is that stray cancer cells had long escaped the prostate and prostate bed, perhaps long before surgery. And they could be anywhere at that point in your body, or as they suspecting with me, there may be multiple clusters growing, that are now causing this large PSA spiking I have going on post SRT.

Like all things PC, never a straight answer, never an easy choice, and always on a patient to patient, case by case basis.

Good luck as you continue to watch your PSA and plan your next step. I hope that you don't have to deal with BCR anytime soon, that would be the best solution.

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 margin
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, 2/11 1.24, 4/11 3.81
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/10

livinadream
Veteran Member


Date Joined Apr 2008
Total Posts : 1382
   Posted 5/8/2011 3:43 PM (GMT -6)   
My PSA has risen to .78 and I am sure when I go back in June it will over the 1 mark but I plan on waiting this thing out for a few more months. Call me crazy but I feel great and I decided I am not going to let this crap rule me. Ok I know I am the rebel here.

peace to you
Dale
I was 45 at diagnosis with PSA of 16.3
http://www.caringbridge.org/visit/dalechildress

My gleason score from prostate was 4+5=9 and from the lymph nodes (3 positive) was 4+4=8
I had 44 IMRT's. Scheduled to have a radical on July 11th, 2007, surgery was aborted when it was discovered it had spread to the lymph nodes.
I was on Lupron, Casodex, and Avodart for two years with my last shot March 2009.
My Oncology hospital is The Cancer Treatment Center of America in Zion IL
PSA July of 2007 was 16.4
PSA May of 2008 was.11
PSA July 24th, 2008 is 0.04
PSA Dec 16th, 2008 is .016
PSA Mar 30th, 2009 is .02
PSA July 28th 2009 is .01
PSA OCt 15th 2009 is .11
PSA Jan 15th 2010 is .13
PSA April 16th of 2010 is .16
PSA July 22nd of 2010 is .71
PSA Sept of 2010 is .71
cancer in 4 of 6 cores
92%
80%
37%
28%

compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7213
   Posted 5/8/2011 4:54 PM (GMT -6)   
James:
 
I only chose SRT because it was my last curative bullet.
 
That would be your reason, too, if you chose SRT
 
Mel

James C.
Veteran Member


Date Joined Aug 2007
Total Posts : 4462
   Posted 5/8/2011 6:40 PM (GMT -6)   
Mel, yes I realize that the SRT is another bullet spent in the fight, and that the drugs is, at best, likely a delaying action. That brings in the pain of attempting a cure or just trying to avoid shooting that probably final bullet as long as possible. That's the agony of the decision.
James C., Age 64, Kingsport, E. TN
Gonna Make Myself A Better Man tinyurl.com/28e8qcg
4/07: PSA 7.6, 7/07 Biopsy: 3 of 16 PCa, 5% involved, left lobe, GS6
9/07: Nerve Sparing open RP, Path: pT2c, 110 gms., clear except:
Probable microscopic involvement-left apical margin -GS6
3 Years: PSA's .04 each test until 04/10-.06, 09/10-.09, 12/10-.09, 02/11-.08
ED-total-Bimix 30cc

TaurusBull
Regular Member


Date Joined Jan 2010
Total Posts : 91
   Posted 5/8/2011 8:05 PM (GMT -6)   
Well, as you can see in my signature, I'm at 0.32 ng/ml and still holding out on SRT. With negative surgical margins I'm not sure if radiation is the best course of action for me. Definitely not an easy decision here. This has been going on for over a year and a half now.

TB
Dx: in 6/2005, 49 yrs old (55 now), PSA 4.1, 2/10 cores pos, G6, T1c
daVinci RRP 8/2005, Hartford Hospital
Post-surgery upgraded G7 (3+4), pT2c, NX,MX, neg. margins, PNI present, tumor focally invades capsule wall, but not entirely through it.
PSA All <0.1 until... 7/2009 0.1, 10/2009 0.2, 1/2010 0.2, 2/2010 0.14, 4/2010 0.16, 8/2010 0.25, 9/2010 0.23, 12/2010 0.22, 4/2011 0.32

