Salvage Therapy or Watchful Waiting?

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Philip B
New Member


Date Joined Mar 2018
Total Posts : 5
   Posted 3/7/2018 10:53 AM (GMT -6)   
This is my first post, I have watched the forum from afar. I have taken great encouragement and learnt a lot without contributing but now is my time to ask. My dilemma ….

Six years after radical prostatectomy (I was 48) my PSA has very slowly reached 0.094. In many respects the surgery was good with full erectile and urinary function. I have recently seen a RT oncologist who suggests 38 sessions of IGRT with Rapidarc equipment. The thinking is that there is a small amount of cancerous tissue in the prostate bed or lymph nodes and that the radiation will give me the cure I am after. With the very low level of PSA I currently have he does not think a scan PET/CT will show anything and thinks that the RT will allow me to see if the pC is local to my pelvis or has spread.

On the other hand i wrote to the surgeon who did the prostatectomy and he describes my PSA as relatively stable at 0.094. And adds that in patients who have erectile recovery it is not unusual to have these very, very low levels. He suggests I wait until my PSA rises to at least 0.3 before I have a PET/CT scan and go from there.

What do you all think …. Let the PSA rise more or get in quickly when outcomes are better?
Is there a question I should be asking my RT oncologist?
Many thanks.


My history is below.

DOB 8/1963
Feb 2012 PSA 6.2 --- Prostatectomy
Biopsy Gleason 3+3 stage pT2cNx one +ve margin - tumour 3% of prostate
PSA: 8/12 0.01, 8/13 0.02, 8/14 0.03, 12/14 0.06, 12/15 0.05, 5/16 0.06, 5/17 0.06 10/17 0.08, 2/18 0.09

Post Edited (Philip B) : 3/7/2018 9:58:16 AM (GMT-7)


Gear
Regular Member


Date Joined Oct 2016
Total Posts : 241
   Posted 3/7/2018 11:03 AM (GMT -6)   
My surgeon also said for me to wait, I forced the issue at 0.20. I wanted to do it earlier but could not catch the Doctor running down the hall. Studies show starting below .2 you can get as much as 4x better results.
DX 9/2011 @ age 50, PSA: 2.1, 10/6/2011 RP Da-Vinci
4-3 Gleason, PT2C, -SV, -Mar,+PI, NX... <.02 first 4+ years
Start SRT@ PSA 0.25, 38 Sessions-68.4 Gy, Finished 02/1/17
PSA: 5/17-.12, 8/17-.031, 1/18~.01,

InTheShop
Veteran Member


Date Joined Jan 2012
Total Posts : 8618
   Posted 3/7/2018 11:29 AM (GMT -6)   
Welcome to HW.

A scan at this PSA isn't going to show anything.

That still not much PSA and you've got a low risk factor.

I am not sure I'd be rushing for more treatment, but there are worse things than SRT.

Hang in there and keep us updated on your progress,
Andrew
I'll be in the shop.
Age 58, 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

Michael_T
Veteran Member


Date Joined Sep 2012
Total Posts : 2812
   Posted 3/7/2018 2:03 PM (GMT -6)   
What was your post surgery pathology? I think your sig says you had a positive margin...was the margin a G6?

If your post-surgical pathology was good, I'd considering moving slowly if at all. If it wasn't as good, then perhaps faster.
Age 57, 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
9/17: PSA = 0.1

hogo2000
Regular Member


Date Joined Jun 2017
Total Posts : 25
   Posted 3/7/2018 2:34 PM (GMT -6)   
Philip, same question about pathology.

We are on similar tracks although my psa has popped with no apparent reason. Doc has ordered path review and decipher and I will meet with him within month.

Interested in your journey. Perhaps order a decipher test to get a sense of the risk of waiting?

My instinct is to go with early SRT considering our ages.
Age at DX and Surgery 48 (2015)
pre-surgery PSA 2.4
RALP 11/15
pt2c tumor volume approx. 5%
3+3, neg SI, Neg nodes, no epe, PNI +, clear margins

5 week PSA <.02
06/16 <.02
12/16 <.02
06/17 .02
09/17 .02
03/18 .04

MGT
New Member


Date Joined Mar 2018
Total Posts : 12
   Posted 3/7/2018 8:52 PM (GMT -6)   
I would wait as you have a low level and at Gleason 6 your long term outcome is excellent even if you wait until .3. That said I had salvage and it was a breeze - some rectal sx and I worked and went to the gym the whole time. No significant effect on erections - Levitra still works two years later- maybe down 10%. My urologist said that if you go into salvage with ED under control you will do OK.
Bx 52yo: 3/2102 G6 (5/12 cores (+) PSA 3.6
RP: 4/2012 G7 (3+4) T2C... (-) for EPE, SV, Margins, (+) PNI - 10% tumor

PSA: 7/2012 (.02) 10/2012 (<.02) 4/2013 (<.1) 1/2014 .1
7/2014 <.1 3/2015 .19 6/2015 .26 7/2015 .26 8/2015 .26 10/2015 .26 12/2015 .32
1/2016 SXRT with IMRT
Next PSA 3/2018 <.1

No incontinence. No major ED issues with Levitra.

Tall Allen
Elite Member


Date Joined Jul 2012
Total Posts : 10125
   Posted 3/7/2018 9:24 PM (GMT -6)   
Same question what was your pathology Gleason score? And how big was your positive margin, and the Gleason score at the margin? Did you ever get a Decipher test? If not, consider it if your insurance will cover it.

