Friend Asked me bout his upcoming "Adjunct" (Sp) Radiation Treatment--

Diseases & Conditions Prostate Cancer
1
Had lunch w a college friend today..& he shared his experience- w His DaVinci surgery-

I told him of mine & all went well ( erectile function-continence & my "Non Detectable" PSA-90 day post surgery--My only issue..as many of you know- was bad constipation (Which has been helped by increase of stool softener ...& prune juice )

He said (This I did not know- hence- I am asking the more erudite posters here) his procedure went well. Till he had his 3 month post DaVinci PSA & it was..(To ME...at least) very high...!
It was 0.41- I am thinking "WOW"...! Anyone ever hear of this high a PSA post surgery before ??
(His PSA before surgery was he said "High teens" )-

**--He was Negative on any spread to bone/lymph & seminal vesicles- Surgeon said it was "Contained to the prostate"...! Can THIS be so?

His Urologist- called & told him his surgeon may wanna do an "Adjunct" treatment..of Radiation ! (I - initially thought this was the "Salvage".)..but he explained- that is the Radiation they do--AFTER time passes & PSA goes up--

Anyway- he will see his surgeon next week & then decide...
I really could not comment on this-- as I never knew anyone in this position-
He seems really "concerned" & worried- (He does not like posting)- I told him..I would post..& "Enlighten" him on anything I learned (I really wanted to calm him down- but-as I knew so little about this- I did not have much to say..! )

So- has anyone here..ever had post DaVinci (Or any surgical ) "Adjunct" Radiation...? (Is that less "Powerful" in radiation-than that given when radiation is the "First line" ? (Sorry my knowlege..of P- ca....is next to nill !-- Now..if you wanna know about cardiac arrhythmias...I am..."Spot on"-
And- was it (The Adjunct radiation) successful....in "Mopping up" any of the stuff causing the PSA...?
Lastly...anyone ever heard of a post surgery- PSA...That high..? (0.41 )??-

Any & all information would be appreciated-(Esp..From Tall Allen )

Regards-
R* smile

Post Edited (Wotan) : 4/26/2018 6:20:41 PM (GMT-6)

2
Adjunctive radiation is radiation administered soon after surgery, generally 6 to 12 months afterwards, when cancerous cells have been discovered to have escaped the prostate. It is nearly as strong as the radiation used as primary treatment.
2014-15: PSA's 9, 12, 20, 25, Neg DRE's, false neg TRUS biopsy
6/16: MRI Fusion biopsy, Right Base, 2x40%+2x100% all G8 (4+4)
8/16: DaVinci RP, PNI, 6mm EPE, 11 LN-, 53g, 25% involved Grp 4, BL SVI, T3b n0m0
1/17: started 18 months Lupron ADT, PSA's ~.03
5/17: AMS800 AUS implanted, revised 6/17
8/17-10/17: RapidArc IMRT 39 tx (70 Gy)
1/18, 4/18: PSA's 0.00, Dx Radiation Colitis...
Now what!
3
Adjuvant (or Adjunct or Adjunctive) radiation therapy (ART) is sometimes offered to men shortly after surgery (generally within the first six months) when the combination of high risk (generally a high Gleason score) plus adverse findings on the post-op pathology (positive margins, etc.) makes waiting to see whether the PSA rises undesirable. ART doesn't usually make sense for low or intermediate risk disease, even if positive margins make it possible something was missed, because the remaining cancerous tissue is unlikely to spread widely through the body -- so it can be hit with radiation later after a rising PSA shows that it is still growing. High risk disease is much more likely to metastasize, often before much PSA rise is apparent, and is treated more aggressively.

I was given adjuvant radiation along with two years of androgen deprivation therapy when my post-op pathology report upgraded my Gleason score from 7(3+4) to 9(4+5) and indicated small areas where the cancer reached the surgical margin.

