Treatment After RP and Before Rising PSA????

H F · New User Joined: 25 Apr 2008 Posts: 4

I am wondering if anyone can guide me to a resource which describes possible treatments initiated after a radical prostatectomy and before PSA starts to rise? (Or is there such a thing?)

Or, if you have had such a treatment, could you briefly describe it?

Replicant · Moderator Joined: 01 Nov 2006 Posts: 124

It's called adjuvant treatment. It's usually not done unless the patient is at high risk of recurrence--for example, if after surgery it was found that the Gleason was high and the pathology report showed positive margins, etc. It should not be done unless there is a reason, because it brings with it at least the possibility of morbidity (side effects).

It comes in different forms, but probably the most common form of adjuvant therapy after RP is radiation. As far as the treatments themselves go, receiving radiation is very easy. Totally painless. My blog (referenced below) describes my experience with salvage radiation. The only difference between salvage and adjuvant is the timing. With salvage, you wait until you see PSA rise before initiating treatment. Adjuvant is started without waiting.

All treatments, including radiation, run the risk of side effects. Radiation side effects are usually much milder and transitory than those from surgery. Radiation to the prostate bed can cause irritation to the bowel and bladder. It's possible to worsen the post-surgery incontinence or ED the patient is experiencing already. Or, like in my case, the bowel was irritated and I had some diarrhea and painful bowel movements. This particular side effect can be treated successfully with medication in its acute form.

Adjuvant therapy could also include other treatments, like hormone therapy (ADT). The patient could even be referred for clinical trials. But that would be at the more severe end of things. For most people, post-RT adjuvant therapy involves radiation in the form of IMRT or IGRT, with or without ADT.

I don't think there is conclusive evidence one way or the other as far as adjuvant vs. salvage.

I'm curious--do you think you should be getting adjuvant treatment?
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T3a, N0M0, 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 <0.1, 12/07 <0.1, 4/08 <0.1
http://pcabefore50.blogspot.com

Replicant · Moderator Joined: 01 Nov 2006 Posts: 124

I see from your other posting the reason you ask about adjuvant treatment--you have adverse pathological findings.

Johnw100, does this fall within your area of knowledge?

My non-professional opinion is that yes, you should at least consult with a radiation oncologist, and probably a medical oncologist as well.

The Han tables, which predict a post-surgical rise in PSA, show your odds of having a rising PSA to be 51% within 3 years, 69% in 5 years, 82% in 7 years, and 89% in 10 years. I used the calculator on the Johns Hopkins Urology website ( http://urology.jhu.edu/prostate/ ). You could also use the post-prostatectomy nomogram from Memorial Sloan Kettering Cancer Center at http://nomograms.org

I don't think you said what the status of your surgical margins was. That is a necessary input in the MSK nomogram.

As you can see, there's a good probability that you'll see your PSA come back within a few years---but it's far from a guarantee. I don't think there's a reason to rush into radiation, but again I'm not the radiation oncologist and you should make your decisions with their guidance.

Best wishes.
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T3a, N0M0, 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 <0.1, 12/07 <0.1, 4/08 <0.1
http://pcabefore50.blogspot.com

H F · New User Joined: 25 Apr 2008 Posts: 4

Replicant – thanks for your very helpful responses. My surgical margins are negative. As you can see, I am still trying to understand what is going on and what I should be doing about it. My postoperative consultation resulted in my agreeing to participate in the Johns Hopkins Clinical Trial identified as TAX 3501. I was randomized to one of the control groups to receive a combination of Eligard and Taxotere (hormone deprivation and chemotherapy) when PSA level hit 0.4. My oncologist told me that the plan if I were not on the study would be to receive hormone deprivation therapy upon risig PSA until resistance appeared and at that point, I would commence with chemotherapy, which was the “standard of care”. I have been comfortable with my decision to participate. However, the Clinical Trial was closed last week at my doctor’s site (I don’t know why) – so I am trying to rethink where I am.

My thinking is focusing on the aggressiveness of my cancer. I have nomograms from several sources, which show a wide range of probabilities – and that has puzzled me. I looked at the Han table on the link you provided and that seemed to allow for a range of probabilities and suggests some sort of mean, although it is not an arithmetical average. So this leaves me still not being able to decide whether I should push for adjuvant treatment or not. If nothing else, your post has given me a vocabulary to use in discussing this question with my oncologist. It may even help me frame my question for my oncologist as: “At what point would we have decided in favor of adjuvant treatment – if I had positive surgical margins and/or seminal vesical involvement and/or some other indicator?” Maybe you can see what I am trying to do in framing my conversation, which I want to have with my oncologist – any help would be appreciated. I am trying to ask whether the aggressiveness of my cancer warrants a more aggressive approach than waiting for PSA elevation.

Thanks for your help. I would also appreciate responses from anyone else.

Replicant · Moderator Joined: 01 Nov 2006 Posts: 124

I have heard about TAX 3501, I think from the Prostate Cancer Update podcast and a brief mention in Dr. Walsh's book. It sound very intriguing. I'm sorry to hear they've left you in the lurch on this, though.

Best wishes on this. I hope some others will jump in and have some more info for you.
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T3a, N0M0, 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 <0.1, 12/07 <0.1, 4/08 <0.1
http://pcabefore50.blogspot.com

johnw100

Mayo Clinic has published material on surgery followed by hormonal therapy which Dr Zincke has used for his patients over a long period.

His results and the work by Dr Messing in relation to lymph node involvement indicate significantly improved results with immediate combined treatment.

Ref: New England Journal of Medicine V341 Decemberr 1999. Messing E.

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