To SRT or Not to SRT? Ignore 24-gene PORTOS Test?

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Tomson
Regular Member


Date Joined Mar 2015
Total Posts : 58
   Posted 11/20/2016 9:15 PM (GMT -7)   
To SRT or not to SRT? That is the question posed by my first visit with a radiation oncologist to discuss salvage radiation therapy after ten months of gradually rising PSA scores. He doesn’t think the answer is simply to fire away with the ray guns and explained why.

A little background: I was diagnosed in February 2015 with a Gleason score of 3+4 = 7 and had a prostatectomy performed by a top surgeon at UCSF in April 2015. The pathology report showed no extra-capsular extension, no seminal vesicle invasion, no lymph node involvement, no cancerous surgical margins (although there was some benign prostatic tissue left at the surgical margin).

In February 2016, my PSA first became detectable and since then has climbed to 0.129 ng/ml. There is still time for “early” salvage radiation therapy. Although early salvage radiation therapy has been shown to benefit many patients, there are some reasons to suspect it may not do much for me.

First, despite favorable results on other factors, the pathologist did report the presence of tertiary Gleason pattern 5 cells in the otherwise 3+4 tumor.

My RO and others take the presence of Gleason 5 very seriously, suggesting that whether it’s called 3+4+5 or 3+5, it’s perhaps time to recognize 7 with grade 5 present as high-risk rather than intermediate-risk cancer. See, e.g., Gleason Pattern 5 Is the Strongest Pathologic Predictor of Recurrence, Metastasis, and Prostate Cancer-Specific Death in Patients Receiving Salvage Radiation Therapy Following Radical Prostatectomy. Gleason Pattern 5 could behave more like, or even worse than, Gleason Score 8 (4+4) in terms of biochemical recurrence, distant metastases, mortality, and, most importantly for me at this moment of decision, response to salvage treatment.

In my RO’s estimation, this suggests that, although SRT is my only remaining hope of a cure, this adverse pathology suggests my chances of a cure from SRT are not great—not 80%, not 50%, but quite a bit lower – perhaps 30% or even less.

Samples of my cancerous tissues were sent down to GenomicsDX in March to obtain a calculation of my Decipher score. According to this genomic analysis, without followup treatment, my odds of distant metastasis within five years are 6.6% and my risk of prostate cancer-specific death within 10 years is 6.3%. The Decipher report from GenomicsDX classifies my risk as intermediate and indicates that I “may” benefit from SRT.

However, the new PORTOS score, which my RO was able to get from GenomicsDX during our meeting last Thursday, was low – suggesting that I am unlikely to benefit from SRT. PORTOS stands for Post-Operative Radio Therapy Outcome Score and it is a new 24-gene analytic tool developed for the express purpose of finding a genetic signature that would identify which patients were likely to benefit from SRT and which would not. PORTOS was developed by Dr. Felix Feng, now at UCSF, and is the subject of a report published in this month’s Lancet Oncology. You can read more about it on Tall Allen’s blog here.

The retrospective test results reported in the Lancet article are eye-popping. PORTOS low scorers (which were ¾ of the group studied) derived on average no benefit from SRT. PORTOS high scorers (the other ¼) were substantially less likely to have metastasis at ten years if they had SRT compared to those who did not.

My RO is none other than Dr. Felix Feng who developed the PORTOS test so you might think he would be gung-ho about advising me against SRT based on my low PORTOS. That is not what he said at all. Dr. Feng cautioned that PORTOS is a new test and requires further validation. Although the development of PORTOS is considered important because PORTOS is the first genomic test to determine the likelihood that a particular therapy will be effective against prostate cancer, it is a new test that requires further validation by other researchers to confirm its value in making clinical decisions. I suspect I am one of the first guys in this community to have a PORTOS score to consider.

Dr. Feng explained that I will have to decide for myself whether to proceed with SRT, depending on whether I am a glass half empty or glass half full person.

If I choose not to do SRT, the reasoning would be: 1) radiation causes side effects; 2) chances that radiation will cure me are low; 3) my Decipher score predicts that I only have a 6.6% chance of metastasis within five years even if I don’t do SRT; 4) the PORTOS genomic test predicts no benefit; and 5) my PSA is still quite low; it may settle down and, if it doesn’t, hormone therapy is an option down the road.

If I decide to go ahead with radiation, the rationale would be: 1) it’s my only chance for a cure; 2) I’m overall very healthy and could live plenty long so even a small chances of a cure is worth quite a bit to me; the Decipher test’s estimate of the risk of metastasis would no doubt be a lot worse at ten years; 3) the PORTOS score is too new to serve as a basis of decision, and 4) the side effects are not likely to be all that bad.

On the way home across the Bay Bridge returning to our beloved Oakland, my wife and I puzzled over whether I am a glass half empty or glass half full person and how, if at all, my inclinations towards half empty or half full glasses apply to this choice. Apparently, evidence-based decision-making still involves hunches and consultations with animal spirits.