As RobLee said, the radiation dose for adjuvant RT is generally similar to that used for primary radiotherapy treatment.
65 Slow PSA rise 2007-2012: 1.4=>8
4 bxs 2010-2012: 1&2 neg, 3 pos 1/14 6(3+3) 3-4% (2nd opn. 7(3+4)), 4 neg
DaVinci 6/14/12. "some" nerve sparing on left
Path: pT3a pN0 R1 GS9(4+5) Pos margins on rt
24 mo ADT3 7/12 - 7/14
Adj IMRT 66.6 Gy 10/17/12-12/13/12
8/2012-3/2015: Incont., Trimix, VED, PSA<0.015.
AUS & IPP installed 3/5/2015
Forum Moderator - Not a medical professional
4
Wotan

With out a prostate, your friend's psa at .41 seems really high. More information would be nice. However, I think most any standard would say psa this high after surgery would indicate recurrence and a second line treatment be appropriate. Radiation normally is started at or below .2. The best results are gained below .1.
I would not delay in getting the best RO to check me out and then get going with treatment.
Diagnosis in August 2007
Age 57
PSA 4.1 Gleason 3+4=7
Robotic Surgery - 10/2007
GS 3+4=7, Stage T3a N0 MX, Margins-, EPE +, PIN+, Nodes-
Post- Surgery PSA .005, Jan. 2015 .06
SRT ended 5/15/15. 35 treatments 70 Gy's 8/1/'15 PSA <.006 11/1/2015 <.006 5/2016 <.006. 12/2016 <.006, 5/2017 <.006, 2/2018 <.006
5
He has persistent PSA, which is not all that unusual. They usually reserve the term "adjuvant radiation" for treatment given before a 3-month PSA is available. But it really doesn't matter if you call it adjuvant, early salvage, or salvage -- it's the same treatment.

He should be seeing a radiation oncologist, not a surgeon.

His first step is to get an Axumin or PSMA-based PET scan to check for any distant metastases. If there are distant metastases, it would not help him to have prostate radiation.

Can you convince him to join HW?
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
•SBRT 9 yr onc. results •SBRT 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
6
Wotan,

My Husband's PSA post surgery was 10. (Decimal point to the right). It happens often. There are several men on this board that have had this issue.

Donna
7
Wotan, this is just speaking from personal experience not only should he be looking at salvage radiation but also some kind of Hormonal treatment which he should start right away with if his number is truly that high. He should have another psa check to verify that it is really that high. And if his number is truly that high like TA said get hooked up with a good RO preferably get a good team in place be his own advocate and proceed. Have him look at the ADT and SRT thread and read the experiences that lots of guys with the same outcome as your friend has and he will see that it isn't the end of the world you dig down get a great team in place and a plan and then proceed yes it's gonna be a few months of devoting his energy into fighting this beast but with SRT and ADT treatment he should be fine!

Larry
Male 62 DX @ 60
Dad had PC
2002. Psa. .08 Enlarged Prostrate
2014. Psa. 3.8
2016. Psa. 19
3-08-17 RP Mayo, Mn
Gleason 9, pt3b, SV + 1 nerve, N-Margins 35 LN removed clear
Prostrate 45 grams
4-20-17 Incarcerated Umbilical Hernia
6-13-17 psa 0.13
7-19-17 psa 0.12 3TMRI with coil - clear
10-11-17 psa 0.16
10-12-17 Lupron
12-13-17 psa <0.10
12-18-17 SRT
2-7-18 SRT done 72gy
8
RandyJoe said...
Wotan,

My Husband's PSA post surgery was 10. (Decimal point to the right). It happens often. There are several men on this board that have had this issue.

Donna
-

Hi Donna--
Thanks & I will tell him-!
My question is (I do NOT wanna scare him ) WHAT was the "cause" of this high post op PSA..?\
And.....how was it treated? Hopefully successful...get back..
R*
9
Tall Allen said...
He has persistent PSA, which is not all that unusual. They usually reserve the term "adjuvant radiation" for treatment given before a 3-month PSA is available. But it really doesn't matter if you call it adjuvant, early salvage, or salvage -- it's the same treatment.

