radation right away or wait for PSA

Operaman · Regular Joined: 01 Jun 2009 Posts: 24

So, I am now 12 days after rrp surgery. I feel that it went really well, I am up and around, have the catheter out, and have some bladder control already. The entire post op was low pain and pretty manageable for me, home after 2 days and off all pain meds including tylenol by day 4. Having the cath removed was much more worry about how it would feel, than what it felt like, it was over in a second and just a bit uncomfortable. It is almost perfect but,

After a very positive report from my surgeon after surgery, stating that it all looked pretty clean and he felt he got everything, had a bombshell with path report. Positive on one margin and the capsule was broken, Gleason 4+3=7 plus 5% tertiary of 5. Both nodes clean, seminal vesicle clean, and no trace of cancer cells in blood vessels. Makes for rather a difficult concern. The margin was close but not through the edge, so it looks to me that the surgeon could have gotten everything.

So I am getting opinions on whether to do adjuvant RT or wait and see what happens with PSA and do salvage.

As you can imagine, I really don't want to do RT if I am already cured, but the numbers don't look good even without the positive margin.

I welcome any ideas regarding the salvage vs. adjuvant question.
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Bioposy March 2008 negative
March 19 2009 4+3=7 PSA 26 positive for 6 out of 12 cores
RRP May 20 2009 Path 4+3=7 tertiary 5
5% Mostly right lobe some left
Stage T3a 1 focally positive margin, clean nodes, clean vesicle, all tests for mets clean
June 22 PSA undetectable, course of Adjuvant RT completed in October with minor side effects, follow up in November

Replicant · Moderator Joined: 01 Nov 2006 Posts: 741

A positive margin by itself does not always mean the cancer has spread. Often it does mean that, but it can also be the case sometimes (according to Walsh) that in the case of thin margins, the margin can just be worn away by handling during and after surgery--the cells get rubbed away. Or in some cases, in spite of the margin, maybe the surgeon DID get it all.

But regardless, it's right to be concerned and you ask a very important question: adjuvant or salvage RT in the case of positive margins?

On the one hand, researcher Andrew Stephenson, just last month, reported that positive margins by themselves do not predict death from prostate cancer. http://tinyurl.com/r79qpe

On the other hand, multiple studies have shown that adjuvant has the edge over salvage in the post-prostatectomy setting:
http://www.ncbi.nlm.nih.gov/pubmed/10725855

"Recent randomized trials have demonstrated that ART significantly improves multiple patient outcomes, including overall and cancer-specific survival, without major untoward effects." http://tinyurl.com/obf7d6

"Adjuvant RT demonstrated improved efficacy against prostate cancer. For patients with poor pathologic features (extracapsular extension, seminal vesicle invasion, positive margins), adjuvant RT improved the biochemical outcome independent of other prognostic factors."
http://tinyurl.com/or47ex

If it were me, I would be looking closely at adjuvant radiation.
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Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T2c, NXMX, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 (and thereafter) <0.1
http://pcabefore50.blogspot.com

Operaman · Regular Joined: 01 Jun 2009 Posts: 24

Thanks so much for the thoughtful and very useful reply. I am obviously concerned about unnecessary treatment, if it is, of this sort. However given the possibility of doing everything possible for a cure, I am most attracted to the ART.

Regarding the studies you have highlighted, I must confess that I am not sure how the research done corrects for the number of people who were treated with ART and did not have biochemical failure but because the original RRP was completely successful. With these numbers the outcomes for those receiving salvage RT have already had a recurring cancer, while a certain number of those getting no therapy and those receiving ART have been cured already. Do you feel that the studies that you have highlighted have taken those situations into account when using the outcomes to suggest treatment?
_________________
Bioposy March 2008 negative
March 19 2009 4+3=7 PSA 26 positive for 6 out of 12 cores
RRP May 20 2009 Path 4+3=7 tertiary 5
5% Mostly right lobe some left
Stage T3a 1 focally positive margin, clean nodes, clean vesicle, all tests for mets clean
June 22 PSA undetectable, course of Adjuvant RT completed in October with minor side effects, follow up in November

Replicant · Moderator Joined: 01 Nov 2006 Posts: 741

What studies on adjuvant radiation generally do is look at the high risk population. Those at high risk are very likely to have biochemical failure. So when you have a control group that does not get adjuvant, and a test group that does, if the test group does better, you know that the adjuvant radiation had some effect--statistically speaking. It does not, of course, guarantee individual results.

So it corrects for those who were cured by their RP by the fact that in a large enough sample, there should be roughly the same percentage of people already cured by RP in each group. If the group that gets the ART does better, yes, you know some of those people were probably already cured, but there must be people who are much better off because they didn't wait to have radiation.

If the sample is small (small n) you could have errors, though--what if your sample was only 10 people in each group (all high risk) and it just so happened that in the ART group 8 of them were already cured by RP? It would appear, erroneously, that ART was very beneficial. You can see that such a scenario is possible.

Now make your sample 1,000 in each group. It's very, very unlikely that by chance the ART group would have 800 men who were cured. It's more likely that a roughly even percentage would be in both groups.

This does assume randomization of the test population, though, and that is VERY hard to accomplish in prostate cancer studies. It's easy for bias to creep in, and have certain groups choose certain paths. It's very hard to do a true, double-blind random study on something that involves treatment choices. So while I do accept the growing number of studies that show an advantage to ART, I don't take it hook, line, and sinker. It could be that there is some inherent bias that is skewing the results somehow. I don't know.