Tomson

P.S. If you are interested in an earlier thread about my negative Gallium 68 PET/MRI scan, that thread is over here.
Dx 2/1/15 (age 65)
8/14 PSA 6.4
2/15 PSA 5.45 (8% free)
DRE+
Bx 1/26/15 8/12 cores; 3 cores G7 (3+4); 5 cores G6 (3+3)
RALP (UCSF) 4/8/15; nerves spared; sling made from vas
Pathology: G7 (3+4, tertiary 5); ECE-, SM-, LN-, SV-; PNI+
Decipher: 6.6% 5-yr metastasis; 6.3% 10-yr PCa mortality
PSA 5/15, 8/15, 11/15: <0.015; 2/16 .031; 5/16 .053; 8/16 .107; 9/16 .129
10/16 Ga68-PSMA PET/MRI: clean

George_
Regular Member


Date Joined Apr 2016
Total Posts : 423
   Posted 11/21/2016 2:02 AM (GMT -7)   
Tomson,

I think cure is an unrealistic objective for an intermediate or high-risk PCa patient. As long as the doctors cannot remove all PCa cancer cells from your blood a chance for a recurrence will always remain.

I am an advocate for treating what you see (e.g. on a PSMA PET/CT) and not primarily to radiate because statistics say it could be beneficial to do so. Churchill said: "Do not trust any statistics...".

Therefore my decision would be not to do an SRT now. The side effects from a futile SRT could reduce your QoL a lot for the next fifteen years.

George

Post Edited (George_) : 11/21/2016 6:42:47 AM (GMT-7)


Wilderness
Regular Member


Date Joined Feb 2015
Total Posts : 272
   Posted 11/21/2016 8:40 AM (GMT -7)   
A tough spot, Tomson - important health decision of life-altering consequence, clock ticking, Dr. Feng calls it 50-50.

In your place I would prefer to go with the advice of someone with far more medical knowledge and experience than myself. Would he answer a question like, "if your father were in my shoes, what would your advice to him be?"

When my wife needed a valve repair last year we had to press excellent surgeons hard to cause them to reveal that open surgery was preferable to laparoscopic for mitral valve repair (after first being told it was 50-50).

Would he answer, "Do you have reason to think PORTOS may not turn out to be predictive?"

Maybe also assure him that you will never question the outcome of his advice - I see evidence that doctors get burned unfairly when things don't work out as hoped. That has to be hard, make them cautious.

Or could you get a second opinion on best course of action?

Please keep us in the loop -

Wilderness
8/14 DRE felt notch
9/14 DX 12 core. One 5% 3+4; one <5% 3+3 confirmed on 2nd opinion
9/14 CT neg
12/14 RRP Dr. McGovern @ MGH pT3a Nx 47g 15% Gl 3+4 in right posterior quad focally & left extensively; "established, extensive" EPE+ PNI+ SM- SV-
PSA 8/14 2.38; 12/14 2.90; 1/15 .01; 3/15 .02; 5/15 .01; 8/15 .02; 10/15 .01; 1/16 .03; 2/16 .06; 3/16 .04; 6/16 .03; 7/16 <.014; 11/16 .03
ED

George_
Regular Member


Date Joined Apr 2016
Total Posts : 423
   Posted 11/21/2016 9:02 AM (GMT -7)   
Tomson said...
In my RO’s estimation, this suggests that, although SRT is my only remaining hope of a cure, this adverse pathology suggests my chances of a cure from SRT are not great—not 80%, not 50%, but quite a bit lower – perhaps 30% or even less.

Wilderness, I understand the decision is 70:30 or maybe even 80:20 in favor of no SRT.

George

logoslidat
Veteran Member


Date Joined Sep 2009
Total Posts : 5383
   Posted 11/21/2016 9:33 AM (GMT -7)   
Well since George just doomed every human being on the earth with cancer that will eventually get us because one cancer cell is out there in the blood floating around...what can any of us say... Be unrealistic and let it ride... Im sure he thought about that as he did say I think...I think he did not think very hard...so remember this is an internet forum...and I see you have been thinking very hard from your very articulate post...on e of the best I have seen. Based on your 3 decimal ultra you are still really a 0.1 on the std test...you do not need SRT based on the vast majority of top experts in the field...it is dectectable but not a recurrence... Check my stats...you should be giving advice to the folks here ...not the other way around...There is more lack of knowledge on this particular website than knowledge...its what one should expect on a internet...but you will never convince that to the vocal few who pass it out...yes we do have 2-3 great researchers here but darn...not a one that will compare with the medico sitting right in front of you...DR Fang...and many others...Studies don't mean squat...most are self serving means to get published and ...Hsving said that... the C word {cure} is meaningless...your endpoint still is death...live with that...we all have to{tho some choose to inwardly die from fear}... but as Churchell once said "Nevah...Nevah..give up" Oh just to clarify " yes Virginia...there is a Santa Claus
open surgery,1 nerve bundle spared 10/09 gl9 {4+3-tert 5}last psa0.15 holding steady
73 all posts arguable as in a court of law.dots can not be connected until seen-living the dream..

