Radiation after RP

New Topic Post Reply Printable Version
[ << Previous Thread | Next Thread >> ]

TomC1962
Regular Member


Date Joined Aug 2015
Total Posts : 41
   Posted 12/6/2017 8:28 PM (GMT -7)   
Hi All.
I went back for my psa test today. The first 5 tests I had done since my RP in 11/15 were all undetectable (<0.03). The doctor switched to a more sensitive test 3 visits ago, and it did detect a reading of 0.02 six months ago. 3 months ago it was 0.021. Today it was 0.027.
My doctor is suggesting radiation therapy. He wants me back in 4 months, and if it is the same as today or less, we will still monitor. But if it goes up again, he feels we should just knock it out, well before it gets to what I read is the standard threshold of 0.4. He did not try and scare me, and did say there is no hurry as it is growing slowly, but there is still something there, and I should not consider this a setback, but just the final leg of my therapy to be cured.
So my question is, what are your opinions? I agree on one hand, that even though it is very small, it is going up, so why wait until it gets higher and maybe harder to treat? On the other hand, I am afraid getting radiation may cause other more serious problems. I think it is 5 days a week for something like 9 weeks?
By the way, my doctor is very well respected and highly recommended by other doctors, so he not a "quack" looking to make money on it. In fact, he no longer takes my insurance but said he would help me find a reliable radiologist that does take my insurance. When I see him I have to pay out of pocket as I want to stick with the same person that did the surgery.
Your advice is appreciated.
Tom
Diagnosed 6/2015 at age 53. PSA 4.0 Positive biopsy in 9 of 12 samples, ranged from 5% to 15% per sample. Gleason score 6.
RP 11/2015, confirmed Gleason 6. 1 open margin of less than 1 mm.
PSA After <0.03 first 5 quarterly visits. Then switched to a more sensitive test and psa was found to be 0.020, 0.021, 0.027 most recent.

Pratoman
Veteran Member


Date Joined Nov 2012
Total Posts : 4981
   Posted 12/6/2017 8:46 PM (GMT -7)   
Standard is .2, for Biochemical recurrence, not .4.
With that said, as I'm sure others will mention, the latest research says .03 is a reliable predictor if BCR, if there is adverse pathology (like your positive margins), and so many RO's are hitting it earlier than .2,, once they see a trend. Yours is not yeti trend. But another rise or two would constitute a trend.

Your RO is being prudent to not rush into anything at such a low reading. It really is low, and very slow rise. On the other hand don't wait for .4, or even .2, especially with a positive margin, which gives you a good chance THT it's in the prostate bed, not elsewhere.

Good luck.
Dx Age 64 Nov 2014, 4.3
BX 3 of 12 cores positive original pathologyG6, G6, G8 (3+5)
downgraded to 3+3=6 by tDr Epstein, JH
RALP with Dr Ash Tewari Jan 6, 2015
Post surgical pathology – G7 (3+4), ECE, Margins, LN, SV all negative
PSA @ 6 weeks 2/15, .<02, remained <0.02 until January 2017, .02, repeat Feb 2017, still .02. May 2017-.033, August 2017- .033 November .046
Decipher test, low risk, .37 score

InTheShop
Veteran Member


Date Joined Jan 2012
Total Posts : 7966
   Posted 12/6/2017 9:18 PM (GMT -7)   
waiting is the right answer. It's not going the direction you want, but it's a small move. Currently thinking is that a rising pattern above .03 is an indicator of BCR. As you doctor said, you're not there yet, but need to monitor it. By .2 you should be doing something.

There are worse things than SRT, it's something 7 or 8 weeks for the dose you'll likely be prescribed. Most guys tolerate radiation with few side effects.

Now it's that horrible thing: waiting.