He should be seeing a radiation oncologist, not a surgeon.

His first step is to get an Axumin or PSMA-based PET scan to check for any distant metastases. If there are distant metastases, it would not help him to have prostate radiation.

Can you convince him to join HW?


Hi "TA"--
Spoke w my buddy on phone last night- not interested (at this time) in joining HW....says he does not wanna read anything that "might Worry" him more !

I told him- guys are very supportive- well..I'm not gonna coerce him.-

He did ask...(I did NOT know the answer..I know you & others here will )
He asked.."Regarding Adjunct..or Salvage radiation..-
"...Why can't they use....the 'Cyber Knife' for a shorter treatment time?"

Good question...I told him..I'd write & find out..
Thanks to everyone here...
R*
10
There are a few clinical trials for it. Drs King and Kishan are running one. The advantage, of course, is that it's 5 treatments and you're done. The big unknown is toxicity. Because SBRT is so concentrated, even one small "miss" can create side effects. And with salvage radiation they have to target the entire prostate bed, and often pelvic LNs as well. Unlike primary radiation SBRT where they can target the prostate by imbedding fiducials within it and readjust the beams automatically throughout each treatment, the loose tissue of the prostate bed can't hold onto them. Intra-fractional tracking is nearly impossible. Some try to put them in the pelvic muscle wall, but the prostate bed tissue moved independently of it. So, hopefully with a really fast linac and care taken to insure a filled bladder, and no treatment with bowel extension, they can minimize the toxicity risk. This will be be resolved in a clinical trial.

/pcnrv.blogspot.com/2018/01/salvage-sbrt-after-prostatectomy.html
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
•SBRT 9 yr onc. results •SBRT 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
11
Your friend has 'persistent PSA, just like me, and a rather high post surgery PSA. He should be at least concerned, if not worried. rolleyes

He should be concerned, researching and discussing with an experienced radiation oncologist, not his surgeon. Surgery, unfortunately, failed! Cyber Knife for salvage radiation is not an approved protocol. There are several clinical trials, with a serious concern being added toxicities.

He should get serious, join HW, do some research, get a good RO, and he needs the scan that TA mentioned, and the sooner the better.

The best thing you can do for him, IMHO, is kick him in the butt. smilewinkgrin
12
I will second. Gary’s comments. With a post surgery PSA of .41, he has some serious issues that need to be addressed. And IMO, no matter how good a friend, and how knowledgeable, you are, he is a fool to put this in someone else’s hands. You should tell him that.
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, March 2018 .06.
Decipher test, low risk, .37 score
My story.... http://tinyurl.com/qgyu3xq
13
Hey folks, let's back of a little on the pronouncements for this guy....I went back and read the initial post...here's what I read:

A post surgery patient, 3 months out, (!) getting ready for his first post surgery check, had his PSA done and it came back at 0.41. He has an appointment with his surgeon (previously scheduled) next week to look at next steps. Surgeon over the phone says, " we may want to send you for adjunct radiation". Sounds like reasonable standard of care to me.

Sounds like--1st post surgery psa and follow up appointment. Surgeon (or maybe his PA) passes on the PSA result and says, we'll see you next week, and may be sending you for a radiation consult. The sky is not falling.

Post surgery, don't we ALL start with the surgeon for follow up? And don't the good surgeons send those with persistent PSA on to a RO?
Age at Diagnosis: 56
RALP on 2/17/15, BJC St. Louis, Dr. Figenshau
58.5g, G3+4, 20%, 4 quadrants involved
PSA 3/10/15: 0.10
5/15: <.04
8/15: <.04
11/15: <.04
2/16: <0.04
8/16: <0.04
2/17: <0.006
8/17: <0.006
3/18: <0.006
My Story: www.healingwell.com/community/default.aspx?f=35&m=3300024
14
Thanks, Halbert-

Yes--Those last 2 previous posts (Gary & Pratoman )- were really scary & irresponsible...!