Grinnell86
Regular Member


Date Joined Feb 2010
Total Posts : 265
   Posted 5/8/2011 9:15 PM (GMT -6)   
TB,
With a 12 month doubling time that you currently have, I would definitely opt for SRT. Being that you are a relative youngster, the side effect risk is lower. I'm curious with your up and down PSA, are you taking supplements? My rise slowed when I started supplements, but still continued a steady rise. I am currently off supplements while doing my SRT, but I will re-start the pom extract and green tea after I am done. I figure if the SRT fails, I can slow the cancer down until they find something that works.
Paul
Age 47
PSA 10/09=4.60
Biopsy 12/09
Left side benign
Rt side 3of 4 cores positive, 70%
Initial Gleason 3+4
2nd Opinion Gleason 3+3
DaVinci surgery 2/16/10
Catheter removed 2/27/10
Gleason 4+3
Tumor quantitation=10%
Positive margins right side
Staging T2C PNX PMX
Post surgery PSA 5/10 <.05, 8/10 .12, 9/10 .12, 12/3/10 .16, 1/27/11 .15,
02/28/11 .17
03/28/11 .19

compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7213
   Posted 5/8/2011 9:17 PM (GMT -6)   
TB:
 
I thought I read that if you get the PC back after a few years, it is very likely in the prostate bed, so you perhaps should NOT wait. Ask your doctor.
 
Mel

compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7213
   Posted 5/8/2011 9:18 PM (GMT -6)   
Hey Grinel:
 
Looking for an update from you. I hope evrything is still uneventful!
 
Mel

Grinnell86
Regular Member


Date Joined Feb 2010
Total Posts : 265
   Posted 5/8/2011 9:24 PM (GMT -6)   
I'll update my journey string.
Age 47
PSA 10/09=4.60
Biopsy 12/09
Left side benign
Rt side 3of 4 cores positive, 70%
Initial Gleason 3+4
2nd Opinion Gleason 3+3
DaVinci surgery 2/16/10
Catheter removed 2/27/10
Gleason 4+3
Tumor quantitation=10%
Positive margins right side
Staging T2C PNX PMX
Post surgery PSA 5/10 <.05, 8/10 .12, 9/10 .12, 12/3/10 .16, 1/27/11 .15,
02/28/11 .17
03/28/11 .19

reachout
Veteran Member


Date Joined May 2009
Total Posts : 725
   Posted 5/9/2011 8:02 AM (GMT -6)   
Thanks for the replies. This board is, as usual, a great source of information both about medical literature and personal experiences.

Galileo, that was the concise answer I was looking for, that helps me a lot. The other responses are also very valuable as far as the difficulty of making decisions as to when, or even if, to start.

Thanks again, guys, and best wishes for many happy years ahead to all those that have, are, or will, go through SRT.
Age: 66
PSA: 7 tests over 2 years bounced around from 2.6 to 5.6
Biopsy 8 of 12 positive, Gleason 3+4, T2a
DaVinci August 2009, pathology Gleason 4+3, neg margins, T2c
Continent right away, ED
Viagra, Cialis did't work, Trimix works well
Post-surgery PSA:
3, month: undetectable <.1; 6 month: undetectable <.014 (ultrasensitive); 9, 12, 15 month: undetectable <.1; 18 month detectable .05

Sagittarian
Veteran Member


Date Joined May 2011
Total Posts : 546
   Posted 5/9/2011 12:21 PM (GMT -6)   
 
may help
Age = 53
PSA = (2011)-JAN 4.8, FEB 4.7. MAR 4.2
Biopsy = April 2011
12 Core, 4 POS, 2 (3+3), 2 (3+4) All Left Side
Percetage on Positive Cores = 2 (40%) 1 (70%) 1 (90%)
PNI = Not Ppresent
Da-Vinci Surgery = 23 May 2011

logoslidat
Veteran Member


Date Joined Sep 2009
Total Posts : 5875
   Posted 5/9/2011 12:57 PM (GMT -6)   
Excellent information, one of the most informative I have read in a while here . thanks
Diagnosed 8/14/09 psa 8.1 66,now 67
2cores 70%, rest 6-7 < 5%
gleason 3+ 3, up to 3+4 @ the dub
RPP U of Wash, Bruce Dalkin,
pathology 4+3, tertiary5, 2 foci
extensive pni, prostate confined,27 nodes removed -, svi - margins -
99%continent@ cath removal. 1% incont@gaspass,sneeze,cough 18 mos, squirt @ running. psa std test reported on paper as 0.0 as of 12/14/10 ed improving

Sagittarian
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Date Joined May 2011
Total Posts : 546
   Posted 5/9/2011 1:49 PM (GMT -6)   
 