Go live life and put this aside until your next test,
Andrew
I'll be in the shop.
Age 57, 52 at DX
PSA:
4.2 10/11, 1.9 6/12, 1.2 12/12, 1.0 5/13, .6 11/13,
.7 5/14, .5 10/14, .5 4/15, .3 10/15, .3 4/16, .4 10/16, .4 5/17, .3 10/17
G 3+4
Stage T1C
2 out of 14 cores positive
Treatment IGRT - 2/2012
My latest blog post

Saipan Paradise
Regular Member


Date Joined Sep 2017
Total Posts : 116
   Posted 12/6/2017 9:29 PM (GMT -7)   
Hi, Tom--
I'm also post-RP and watching my PSA closely for a sign it's time for additional tx.
I agree with Pratoman that there's no need to rush, the timeline your doctor (uro/surgeon, right?) has set out seems fine.
Five times a week for around 8 weeks (40 sessions +/- a few) sounds typical.
From what I've been reading in other threads, most of those who have undergone SRT report that the SEs are tolerable and they're able to continue working on treatment days.
Has your doctor suggested ADT in addition to RT? That's what one RO I've consulted is recommending, but my pathology and hx are different from yours, and I'm certainly not knowledgeable enough to give an opinion on what's right for you. But it's a question you might want to raise if you're trying to plan two steps ahead. ADT seems to have rougher SEs than RT.
If you have a bunch of concerns about RT, you might want to consult an RO now to get a clear picture of what SRT tailored to your pathology would be. Also, it sounds like rapport with the treating physician is a priority for you, so you might want to interview a couple of ROs before the next PSA, get one on your team and establish a good relationship. That way, if the time comes for SRT, you've already found an RO you're comfortable with and are ready to move forward. Just a thought.
Best wishes, my friend.

TomC1962
Regular Member


Date Joined Aug 2015
Total Posts : 41
   Posted 12/6/2017 9:49 PM (GMT -7)   
Thank you everyone for the advice and words. I appreciate it a lot.
Seems like I keep squeezing through the cracks. Every test I take puts me at the low risk of everything, yet one thing after another keeps popping up. After my RP he did some genetic testing on the prostate, it was confirmed Gleason 6, and whatever the genetic test was about did put me at the very low risk end if the spectrum as far as recurring. Yet here I am talking about radiation.
Well at least he did tell me the success rate is extremely high with the radiation and I am not going to dies from prostate cancer...yes I did ask him! So I'll take that as the good news, and the rest as another inconvenience in life.
Happy Holidays to all.
Tom
Diagnosed 6/2015 at age 53. PSA 4.0 Positive biopsy in 9 of 12 samples, ranged from 5% to 15% per sample. Gleason score 6.
RP 11/2015, confirmed Gleason 6. 1 open margin of less than 1 mm.
PSA After <0.03 first 5 quarterly visits. Then switched to a more sensitive test and psa was found to be 0.020, 0.021, 0.027 most recent.

Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 8951
   Posted 12/6/2017 10:15 PM (GMT -7)   
You really have no adverse pathology (we'll ignore the focal positive margin because of the GS6), and your PSA is still below 0.03, and there is no trend - I can't think of a single reason why you'd treat.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

TomC1962
Regular Member


Date Joined Aug 2015
Total Posts : 41
   Posted 12/6/2017 10:26 PM (GMT -7)   
Hi Allen,
I think that’s why he wants me back in 4 months. He said if it rises again then he recommends treatment. If it stays the same or goes lower, we will continue to watch. But being st .027, another rise would put me right at or above the 0.03 you mentioned. I guess I’ll just expect the worse and hope for the best.
Tom
Diagnosed 6/2015 at age 53. PSA 4.0 Positive biopsy in 9 of 12 samples, ranged from 5% to 15% per sample. Gleason score 6.
RP 11/2015, confirmed Gleason 6. 1 open margin of less than 1 mm.
PSA After <0.03 first 5 quarterly visits. Then switched to a more sensitive test and psa was found to be 0.020, 0.021, 0.027 most recent.