The fairly steady upward trend is still slow, so something is growing but not metastasizing yet.
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

Philip B
New Member


Date Joined Mar 2018
Total Posts : 5
   Posted 3/7/2018 9:57 PM (GMT -6)   
Thanks everyone - this is what we do and it is great to have the engagement and support.

My prostate pathology was as follows. Gleason 3+3 bilaterally but mainly in the right about 3% by volume. Circumferential margin positive over 3mm. Perineural invasion Present. Vascular/lymphatic invasion Negative - seminal vesicles negative and extraprostatic extension negative. It will not be possible for me to get the Decipher test.

Treating prostate cancer seems to involve more choices at every stage than any other thing in life!

In short, it seems that my PSA is rising slowly and at some point in the next 12 months I will hit the 0.2 line - even with my pathology I think the sooner I can start SRT the better. Given my age and current good health and no ED I think I am also prepared - no major flaws in my thinking?. I appreciate there are long term SE with IGRT but hopefully minimal - that seems to be what I am hearing?
Side effect and fatigue how bad? Thanks

Philip

-------------------------------
DOB 8/1963
Feb 2012 PSA 6.2 --- Prostatectomy
Biopsy Gleason 3+3 stage pT2cNx one +ve margin - tumour 3% of prostate
PSA: 8/12 0.01, 8/13 0.02, 8/14 0.03, 12/14 0.06, 12/15 0.05, 5/16 0.06, 5/17 0.06 10/17 0.08, 2/18 0.09

Post Edited (Philip B) : 3/7/2018 9:13:13 PM (GMT-7)


InTheShop
Veteran Member


Date Joined Jan 2012
Total Posts : 8618
   Posted 3/7/2018 10:18 PM (GMT -6)   
Everyone responses differently. Some get hard with fatigue while others don't get it at all. Exercise during treatment seems to reduce fatigue. Bowel issues are possible. My hemorrhoid went from a little annoying to nearly unbearable. Urgency can be a problem.

Post treatment, I have some ED, urgency can be a problem at times, and I've had radiation proctitis which required treatment a few years after my IMRT. While all of this is manageable, it's best to avoid if possible.

What you do is your choice - just understand the risks you're taking.

Andrew
I'll be in the shop.
Age 58, 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

Tall Allen
Elite Member


Date Joined Jul 2012
Total Posts : 10125
   Posted 3/8/2018 12:02 AM (GMT -6)   
There is nothing magic about 0.2 - it's an imaginary and not very useful line in the sand.

With a GS6, the SRT decision is more difficult. It is likely that a bit of GS6 was left behind - but does that mean it needs treatment? Most men with GS6 can live out their lives without needing treatment.
Here are some things to consider:

/pcnrv.blogspot.com/2017/11/myth-gleason-6-never-progresses.html
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

fiddlecanoe
Regular Member


Date Joined Oct 2016
Total Posts : 323
   Posted 3/8/2018 4:10 AM (GMT -6)   
I have no idea whether you need treatment or not. However, consider that if you do opt for RT the docs in all likelihood will not use ADT in conjunction.
Age: 62
Diagnosed in July 2016 with G7 (4+3) PC & PNI
Bone & CT scans clear
Surgery at Lenox Hill Hospital in NYC, 9/12/2016
Post-surgery pathology showed G7 (3+4), with SVI and PSM
Lymph nodes clear
First post-surgery PSA October, 2016: <.008
Second post-surgery PSA December, 2016: 0.01
Third post-surgery PSA June 2017: 0.05
IMRT begun: July 18, 2017 (35 fractions)
Post-SRT PSA, 11/17: <.008

Bobbiesan
Regular Member


Date Joined Mar 2012
Total Posts : 236
   Posted 3/8/2018 6:53 AM (GMT -6)   
Philip B said...
On the other hand i wrote to the surgeon who did the prostatectomy and he describes my PSA as relatively stable at 0.094. And adds that in patients who have erectile recovery it is not unusual to have these very, very low levels.


Have not heard about ED recovery being linked to uPSA scores. If so, wonder what the underlying biological mechanism is for that. Did your doc mention anything else regarding this topic? It would help me to know.

Best wishes in your decision. You are right that there are so many choices -- medical opinions --, and not a lot of definitive research to guide us. Or at least not definitive enough for an individual case. Each guy's docs have different slants on things. Boy, u don't have to read many posts here for that to sink in.

Robert
68 now
Jan '08-'11 PSAs 2.2 2.5 2.7 2.6, DREs-
Jan '12: PSA 3.6, DRE+
Jan '12: MRI inconclusive
Feb '12: PCaDx pT2a, 4/12+ (3 @ 3+3, 1 @ 4+3); 3% tot cores; bone scan-
Apr '12: RALP; 3+4=7; pT2c pN0 pMx; 30%; 3mm r lat margin of 3+3=6 so pT2+; EPE-; PNI+; 8 LN-; SV-
TRT 03/'14-now; uPSAs: <.015 til 02/17; up/down wildly .017-.032 since

Philip B
New Member


Date Joined Mar 2018
Total Posts : 5
   Posted 3/8/2018 7:53 AM (GMT -6)   
Robert - thanks for your support. My surgeon has made this comment since my numbers moved off the 0.02 level and at the time back in 2013 he linked it to the nerve sparing surgery and my very good ED recovery. His comment was that in my circumstances this was quite common but no mechanism was mentioned.

https://www.birminghamprostateclinic.co.uk/our-team/mr-alan-doherty/

Tall Allen
Elite Member


Date Joined Jul 2012
Total Posts : 10125
   Posted 3/8/2018 11:41 AM (GMT -6)   
I think he just meant that with nerve sparing, there's more of a danger that small amounts of cancer were left behind.
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
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