Your welcome, here is another.
Radiation already on radar, surgery 2 weeks away.
Trying to cover all angles, while I still have some sanity.

compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7213
   Posted 5/9/2011 2:23 PM (GMT -6)   
Thanks for those articles. Very iinformative
 
Mel

reachout
Veteran Member


Date Joined May 2009
Total Posts : 725
   Posted 5/9/2011 2:35 PM (GMT -6)   
Sagittarian thanks for those articles. That last one seems to be about Adjuvant rather than SRT, isn't it? I wonder how long one has to wait beyond surgery for it to be SRT rather than Adjuvant.
Age: 66
PSA: 7 tests over 2 years bounced around from 2.6 to 5.6
Biopsy 8 of 12 positive, Gleason 3+4, T2a
DaVinci August 2009, pathology Gleason 4+3, neg margins, T2c
Continent right away, ED
Viagra, Cialis did't work, Trimix works well
Post-surgery PSA:
3, month: undetectable <.1; 6 month: undetectable <.014 (ultrasensitive); 9, 12, 15 month: undetectable <.1; 18 month detectable .05

Sagittarian
Veteran Member


Date Joined May 2011
Total Posts : 546
   Posted 5/9/2011 2:42 PM (GMT -6)   
 
My mind is about to explode, information overload.....
Age = 53
PSA = (2011)-JAN 4.8, FEB 4.7. MAR 4.2
Biopsy = April 2011
12 Core, 4 POS, 2 (3+3), 2 (3+4) All Left Side
Percetage on Positive Cores = 2 (40%) 1 (70%) 1 (90%)
PNI = Not Ppresent
Da-Vinci Surgery = 23 May 2011

reachout
Veteran Member


Date Joined May 2009
Total Posts : 725
   Posted 5/9/2011 2:50 PM (GMT -6)   
Sagi, you're scaring me man :) Not about the info, but about how quickly you come up with it.
Age: 66
PSA: 7 tests over 2 years bounced around from 2.6 to 5.6
Biopsy 8 of 12 positive, Gleason 3+4, T2a
DaVinci August 2009, pathology Gleason 4+3, neg margins, T2c
Continent right away, ED
Viagra, Cialis did't work, Trimix works well
Post-surgery PSA:
3, month: undetectable <.1; 6 month: undetectable <.014 (ultrasensitive); 9, 12, 15 month: undetectable <.1; 18 month detectable .05

BB_Fan
Veteran Member


Date Joined Jan 2010
Total Posts : 1011
   Posted 5/9/2011 3:33 PM (GMT -6)   
Started SRT when PSA got to .5. It went from .07 to .5 in 4.5 months so I didn't want to delay. I'm doing HT with SRT, 12 months. Will be finishing up HT next month. I already have my fingers crossed.
Dx PCa Dec 2008 at 56, PSA 3.4
Biopsy: T1c, Geason 7 (3+4) - 8 cores, 4 positive, 30% of all 4 cores.
Robotic RP March 2009
Pathology Report: T2c, Geason 8, organ confined, negitive margins, lymph nodes - tumor volume 9%, nerves spared, no negitive side effects.
PSA's < .01, .01, .07, .28, .50. ADT 3 5/10. IMRT 7/10.
PSA's post HT .01, < .01

TaurusBull
Regular Member


Date Joined Jan 2010
Total Posts : 91
   Posted 5/10/2011 8:20 PM (GMT -6)   
@Grinnell: I've been drinking 4 oz of pom juice just about every day for the past 5 1/2 years. I have also been taking lycopene and green tea extract for about 8 months. Truthfully, I don't think supplementation has made a huge difference. I'm going to drop the lycopene and green tea extract, but I've actually acquired a "taste" for the pom juice. While my PSADT is somewhat favorable, the spikes have also occurred while I was on these supplements. I exercise and am in relatively good shape (6 feet 175 lbs), so I don't think I have to worry about my weight (the obesity factor), at least not for now.

@ Compiler (Mel): You are correct, sir. Walsh and Scardino (and others, I'm sure) both point out that if your PSA returns 3 years or more after prostatectomy, the PSA recurrence is most likely due to localized cancer. I did ask my doctor (a urologist) about this. His reply to me was, "what do you want to do?" I have already seen a radiation oncologist at Yale - Smilow Cancer Center. That was in Oct 2010.

Wondering if I should now talk with a good medical oncologist - but that's a question for another thread. smilewinkgrin
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