Post Edited (Bololidat) : 11/21/2016 9:37:09 AM (GMT-7)


Michael_T
Veteran Member


Date Joined Sep 2012
Total Posts : 2537
   Posted 11/21/2016 9:46 AM (GMT -7)   
Well, this has been an unsettling thread as I've just learned my goal of a cure is unrealistic. I better not break that news to my wife. Happy Thanksgiving to me!

As to your question Tomson, my non-medical expert opinion would be that there would be a benefit to the SRT to the extent that there are some cells hanging out in the prostate bed. I wouldn't take the SEs lightly, but there have been a lot of guys here that have breezed through SRT, although with radiation none of us really knows what's up for several years.

To the extent that your RO's 30% chance of a cure is accurate, I'm guessing that the chances of long-term control are even higher then. My two cents. Good luck as this sure ain't easy...
Age 56, Diagnosed at 51
PSA 9.6, Gleason: 9 (5+4), three 7s (3+4)
Chose triple play of HDR brachy, IMRT and HT (Casodex, Lupron and Zytiga)
Completed HT (18 months) in April 2014
11/16: T = 162, PSA = 0.18

George_
Regular Member


Date Joined Apr 2016
Total Posts : 423
   Posted 11/21/2016 11:05 AM (GMT -7)   
Let me try to explain what I meant with cure being an unrealistic objective.

If you had an operation or radiation and you ask your doctor after that: can I now be sure that there will be no recurrence? The doctor will always answer, "I cannot promise that".

You can achieve a remission for many years but there will always be the concern that the cancer will one day resurface. You can also achieve good control of your cancer so that that it doesn’t negatively impact your life. I also think most PCa patients will die from causes other than prostate cancer. But I do not think you can achieve cure in a sense that there will be no chance of recurrence any more.

George

Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 3951
   Posted 11/21/2016 11:23 AM (GMT -7)   
George_ said...
But I do not think you can achieve cure in a sense that there will be no chance of recurrence any more.


As a glass half full kinda guy I find that to be an extremely pessimistic view. "No chance of recurrence" is an unrealistically high standard in my opinion. Geez...after 8 years of great post-brachy life I feel I am cured but under that definition I am certainly not. I guess I prefer my own view of cured...

Anyway, Tomson, now that you know my optimistic self you might guess that if I was in your shoes I would go for the SRT. Also, Tall Allen is on his writing sabbatical but I know he is accepting emails. You might consider contacting him for his studied opinion.

Good luck in any case.

Jim
Forum Moderator-Prostate Cancer. Age 62 (69 now), G 3 + 4 = 7, T1C, PSA 4.2, 2/16 cancerous, 27cc. Brachytherapy 12/9/08. 73 Iodine-125 seeds. Everything continues to function normally. PSA: 6 mo: 1.4, 1 yr: 1.0, 2 yr: .8, 3 yr: .5, 4/5 yr: .2, 6 yr: .1, 7 yr: .1. My docs are "delighted"! My journey:
http://www.healingwell.com/community/default.aspx?f=35&m=1305643&g=1305643#m1

lapilot
Veteran Member


Date Joined Nov 2012
Total Posts : 820
   Posted 11/21/2016 4:15 PM (GMT -7)   
I believe you made the correct decision for several reasons. First off, if PSA continues to rise you will probably kick yourself in the butt for not trying SRT while the PSA was low. Second, you had extra prostate tissue which could harbor PCA even though the pathologist couldn't find it on the post prostatectomy biopsy.

The only negative is that pathology report didn't show any positive margins, which could have been missed during the biopsy examination. Having a positive margin could explain your rising PSA and therefore minimize the likelihood of PSA increase from metastatic occurrence.
Age 60, mpMRI 8/18/13 negative
biopsy 9/5/13, PSA 6.2, 13 core of which 6 are postive
pT2pNO
left laterial base 10% G6(3+3)
left laterial apex 10% G6(3+3)
right base 15% G7(3+4)
right laterial base 15% G6(3+3)
right laterial mid 60% G6(3+3)
right lateral apex 20% G6(3+3)
daVinci 11/11/13
path T2c N0 Stage IIB
PSA 0.1 to 11/15 then 0.2
11/15 IGRT 39 sessions 72 grays. ZERO problems.

Tomson
Regular Member


Date Joined Mar 2015
Total Posts : 58
   Posted 11/21/2016 4:35 PM (GMT -7)   
To everyone, thanks for your insights.

George suggests waiting on SRT until metastases are detectable using a PSMA PET/CT. In October, I actually had a Gallium-68 PSMA PET/MRI scan (one of the most sensitive new imaging methods) that showed no PSMA-positive lesions anywhere in my body. This means that whatever prostate cancer cells are producing my detectable PSA are not in any sufficiently large clump to be detectable using the PSMA scan.

Dr. Feng commented that he was not surprised at this result because he would not have expected the scan to show visible metastases with my PSA at 0.129.