My poor friend read this....& was "Scared out of his head"-
smhair

Look....All I said was....exactly as Halbert stated---
My friend (A very sensitive guy) WILL be seeing his urology surgeon....& getting his next steps,..!
His surgeon..(Same as mine )- At Penn/Pres....a well known..nationally acclaimed prostate surgeon...
WILL surely lead him...correctly...! -

NO Pratoman--he is no "Fool" & he certainly is NOT "Putting this in someone else's hands"-!
WHERE did you get this idea...?
It (The post surgery 0.41 PSA ) could be something--in which case....the R/O...will come into play...OR..it could be nothing !!! (I wish..Donna would post again..Her post was soothing & calming..& isn't this what this Forum..is supposed to be..?

And..Gary ..you did one helluva "Good" job.in worrying my friend-- He called me...after reading these 2 irresponsible posts (By Gary & Pratoman: & his decision..is to stay with his urology..RO team...at Penn-Pres.....& NOT join this Forum..where a few guys..not all....have a "The Sky is falling" mentality !!-

I started on HW..back,,in 2005...or so--in the "Cardiac" forum..where Cardiac ablations were discussed--various meds & modalities....It was--really very helpful !

THIS place has not been--! It seems my friend was correct I not joining-- & a short while ago---after he emailed his Urologist (& sent the "Cut & pasted" SCARY comments....his urologist told him...
"Jeff--Do NOT worry....you will be fine ! We will get to the bottom of this..& Wed...You will see your surgeon (and colleague of his )...& he will give you the next steps...! And.As I told you--please...STAY OFF OF THE BOARDS !"
(Heck...what did you EXPECT the Dr....to say...after reading--those scary posts--from Gary & Pratoman....)-

Anyway...I will be leaving THIS forum (Pros-C) & sticking with the cardiology...(Where I really like..helping people--in their time..of fear & anxiety...! And,,,also--the IBS....(Like I said...joined...2005..or so )

I really do hope the Moderator reads this..& SEES what I am saying..!

Stoking up fears.....& anxieties in people....in NOT a "Support Group" mentality...

Thanks again..to Halbert....(A fine...calm...logical guy ) & to Donna....(Wish she would get back..)

So long--Auf Wiedersehen....Ciao....to THIS Forum....!

Wotan...
15
Wotan, apologies to your friend, I did not mean to scare him. You DID say he would not join HW, and that is fine, it’s a personal decision. But it gave me the impression that he wasn’t reading on here either.
Your posts also made it seem like he was asking you to find information for him. Which in my opinion, is a fools errand. So it’s good that he is on here at least reading on his own.

I do think you are overreacting a bit, nobody was trying to be insensitive, only reacting to the impression that, at least I, got from your posts.

Good luck to your friend. And you.
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, March 2018 .06.
Decipher test, low risk, .37 score
My story.... http://tinyurl.com/qgyu3xq
16
That's OK....Pratoman-

Just happened to see your response--

Well- my buddy kinda surprised me,,when he read the post-

He's very private-even his other friends do not know anything-
But- since we have the same urologist (And Surgeon ) he kinda confides...

The "Phys Asst" a really nice gal-- said when he meets w surgeon Wed....the Surgeon does have a colleague who is an excellent....RO--! But, as she told him- Wait till you talk w the Urologist--Then..the RO,,,,(As a team) & see what they recommend !

Like me..HE is a REALLY bad..."Worry Wart" .....& always sees the worst...!! Bad trait..
He did tell me......Phys asst,,,told him to get another Ultra/PSA.....just to be sure...it was accurate--(Heck,,it can't hurt...what if it were a lab error..??? )-

But--as I wrote--& Halbert stated..he DOES need....to keep his Appt with the surgeon....& then...he did mention an RO....Dr.....that they feel very good about...