Which brings up a key point in the ART vs. SRT argument. Given the fact that you will inevitably radiate some men who don't need it with ART, should it be a standard practice in high risk cases? The studies seem to indicate yes, recently. It's true that radiation carries with it some risk of side effects, but USUALLY the side effects are mild and temporary. I'm a good example of that. No side effects to speak of at this point, although I know it's possible that the ED I have from surgery may get worse over time because of the radiation. So far I don't think I notice anything different.

I think you see the question before you clearly. My two cents on your situation is--do you want to give yourself a slight statistical edge by having adjuvant RT, with the price being that you may--MAY--suffer side effects unnecessarily, or do you want to watch your PSA? (Plus you do increase your odds of rectal and/or bladder cancer because of collateral damage). Stephenson, my favorite researcher on salvage, would probably say that you would be okay going the second route (salvage) as long as--and this is absolutely critical--you moved quickly and got started before PSA hit 0.5 optimally, or 1.0 more realistically. None of this should substitute for the advice of a good radiation oncologist, though. I would make an appointment with one just to review your case.

In the past, if I were in your shoes, I probably would have waited and not done ART. In fact, that's what I did. But I didn't know that I had a positive margin until my record was reviewed by oncologists after my PSA went up! My uro, God love him, got into his head that I had negative margins and even put a cover letter on my record to that effect. Opening the record was quite a surprise to the oncologists and to me. So I didn't do ART, and if I had the information immediately after my RP about the margin, I probably still would have waited.

But here in 2009, after seeing the studies about ART vs. SRT, I *might* go for ART.

Now that I've rambled on too long and probably confused you, I'll sign off!

Best wishes!
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T2c, NXMX, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 (and thereafter) <0.1
http://pcabefore50.blogspot.com

Jean222 · Senior User Joined: 14 Dec 2008 Posts: 249

Replicant,

Are you saying that if a fellow has Radiation Therapy after his RP, with a PSA that's fairly low (eg .16), he's having ART as opposed to SRT??

I'm not sure if Hubby is having ART or SRT, just that it's part of the 'arsenal' that he was promised to try for an enduring remission. Cure was the hope, but with a positive node, it's not possible.

I had also thought that Hubbys' radiation would only be 'if needed' but Dr. Nam had mentioned that the combination of surgery plus radiation would be better for a Gleason 9.

Thanks in advance for any insight you can provide, as always.

Jean

Replicant · Moderator Joined: 01 Nov 2006 Posts: 741

Hi Jean.

If someone gets the prostate bed radiated after surgery without waiting for biochemical failure (recurrence), it's adjuvant. I've also heard adjuvant called radiation within the first 6 months after surgery.

At any rate, salvage is when the radiation is done after the patient is in biochemical failure--PSA is rising.

It's a matter of timing.

I'm not sure how your husband's radiation oncologist will describe the treatments. It's beyond my limited layperson's scope of knowledge. But I certainly am keeping my fingers crossed for you guys. Maybe a cure isn't possible, as you say, but hopefully the treatments will knock it into a complete and long-lasting remission.

And maybe one of these days the silver bullet--a cure for advanced prostate cancer-- will be here. There's no reason to think it won't.

Best wishes.
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T2c, NXMX, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 (and thereafter) <0.1
http://pcabefore50.blogspot.com

RobCos · Regular Joined: 08 Jun 2009 Posts: 10

This study suggests salvage over ART-what do you guys think?

http://www.eu-acme.org/europeanurology/upload_articles/boccon%20gibod%20supp.pdf

Its from 2007 and there are others that seem to favor ART but thought this was worth posting.
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RC

Hawk · Senior User Joined: 22 Nov 2006 Posts: 406

Rob, I responded under your other identical post. It is best not to make duplicate posts on the forum as it tends to confuse the conversation.
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History: PSA's 6.7 neg. biopsy - PSA 16.6 neg. biopsy - PSA's 8.2, 8.1, 8.7 - Biopsy. 4+4 Gleason 8. Lap RP Apr 2004, age 52 All neg margins, nodes, and structures. (T2a). Post RP PSA: every 6 mo. <.1 until Feb, 08 (46 mos) PSA .1 - I then got sensitive tests (all in 2008) showing:
Feb .06, May .09, Jun .10, Aug .10, Nov .15 -SRT

Operaman · Regular Joined: 01 Jun 2009 Posts: 24

So here are some updates. I had my one month meeting with my surgeon and had 0.0 PSA. It was at once wonderful and stressful. Great to know that he was successful in getting everything he could. Stressful insofar as my surgeon has suggested waiting before doing any further treatment. He believes in following PSA closely and choosing salvage therapy at the time of biochemical failure. Other than him, most everyone has recommended ART due to the negatives in the surgical pathology. Also, of interest, one ontological radiologist has recommended hormone blocking therapy both before and after the radiation treatment, totaling 8 months.

It is a cipher just at the minute. Kind of frustrating to get such excellent news and still be facing the daunting possibilities of one, or two significant courses of treatment. I am seeing a second set of physicians this week. I'll report on any differences they have with what I have heard.
_________________
Bioposy March 2008 negative
March 19 2009 4+3=7 PSA 26 positive for 6 out of 12 cores
RRP May 20 2009 Path 4+3=7 tertiary 5
5% Mostly right lobe some left
Stage T3a 1 focally positive margin, clean nodes, clean vesicle, all tests for mets clean
June 22 PSA undetectable, course of Adjuvant RT completed in October with minor side effects, follow up in November

Replicant · Moderator Joined: 01 Nov 2006 Posts: 741

Operaman, good to hear back from you. Great news on the PSA. Hang in there; the ambiguity doesn't last forever.
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T2c, NXMX, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 (and thereafter) <0.1
http://pcabefore50.blogspot.com

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