garyi
Regular Member


Date Joined Jun 2017
Total Posts : 315
   Posted 12/6/2017 10:30 PM (GMT -7)   
Tom... at this point you have nothing to worry about. Your numbers look great. Really no need for you to be getting quarterly tests, especially if you're paying out of your own pocket. Twice a year is enough. With a bit of luck you'll never need RT.
70 years old @ Dx, LUTS for 7 years
PSA's never over 3.0
Ulcerative Colitis since 1973
TURP 2/16, G3+4 discovered,
3T MRI fusion guided biopsy 6/16
14 cores; G 3+3, one G3+4, Grade T1b
Second 3T MRI 1/17
RALP 7/17 Dr. Gonzaglo The Univ of Miami
G3+4 Organ confined
pT2c pNO pMn/a
Mostly Dry
10 week PSA .32
12 week PSA .40
14 week PSA .42
17 week PSA .54
Persistent PSA - 1" tumor still in cavity

Saipan Paradise
Regular Member


Date Joined Sep 2017
Total Posts : 116
   Posted 12/6/2017 10:53 PM (GMT -7)   
Looks like this is a lesson in the drawbacks of over-ultrasensitive PSA testing when it's not absolutely necessary. Tom, if your doctor hadn't switched tests, you'd still be <.03 and anxiety-free. And you wouldn't be any the worse off for it, because your doctor wouldn't recommend further treatment until you had lost the less-than sign anyway. For all you know, you may have been cycling between .020 and .029 for the last two years, and what of it? So all that the extra information is giving you is tsoris.

Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 8951
   Posted 12/7/2017 12:34 AM (GMT -7)   
Tom-

0.03 is not when you require treatment, it's when you might want to start watching for patterns. There really are no red flags yet - not even if your next PSA is over 0.03.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

Howard3569
Regular Member


Date Joined Nov 2014
Total Posts : 277
   Posted 12/7/2017 4:02 AM (GMT -7)   
Yes, my PSA after surgery was undetected, then it slowly started to rise from .05 to now .13, but I lined up an oncologist at the .05 mark. I did not rush. It took about three years for PSA to rise to .13. I pulled the trigger at .13 and am being treated at a higher dosage over a shorter period. I am at the end of the second week. No real SE yet.
Surgery Nov, 14 2014 Negative margins, negative lymph nodes, negative vessels
Gleason 3+7 PSA .08 Dec 14, 2004; <0.05 on March and July 2015; 0.05 on Oct 2015 and 0.07 on January 2016, .06 on July 2016 and .10 on Oct 2016

TomC1962
Regular Member


Date Joined Aug 2015
Total Posts : 41
   Posted 12/7/2017 6:46 AM (GMT -7)   
Thank you again guys. All this info helps a lot!
Good luck Howard. Let me know how it goes. I didnt know there was a shorter/higher dosage treatment
Diagnosed 6/2015 at age 53. PSA 4.0 Positive biopsy in 9 of 12 samples, ranged from 5% to 15% per sample. Gleason score 6.
RP 11/2015, confirmed Gleason 6. 1 open margin of less than 1 mm.
PSA After <0.03 first 5 quarterly visits. Then switched to a more sensitive test and psa was found to be 0.020, 0.021, 0.027 most recent.

John_TX
Veteran Member


Date Joined Jan 2015
Total Posts : 900
   Posted 12/7/2017 8:20 AM (GMT -7)   
Like the guys said if you ever need to go to step two, SRT, it's really not a big deal. I was scheduled for 35 sessions and my RO dropped it back to 33. The major inconvenience (for me anyway) with SRT is logistics - going five days a week maybe at different times of the day and getting hydrated enough for a proper bladder volume.