However, the problem with waiting until a scan will show metastases is that there is evidence that very early salvage RT (PSA < 0.2) is associated with substantially better outcomes than early savage RT (PSA between 0.2 and 0.5) and early salvage RT with substantially better outcomes than later RT (i.e., PSA > 0.5). So, while waiting for visible metastases to emerge, the odds that the SRT will be effective go down. (See Tall Allen's analysis of this research, Very early salvage radiation has up to fourfold better outcomes and saves lives.) From that standpoint, as Wilderness put it, "the clock is ticking."

I should also clarify that Dr. Feng did not say that the decision is 70:30 or maybe even 80:20 in favor of no SRT, only that my odds of a "cure" from SRT (setting aside the PORTOS score) would be approximately 30%. I'm not sure exactly what definition of "cure" he had in mind, but I assumed by "cure," he did not mean receiving an "all clear" signal and no more PSA tests for the rest of my life, but freedom from biochemical failure for a good long time (10 years?).

In retrospect, I should have asked him to explain what he meant by "cure" and I'll follow up on that to make sure I did not misunderstand him. He did use the word "cure", however, and I think it would probably meet with universal assent in these quarters that if all of us could take a pill tomorrow that had no side effects and offered a 30% chance of a durable cure of our cancer, we'd be lining up to take our medicine without much ado. It wouldn't be a 70:30 decision. None of us would pass it up, right?

So what's different here? (1) potential side effects and (2) the PORTOS score.

I didn't run down all of the things Dr. Feng told me about side effects, but generally, he said the short-term effects are almost always gone within two months. Long-term urinary problems can be severe but are very rare. Rectal bleeding is rare but can be treated effectively in the overwhelming majority of cases. Loss of sexual function is harder to dismiss. Some men who are functioning well before SRT function as well after; some suffer losses a few years down the road but it is hard to allocate the blame between SRT and aging. However, I am just starting to see some improvement after being knocked for a loop by the prostatectomy and it is sad to think of taking another kick from radiation. (I had nerves spared on both sides but that was not magic.) I'd be happy to hear evidence-based and/or personal comments about the side effects of SRT.

The PORTOS score does throw some ice water in my direction. However, Tall Allen was kind enough to interrupt his sabbatical long enough to comment on PORTOS in response to my earlier posting
The science experiment continues: Gallium-68, Decipher, SRT, and who knows?


Tall Allen said...
Remember that their PORTOS study was a retrospective study, and they lacked info on PSA kinetics and other disease characteristics that influenced whether SRT was given. Many had inadequate radiation doses by today's standards, and use of ADT was certainly inadequate based on what we now know. If your PORTOS score is zero, I'd be very dubious about letting that dictate your SRT decision.

Tall Allen said that before he knew my score ... before Dr. Feng or I knew my score ... so there is no chance he was trying to cheer me up when he said that. Without the tertiary Gleason Pattern 5 and the PORTOS score, my prospects of benefit would definitely outweigh the risks of side effects.

The idea of a getting a second opinion intrigues me, but seems a bit daunting to arrange. I can definitely ask Dr. Feng more questions but I thought I would check in with you all first to see what comes up. I see that lapilot just added a comment about the benign prostatic tissue found on the surgical margin in the post-op pathology report. I agree that is a possibility and it would favor going ahead with the SRT. As I see it, there are two ready reasons the SRT may fail: (1) the cat is already out of the bag and there are cells growing somewhere outside the prostate bed and (2) my cancer is resistant to radiotherapy. At this point, I don't know either of them to be true although PORTOS may be indicative of the latter.

Tomson
Dx 2/1/15 (age 65)
8/14 PSA 6.4
2/15 PSA 5.45 (8% free)
DRE+
Bx 1/26/15 8/12 cores; 3 cores G7 (3+4); 5 cores G6 (3+3)
RALP (UCSF) 4/8/15; nerves spared; sling made from vas
Pathology: G7 (3+4, tertiary 5); ECE-, SM-, LN-, SV-; PNI+
Decipher: 6.6% 5-yr metastasis; 6.3% 10-yr PCa mortality
PSA 5/15, 8/15, 11/15: <0.015; 2/16 .031; 5/16 .053; 8/16 .107; 9/16 .129
10/16 Ga68-PSMA PET/MRI: clean

Bohemond
Veteran Member


Date Joined Apr 2012
Total Posts : 856
   Posted 11/21/2016 5:34 PM (GMT -7)   
Tomson,
You are in a gray area with no clear guidelines and are obviously doing a
thorough job of dredging up all the information you can find. I wish I could give some clear guidance but I can't.

I will suggest that aside from considering if SRT may be curative, you also weigh whether it may buy you some added years before maybe needing to move on to ADT. This has been, or at least I believe it has been my case. I am now faced with SRT failure, but if I hadn't had SRT I'd have been on ADT treatment some years ago. That said, the course of this disease differs greatly even among patients who have similar clinical findings.

I was high risk post-surgery due to seminal vesicle involvement and a pretty extensive tumor burden. I also had a potential SRT success rate in the neighborhood of only 30%. Nonetheless, my PSA rose only very slowly and went 7 years before having SRT. Likewise post-SRT my PSA stayed very low for another nearly 5 years. So in my particular case, though I was high risk, and though the facts have shown SRT was not curative, I believe it bought me an additional 6 years of more or less normal life before needing to take on more extreme treatment.