I will try to keep you informed...
A quick PS....I REALLY wish that "Donna" wife of "Randy Joe"---would respond...again..Her hubby...had a post surgical....Ultra--PSA...of TEN ! (As she wrote..." a 10. DECIMAL POINT ON THE RIGHT !!!!-) Donna said ..there were "Quite a few guys.on here....that DID have a Post surgical..PSA.....higher--than the .41- BUT..............a TEN !!! Wow...Ever hear of that before..?
Wow..I wonder how HE made out...!!

Yes....I worry about myself--also---I am "Hyper"...(Which seems to be a common trait,,,esp...in Italian/Americans...in Philly !!

Take care....
Call me....MATTY....(In college..I was "Matty Baseball" Big on Stats)--NOW called SABR Metrics
17
Matty,

You asked for a moderator to read the thread. Ok, I read back through it. There were a few comments that were a bit clumsily worded, possibly because someone missed a sentence or two in your posting, but none were really out of line. As far as I can see everyone was trying to be helpful.

I've been where your friend is now, more or less, I was decidedly unhappy when my post-op pathology report showed that my surgery hadn't been enough. I was scared. I was angry. I had control issues. I almost got into a fist fight with a neighbor about a neighborhood parking dispute.

I'm sorry your friend was scared by what he read here. But he's in a scary place right now and there isn't much we can tell him to make his worries go away -- not much that's true anyway. What we can offer by way of support is the experiences of guys who have gone through what he is going through and have come out OK in the end. Once he calms down a bit he may find that a comfort.

You said your friend is a private person and that none of his other friends know about his disease. That's actually a reason why he should consider joining us. Most of us here are "private" guys. That's one of the hard things about prostate cancer -- nobody likes to talk about it. It's frightening in ways that men don't like to talk about... not to their friends... not to their wives... not to anybody. They can talk to their doctors but those conversations are stilted, confusing, and brief. The anonymity that this online forum gives us can help a man open up.

My name's not Peter. PeterDisAbelard is a name I made up when I joined. That was right after I found out that I needed radiation on top of my surgery and, what scared me more, I was scheduled for two years of androgen deprivation therapy (aka chemical castration). There was exactly no one on earth I could talk to about how much that all scared me. No. One. So I joined this forum and complained endlessly and anonymously. It helped keep me sane... well, sorta sane... on odd numbered days anyway... usually. The other guys were very patient with me and the moderator gig is my way of trying to pay the debt forward.

Oh, and it's funny that you told Pratoman that you and your friend are worry warts because Pratoman is one of our most accomplished worriers.
65 Slow PSA rise 2007-2012: 1.4=>8
4 bxs 2010-2012: 1&2 neg, 3 pos 1/14 6(3+3) 3-4% (2nd opn. 7(3+4)), 4 neg
DaVinci 6/14/12. "some" nerve sparing on left
Path: pT3a pN0 R1 GS9(4+5) Pos margins on rt
24 mo ADT3 7/12 - 7/14
Adj IMRT 66.6 Gy 10/17/12-12/13/12
8/2012-3/2015: Incont., Trimix, VED, PSA<0.015.
AUS & IPP installed 3/5/2015
Forum Moderator - Not a medical professional
18
Matty....I was, and am still, concerned about your friend. He has a serious condition that I’m quite familiar with, and I gave you the experienced based advise you requested. I didn’t realize you only wanted feel good information. Your reaction was uncalled for.

Your suggesting my post was “sky is falling” and irresponsible was unfortunate and wrong. I believe you’re overreacting, a common trait of self admitted “worry warts”. ;-) Yes, Pratoman is the president of that club.

In any event, good luck to both of you. Coming out of the shadows, and communicating directly rather than through an intermediary will help you friend and reduce knee jerk miscommunication IMO.

Post Edited (garyi) : 4/29/2018 11:53:17 PM (GMT-6)