Several of the guys I met in the locker room while undressing/dressing still worked and incorporated the treatments into their work day.
DX - 1-13-2015 (age 66) -- PSA 4.02 (9-16-2014) to 4.38 (12-5-2014)
RALP on March 2, 2015
G6 to G7(3+4) to G7(4+3)
Stage pT3aN1
10/2017 PSA < 0.1
7/31/2015 HT - six month's injection of Lupron
ART 11/2015, 33 sessions

RobLee
Regular Member


Date Joined Apr 2017
Total Posts : 395
   Posted 12/7/2017 8:39 AM (GMT -7)   
John_TX said...
SRT, it's really not a big deal. I was scheduled for 35 sessions ...


Well, for me it really was a "big deal"... 39 Tx or 70 Gr, begun approx one year post-RP due to T3B/SVI, which apparently is also a "big deal".

Diarrhea started the second week of RT and continued off and on for weeks following the conclusion. Today proctitis and hemorrhoids - which I'd never had before in my life, still persist. A real PITA. Hoping this lets up at some point, eventually.
2014-15: PSA's 9, 12, 20, 25... Neg DRE, Neg TRUS biopsy
6/16: MRI Fusion biopsy, Right Base, 2x40%+2x100% all G8 (4+4)
8/16: DaVinci RP, 6mm EPE, PNI, 25% G4, BL SVI, stage T3B N0M0

1/17: started 18 months Lupron ADT, PSA's ~.03
5/17: AMS800 AUS implanted, revised 5/30
39 tx RapidArc IMRT (70 Gy) Aug-Oct 2017

hogo2000
New Member


Date Joined Jun 2017
Total Posts : 13
   Posted 12/7/2017 9:16 AM (GMT -7)   
Hi Tom

Sorry for the anxiety. A question...as my situation is a quite similar with exception of the positive margin.

Why and how did this happen? "After my RP he did some genetic testing on the prostate, it was confirmed Gleason 6, and whatever the genetic test was about did put me at the very low risk end if the spectrum as far as recurring"

Did they go back in and get a biopsy of prostate bed? What and why was the genetic test done? Was your post RP pathology looked at by a second pathologist?

Thanks!
Age at DX and Surgery 48 (2015)
pre-surgery PSA 2.4
RALP 11/15
3+3, neg SI, Neg, nodes, PNI +, clear margins

5 week PSA <.02
06/16 <.02
12/16 <.02
06/17 .02
09/17 .02

Wilderness
Regular Member


Date Joined Feb 2015
Total Posts : 273
   Posted 12/7/2017 9:57 AM (GMT -7)   
Hi Tom -

If it might suit you, you could take a shot a slowing any progression with a favorable diet. Some of us are having some apparent success - with an unfavorable pathology, I've been as high as .06, currently undetectable. I wish I'd been alerted to this option earlier. Let us know if it interests you.

Best to you -
Wilderness.
8/14 DRE "notch"
9/14 DX 12 core. One 5% 3+4; one <5% 3+3
12/14 ORP Dr. McGovern MGH pT3a 47g 15% Gl 3+4 in rpq focally & l. extensively; "established, extensive" EPE+ PNI+ SM- SV-
2/16 diet upgrade
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; 1/17 .06; 3/17 .03; 6/17 .03; 8/17 <.014; 11/17 <.014

garyi
Regular Member


Date Joined Jun 2017
Total Posts : 315
   Posted 12/7/2017 3:40 PM (GMT -7)   
RobLee said...

Well, for me it really was a "big deal"... 39 Tx or 70 Gr, begun approx one year post-RP due to T3B/SVI, which apparently is also a "big deal".

Diarrhea started the second week of RT and continued off and on for weeks following the conclusion. Today proctitis and hemorrhoids - which I'd never had before in my life, still persist. A real PITA. Hoping this lets up at some point, eventually.


Any idea if your symptoms were caused by the SRT or the ADT, Rob??

Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 8951
   Posted 12/7/2017 5:20 PM (GMT -7)   
Those are typical radiation proctitis symptoms - has nothing to do with ADT. Salvage radiation often has worse SEs than primary radiation because there's no prostate in the middle to block the radiation and separate organs, the anastomosis is totally exposed, and the margins include more of the organs at risk. That's why i always caution those who say "well, I could always just have radiation later" -- it's not the same as radiation for primary treatment.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

TomC1962
Regular Member


Date Joined Aug 2015
Total Posts : 41
   Posted 12/7/2017 5:24 PM (GMT -7)   
Hi guys,
Can I ask your opinions on something else now that I was told? I talked to a regular doctor today, that I know from my work. He is not a urologists nor does he deal with prostate cancer, but is knowledgeable about most things in the medical industry.
He told me I should get a PET scan right away to make sure that whatever is still in me is still in the prostate bed, and is not something that traveled to my spine or other bones.
I would think my urologist/surgeon would have thought of that.
So my question is, do you think its possible what he is saying, being that my Gleason was confirmed a 6, and my current psa is 0.027?
Thank again,
Tom
Diagnosed 6/2015 at age 53. PSA 4.0 Positive biopsy in 9 of 12 samples, ranged from 5% to 15% per sample. Gleason score 6.
RP 11/2015, confirmed Gleason 6. 1 open margin of less than 1 mm.
PSA After <0.03 first 5 quarterly visits. Then switched to a more sensitive test and psa was found to be 0.020, 0.021, 0.027 most recent.

Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 8951
   Posted 12/7/2017 5:27 PM (GMT -7)   
Nope - useless at that PSA.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

TomC1962
Regular Member


Date Joined Aug 2015
Total Posts : 41
   Posted 12/7/2017 5:30 PM (GMT -7)   
Thats the answer I wanted to hear!
Thank you.
I wish doctors could put me at ease as much as you guys do!
Tom
Diagnosed 6/2015 at age 53. PSA 4.0 Positive biopsy in 9 of 12 samples, ranged from 5% to 15% per sample. Gleason score 6.
RP 11/2015, confirmed Gleason 6. 1 open margin of less than 1 mm.
PSA After <0.03 first 5 quarterly visits. Then switched to a more sensitive test and psa was found to be 0.020, 0.021, 0.027 most recent.

Saipan Paradise
Regular Member


Date Joined Sep 2017
Total Posts : 116
   Posted 12/7/2017 9:00 PM (GMT -7)   
Tall Allen said...
Those are typical radiation proctitis symptoms - has nothing to do with ADT. Salvage radiation often has worse SEs than primary radiation because there's no prostate in the middle to block the radiation and separate organs, the anastomosis is totally exposed, and the margins include more of the organs at risk. That's why i always caution those who say "well, I could always just have radiation later" -- it's not the same as radiation for primary treatment.

Allen--
Is there any ongoing research to develop protection for the rectum during SRT, similar to SpaceOAR when the prostate is intact? Or would that defeat the purpose of SRT because all the remaining structures -- rectum, anastomosis -- need to be radiated?

Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 8951
   Posted 12/7/2017 10:41 PM (GMT -7)   
What really shields the rectum more than anything, and this is true of both primary and salvage radiation, is setting a zero margin at the rectum and tight dose constraints, including point dose constraints for the rectum. IGRT (image guidance) is important too. With primary radiation, fiducials (or transponders) can very accurately help aim the radiation (this is done continually throughout each session with SBRT for super-accurate beam localization).But with salvage radiation, IGRT is problematic. While some ROs seem able to use fiducials somehow (i.e., at UCSF), others say they don't hold in the loose fossa tissue and move around too much to be useful. They use soft tissue landmarks instea, at the start of every treatment with cone beam CT or stereoscopic Xrays. Some use bones as landmarks, which is a particularly bad idea (although easier to do). It's a bad idea because soft tissue is highly deformable and continually changes its shape and position with respect to bones. Those who site on bones will miss the proper targets and increase toxicity. The problem is compounded when there are two targets, as there are when both the pelvic lymph nodes and prostate bed are treated. The two targets change their shape and position with respect to each other, increasing the risk of misses. UCSF has an algorithm for dealing with this, others use judgment.