So maybe extending remission before needing ADT is another variable to throw into the mix as you weigh what to do next. However I see that your PSA has risen much faster than mine did since your surgery. Maybe this suggests it might rise equally fast after SRT. I don't know -- just speculating. But maybe this is something else you should discuss with your doctors.

As for side effects of SRT, mine were minor. I began having urinary urgency around week 5 or so of treatment, but this resolved to near-normal within a month or so after the radiation was complete. I still sometimes need to exercise mind over bladder when standing after I've been sitting or driving for a while, but not all that often. I began having rectal bleeding about 8 months after treatment ended, but it was intermittent and gradually resolved back to normal over the following year. As for ED - I already had it from the surgery, so the SRT couldn't make it worse. But since you have some luck in that department, that is one more thing to weigh in your decision.

Good luck, whatever you decide. And whatever course of treatment you choose, don't look back.

Jim
Age 70
-DX March 2002-PSA 9.4, 5 of 10 cores positive - 30-50%.
-RP April 2002. PT3B N0 MX Gleason=7 (3+4), 75% left lobe; small focus right lobe.
-Post-surgery PSA low of 0.01; slow rise to 0.4 (Aug 2009).
-SRT Jan/Feb 2010. Enlarged lymph node near prostate bed targeted. Casodex 3 months during SRT -PSA 0.00 2010 through Apr 2014; 0.02 Oct 2014; 0.05 Apr 2015; 0.04 Apr 2016; 0.23 Oct 2016

Post Edited (Bohemond) : 11/21/2016 5:40:24 PM (GMT-7)


logoslidat
Veteran Member


Date Joined Sep 2009
Total Posts : 5383
   Posted 11/21/2016 6:08 PM (GMT -7)   
If you had never had the ultra sensitive...and if it were indeed moving the wrong way...you would know soon enough...A study is nothing more and nothing less then a argument in the scientific method...it may be right ... it may be wrong...a study alone can not by definition provide anything but a hope{thats a good thing...but when a guru{TA} always seems to side with the worse interpretation{believe the study it MAY be right...totally disregarding that it may be wrong{which is why I say the worse interpretation} that is taking sides in a process that has no sides...only more questions....This fits in nicely with those who would rather have ...blindly I would add...some one else make the decisions for them...hence having no responsibility for that call themselves...Any thing TA says is what I should do...its wrong on its very face...but as we all have seen it is the sign of the times white horse black horse ich mach nix
open surgery,1 nerve bundle spared 10/09 gl9 {4+3-tert 5}last psa0.15 holding steady
73 all posts arguable as in a court of law.dots can not be connected until seen-living the dream..

Tomson
Regular Member


Date Joined Mar 2015
Total Posts : 58
   Posted 11/21/2016 7:58 PM (GMT -7)   
Jim, thanks for sharing your story. I do appear to be moving faster in the post-RP PSA derby and. if that's a function of my tertiary GP5, it could also be an omen of what will happen after SRT. BUT, this disease can take so many different paths that I'm going to take to heart your admonition not to look back. The truth is that, whatever I do, I'll never know how things would have turned out if I had chosen differently.

Bololidat, in this case, at least, TA is saying "don't believe the study, it may be wrong," not the opposite as you seem to suggest. My radiation oncologist, who developed the PORTOS test, is proud of PORTOS but also urges caution in letting it be the sole basis for a decision. Although the 24-gene PORTOS molecular signature did a very good job of predicting which patients were unlikely to benefit from salvage radiation therapy, views on how much weight to give it are varied. Some clinicians are going to wait and see before using it to guide decisions on whether to recommend SRT; others will be early adopters. A publicly accessible Medscape article reports on the variety of views.

Speaking of signatures, Bololidat, it's great to see a fellow tertiary GP5 holding steady at PSA 0.15 seven years after RP. Did you ever have undetectable PSA after surgery?

Tomson
Dx 2/1/15 (age 65)
8/14 PSA 6.4
2/15 PSA 5.45 (8% free)
DRE+
Bx 1/26/15 8/12 cores; 3 cores G7 (3+4); 5 cores G6 (3+3)
RALP (UCSF) 4/8/15; nerves spared; sling made from vas
Pathology: G7 (3+4, tertiary 5); ECE-, SM-, LN-, SV-; PNI+
Decipher: 6.6% 5-yr metastasis; 6.3% 10-yr PCa mortality
PSA 5/15, 8/15, 11/15: <0.015; 2/16 .031; 5/16 .053; 8/16 .107; 9/16 .129
10/16 Ga68-PSMA PET/MRI: clean

logoslidat
Veteran Member


Date Joined Sep 2009
Total Posts : 5383
   Posted 11/21/2016 9:08 PM (GMT -7)   
I actually made mention of that data point of TA's on GCC's recent thread on this same issue...you can read my take on that
My psa was always ) 0.1 stdard untill 2 years ago...I did a retest ultra imediately....0.07...did another ultra a year later went ot 0.14...6 mos later went to 0.15...{uro did not cosider it a recurrence and I was going to get one this october...but passed and will pass on psa tests into the distant future...will never do SRT ever...I will wait until symptoms and then get an orcho whatchamacallit and spend what ever the time I have left...it will be in my 90's...getting fat and smoken da kine...even if its bad for me I will be fine...We all die of something and does anyone actually believe 5-10 15years really changes any kine calculus for any one in the grand scheme of things...It might to those who have not created a scheme of any thing beyond the veil ...I can understand those of that faith wanting to get as much as they can...When I dream...I dream big My favorite tune is dream...big band style...think "Boiling Point"
dennis hopper..wesley snipes...lolita davidavich...and a young virgo mortenson that an Nat king coles "Stardust" Hoagy Carmichael You asked ...I ate bird seed for dinner Heckle Jeckyl and Hide
open surgery,1 nerve bundle spared 10/09 gl9 {4+3-tert 5}last psa0.15 holding steady
73 all posts arguable as in a court of law.dots can not be connected until seen-living the dream..

Tomson
Regular Member


Date Joined Mar 2015
Total Posts : 58
   Posted 11/21/2016 10:42 PM (GMT -7)   
Bolo, I get it now if I didn't get it before. Your plan, however it came to you, makes lots of sense given how slowly your PSA is rising and what you do and don't want to focus on. Peace. T
Dx 2/1/15 (age 65)
8/14 PSA 6.4
2/15 PSA 5.45 (8% free)
DRE+
Bx 1/26/15 8/12 cores; 3 cores G7 (3+4); 5 cores G6 (3+3)
RALP (UCSF) 4/8/15; nerves spared; sling made from vas
Pathology: G7 (3+4, tertiary 5); ECE-, SM-, LN-, SV-; PNI+
Decipher: 6.6% 5-yr metastasis; 6.3% 10-yr PCa mortality
PSA 5/15, 8/15, 11/15: <0.015; 2/16 .031; 5/16 .053; 8/16 .107; 9/16 .129
10/16 Ga68-PSMA PET/MRI: clean

John_TX
Veteran Member


Date Joined Jan 2015
Total Posts : 893
   Posted 11/22/2016 6:43 AM (GMT -7)   
Tomson said...
To SRT or not to SRT? .........In February 2016, my PSA first became detectable and since then has climbed to 0.129 ng/ml. There is still time for “early” salvage radiation therapy. Although early salvage radiation therapy has been shown to benefit many patients, there are some reasons to suspect it may not do much for me.........

That's quite the conundrum you are faced with. Perhaps it's time for another medical opinion from another world-class cancer center.

As far as the cured vs. remission dialog, my thought is if I don't expire from prostate cancer, then I'm cured. wink
DX - 1-13-2015 (age 66) -- PSA 4.02 (9-16-2014) to 4.38 (12-5-2014)
da Vinci RP on March 2, 2015
---------------------
Stage pT3aN1
7/01/2016 PSA < 0.01
7/31/2015 HT started - six month's injection of Luperon
ART 11/2015, 33 session

teddy9
Regular Member


Date Joined Sep 2015
Total Posts : 106
   Posted 11/22/2016 8:06 AM (GMT -7)   
Tomson
Yes a difficult decision. However it comes to this - no test is fully predictive of future results. And salvage radiation still is your best chance of cure and the side effects are minimal for most people. Grab the brass ring and go for the radiation otherwise you have forever lost your chance of cure - unless some new technology comes along down the road. You do not want to live with the fact that you might have had a cure when you are faced with metastatic cancer years later.

good luck

Teddy
psa 4.5, 4 cores by MRI guided biopsy 2/13 after 2 neg biopsies a year apart at psa 2 &3, in 2011-12. gl 4+3, 8% cancer in prostate, neg margins, neg nodes
RP 3/13, gl 4+3, PSA < 0.008 from 5/13 - 7/14,
PSA 0.01 10/14, 0.03 2/15, 0.04 5/15, 0.046 6 /15 (now different lab), 0.79 9/15, 0.087 10/15, 0.108 12/15
1/16 firmagon & lupron - psa 0.015
4-5/16 IGRT, 37 sessions
8/16 psa <0.014

logoslidat
Veteran Member


Date Joined Sep 2009
Total Posts : 5383
   Posted 11/22/2016 9:34 AM (GMT -7)   
How would you ever know tho teddy...that has always been my point...getting SRT...did the srt cure you or were you cured before the srt ever took place...my decision which is set in wet cement{it will be fluid always... not a big fan of shermanesqe statements}to do nothing untill or when symptoms arise is based on my own personal metrics such as knowledge of placement of main tumour....placement relatively good distance from edge..totally contained within the prostate itself the tert 5 were foci...the path report itself was worded funny so as to have it both ways...after it assigned a gl 9 due to gl5 foci...it seemed to backtrack by saying " although the cancer is primarily gl3 and some gleason4 there are a "few" foci of gl 5. My local uro who di post op care questioned the way it was wriiten but put it down as 4+3 tert 5...my surgeon in seattle also confused laid it down as 3+EDIT4 tert 5.. the total volume of cancer was 9% of a moderate sized prostate...My fitness level then{even better now} is off the charts...I don't slit my wrists every time I screw up...I put things behind me very quickly I have no fear of death{ but like woody allen...I just don't want to be there when it happens.} Anyway the point is decisions like this are uniquely my own and I know I can [operative word coming}Live with any " negative '' issues that arise or fall... living is not for sissies if I may paraphrase Chesterson's quote...tho I believe " dying " may well be such... thanks for the ear...good luck on your life's journey to all....
open surgery,1 nerve bundle spared 10/09 gl9 {4+3-tert 5}last psa0.15 holding steady
73 all posts arguable as in a court of law.dots can not be connected until seen-living the dream..