The single best aid is a full bladder. It anchors the tissue in the prostate bed and lifts most of the bladder away from the radiation target. A similar thing can be done in the rectum with an inflatable rectal balloon. It lifts most of the rectum away from the radiation field, although the anterior part is actually moved closer to it. (It's the approach they use with primary proton therapy). It also obviates the problem of gas passing through which changes the shape of everything.

I should rush to say that despite the anecdotal complaints you hear on HW (which I am not at all discounting), rectal side effects are typically mild and transient. They are rarely severe or long-lasting with today's very accurate linacs. For example, in the following study at UOP, there was no late-term rectal toxicity (≥grade 2) among men getting 70 Gy of salvage prostate bed radiation.

www.redjournal.org/article/S0360-3016(11)00562-1/fulltext

(BTW - late term rectal toxicity is similarly rare after primary radiation, which is why I consider SpaceOAR to be an expensive solution in search of a problem).
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

Saipan Paradise
Regular Member


Date Joined Sep 2017
Total Posts : 116
   Posted 12/7/2017 10:55 PM (GMT -7)   
Tall Allen said...
While some ROs seem able to use fiducials somehow (i.e., at UCSF), others say they don't hold in the loose fossa tissue and move around too much to be useful. They use soft tissue landmarks instead.

That's like word for word what Dr. Ko on Guam told me -- fiducials won't hold, he doesn't use them for SRT.

Break60
Veteran Member


Date Joined Jun 2013
Total Posts : 1782
   Posted 12/8/2017 8:25 AM (GMT -7)   
I’ll just add that from my experience it’s vital to have a RO and team who are expert at developing the radiation plan and executing it. I had bad rectal bleeding with 68.2 grays of SRT back in 2014 using a community hospital which treated PCa infrequently. I required endoscopic radio frequency ablation to heal the bleeding but I still have occasional bleeding.
Bob
DOB January 1944
8/’12 PSA 2.7; 5/’13, PSA 6.6 (actually double due to finasteride)
7/’13 Bx GS 4+5=9 , 2 of 6 cores, 10%, 40%; stage Pt1c
9/’13 ORRP, pathology GS 4+5=9, EPE and margin+ at base (4mm, GS7), BLSVIs+, 10 lymph nodes resected (clear); stage upgraded to Pt3bN0M0
11/’13 - 5/’14, PSA 0.1 to 0.3
6/’14 SRT by IMRT/IGRT (68.2 grays/38 Fx) to prostate bed, ADT (6 months Lupron)
9/’14 - 8/’15: PSA: <.1, to 1.2
9/’15 MRI, CT-PET finds two iliac lymph nodes suspicious for PCa; started 13 months of ADT3 (Lupron, bicalutamide, dutasteride) plus plus metformin, cabergoline, estradiol patches, prolia , vitamin D3, calcium. IMRT/DART (75 grays/50 Fx) to pelvic lymph nodes. Stopped ADT3 11/’16.
11/’15 - 5/’17: PSA .03 to 2.3.
2/’17: Rx finasteride added
5/’17: F-18 Fluciclovine (axumin) PET/CT scan finds 9 mm femur met. Restart ADT3; start monthly Xgeva, stopped finasteride.
6/’17 SBRT via IMRT (27 grays/3 Fx) to femur met.
6/’17 - 10/’17 PSA .3 to <.1
New Topic Post Reply Printable Version
Forum Information
Currently it is Sunday, December 17, 2017 8:44 PM (GMT -7)
There are a total of 2,906,612 posts in 318,977 threads.
View Active Threads


Who's Online
This forum has 158318 registered members. Please welcome our newest member, Boston48.
508 Guest(s), 11 Registered Member(s) are currently online.  Details
Crispix, Erichardson234, PeteZa, oldbeek, Oldbuddy, LymeSick 🌟, countess18, doors12, The Dude Abides, Chantrelle99, (Seashell)