Post Edited (Bololidat) : 11/22/2016 4:43:19 PM (GMT-7)


George_
Regular Member


Date Joined Apr 2016
Total Posts : 423
   Posted 11/22/2016 1:20 PM (GMT -7)   
Tomson,

the statistics you mention are based on radiating the prostate bed. If you plan to do an SRT you have to decide if you will do the prostate bed only or the pelvic lymph nodes too. If you have a high Gleason score usually one can assume that there are micromets and radiating the pelvic lymph nodes would make sense then.

Also SRT could also be done with SBRT / CyberKnife or brachytherapy, possibly with less side effects than IMRT. If you just want to treat the prostate bed you could also do that with focal therapies like HIFU and IRE/NanoKnife. However, there is no level 1 evidence for these focal therapies yet.

I have not read about prostate cancer cells to become resistant against radiation yet. But you probably have found a study about this.

George

Graytech
Regular Member


Date Joined Nov 2014
Total Posts : 304
   Posted 11/22/2016 1:48 PM (GMT -7)   
Tomson - Really a tough call.

I just started salvage treatment, 6 months Lupron / 25 x 2.5gy per day = 62.5gy total Tomotherapy no nodes with about a 70% success rate. I waited 3 additional months "just to be sure" my PSA was still on the rise. I agonized daily over what to do for those three months. After getting the Lupron yesterday I feel like life will go on, taken day by day, SE by SE as they come.

If I was given 30% as you are now and you also have test results I didn't have. I'm really not sure I would have moved forward. I don't know if I could let it go though. Just the 3 months waiting for the next PSA was agonizing.

If you don't pursue treatment will you be able to let it go and get on with life?

Jon
Age at Dx 54 10/23/14 PSA 9.75 DRE- T1c
Biopsy: 2 of 12 GS7 (3+4) 7% of sample #1=20%G6, #2=10%G7
Scans: 1/22/15 CT / Bone Clear
DaVinci: 1/27/15 Prostate 36gr GS7 (4+3) 8% of organ
PNI+ EPE- SV- LN- Clear Margins pT2c
---uPSA Post Surgery Every 3 Months ---
03 Mon <.05
06 Mon <.05
09 Mon .03
12 Mon .03
15 Mon .05
18 Mon .07
21 Mon .09

lapilot
Veteran Member


Date Joined Nov 2012
Total Posts : 820
   Posted 11/22/2016 4:30 PM (GMT -7)   
Tomson,

I started SRT exactly 12 months ago and finished up on Jan 2, 2016. I had many concerns about SRT side effects. I can tell you for me it as a non-event. I had 39 treatments (70.2 grays). I had zero side effects during or after SRT. I never had loose bowels or other GI problems. Never had any urinary problems. As of yet I have no ED problems either. I can attribute this to IGRT/IMRT at a busy hospital's radiation oncology center and a very good RO, and radiation techs. In fact after all of my treatments were over and my exist exam with the RO, I honestly asked him if he actually had the beam energized during my treatments.

Thinking back I might had a very limited fatigue towards the end and for a month after, but I have a very busy job, so it is hard to actually say it was from the radiation or the seasonal changes. I was probably 99% continent after surgery and I can say that I am now around 95% continent. There was a very slight change downward, but I can tell you it isn't a problem, only very minor stress incontinent.

It is a hard decision you will have to make. For me it was easy. I knew if I didn't partake SRT and I developed metastases I would really be mad and kick myself in the butt.
Age 60, mpMRI 8/18/13 negative
biopsy 9/5/13, PSA 6.2, 13 core of which 6 are postive
pT2pNO
left laterial base 10% G6(3+3)
left laterial apex 10% G6(3+3)
right base 15% G7(3+4)
right laterial base 15% G6(3+3)
right laterial mid 60% G6(3+3)
right lateral apex 20% G6(3+3)
daVinci 11/11/13
path T2c N0 Stage IIB
PSA 0.1 to 11/15 then 0.2
11/15 IGRT 39 sessions 72 grays. ZERO problems.

logoslidat
Veteran Member


Date Joined Sep 2009
Total Posts : 5383
   Posted 11/22/2016 5:18 PM (GMT -7)   
Sorry gents, I still see it as OT when the stats im seeing from the guys who want the trigger pulled have stats that could easily qualify for AS or at the least wait for something the ray gun can find...you can kick youself in the butt all day long lapilot about the mets tou may get...but the truth is you do not know and still don't that with your metrics whether they would occur or not...everyone is thinking the worst case scenario...having much faith that the worst case will happen and no faith in the best...what does that tell about you??? I said Im sorry because thas what I'm supposed to say...Yuk...no more jello for me mom...ive lived to long to pretend about this BS... and the fear of "MEN"..boo hoo ...so you die...big deal...did you ever LIVE.... post is generic...not specific to anyone..tho lapilot whose stats fit the bill of my thesis...happenstance...when a five mile hole in the sequence presents itself im gonna fill it..if the the lapilot refers to aviation... he will understand what im talking about...anything I say is only true if it rings the bell...other wise ...'just a pilgrim looking for the city...a little silver...a little gold...' be cool...offense is for boys....
open surgery,1 nerve bundle spared 10/09 gl9 {4+3-tert 5}last psa0.15 holding steady
73 all posts arguable as in a court of law.dots can not be connected until seen-living the dream..

Tomson
Regular Member


Date Joined Mar 2015
Total Posts : 58
   Posted 11/22/2016 11:21 PM (GMT -7)   
Since this thread began, I got calls from UCSF and, if I decide to move forward with SRT, they will insert gold fiducials on December 13, do a CT scan to map out my innards on December 22, and, a couple of weeks later, begin 39 sessions of nuclear medicine. Given this schedule, I do not need to rush to a conclusion. I can still ask Dr. Feng questions and having this interaction with you is helping me figure out what to ask him.

I think it is significant that lapilot, teddy, and jon have all pushed me to think about the same question: If I choose not to do SRT and then develop metastases, how well can I live with my choice to pass up a potentially curative therapy? I think Dr. Feng was wise to say that this depends on what kind of person I am. I think of myself as a pessimist of the intellect and an optimist of the will--in other words, I see the glass as half empty and half full with different parts of my brain. Fortunately, I have a loving wife and good friends who will support me in whatever choice I make.

George, Dr. Feng said there is not good quality evidence to support radiation of lymph nodes, at least in my case, and any possible benefit is outweighed by greater GI side effects. As for the Cyberknife, HIFU, etc., I don't think that any of these have been shown to be superior if they have been used for SRT. I don't think brachytherapy is an option since I don't have a prostate.

John_TX said...
That's quite the conundrum you are faced with. Perhaps it's time for another medical opinion from another world-class cancer center.

I don't think I'd want to travel somewhere else for treatment, but I certainly wouldn't mind getting input from another expert of Dr. Feng's caliber before going ahead with treatment or deciding to forego it. I see Johns Hopkins has a remote second opinion service that costs $550. Does anyone here have experience with the Johns Hopkins service or a like on at one of the other major centers?

John_TX said...
As far as the cured vs. remission dialog, my thought is if I don't expire from prostate cancer, then I'm cured.

In drafting one of my replies, I had defined "cured" as a box that could only be checked by my survivors, but I thought this i was being a little too cute and deleted it. Same idea as you expressed quite well. Of course, we PCa survivors have to look over our shoulders for the rest of our lives no matter how many undetectables we string together. Still, I felt cured when the first three post-RP tests came up undetectable, and if I banish the PSA again by SRT, I will again feel cured until I don't.

Tomson
Dx 2/1/15 (age 65)
8/14 PSA 6.4
2/15 PSA 5.45 (8% free)
DRE+
Bx 1/26/15 8/12 cores; 3 cores G7 (3+4); 5 cores G6 (3+3)
RALP (UCSF) 4/8/15; nerves spared; sling made from vas
Pathology: G7 (3+4, tertiary 5); ECE-, SM-, LN-, SV-; PNI+
Decipher: 6.6% 5-yr metastasis; 6.3% 10-yr PCa mortality
PSA 5/15, 8/15, 11/15: <0.015; 2/16 .031; 5/16 .053; 8/16 .107; 9/16 .129
10/16 Ga68-PSMA PET/MRI: clean

Graytech
Regular Member


Date Joined Nov 2014
Total Posts : 304
   Posted 11/23/2016 7:06 AM (GMT -7)   
Tomson said...
I see the glass as half empty and half full with different parts of my brain.


Tomson, my friend, you are faced with a decision none of us should have to make.

logoslidat
Veteran Member


Date Joined Sep 2009
Total Posts : 5383
   Posted 11/23/2016 8:53 AM (GMT -7)   
I get the logic of your last paragraph...I do think way too much emphasis on the word cured from most...ich mach nix....UCSF is really one of the best...so what ever you decide to do...they will do it very well..I lived in SFO thruout the 70's...one of the best decades in the City...brings a tear to my eye thinking about those "glory days"...Keep it clean Ed...lol Im talking springsteen here...not manilow and midler....
open surgery,1 nerve bundle spared 10/09 gl9 {4+3-tert 5}last psa0.15 holding steady
73 all posts arguable as in a court of law.dots can not be connected until seen-living the dream..
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