Advice on SRT

slides · Regular Joined: 18 Sep 2009 Posts: 10

Hello! I've never posted here so I hope I get this right!

A rising PSA prompted my family doc to send me to an urologist who performed a biopsy and found prostate cancer. Highest PSA was 5.1. I had a robotic prostatectomy 9/2/08 with extra capsular extension, a single focal positive margin on the left posterior and a Gleason score of 4+3=7. No seminal vesicle invasion but small vessel lymphatic invasion was present. No lymph nodes were checked.

First PSA at 6 weeks was .02, and dropped to .01 6 weeks later. Next two were .03 in March and .04 in June. This summer I continued to drink pomegranate juice, ate lots of veggies and lost 20 pounds. The next psa, 3 months later and on the anniversary of my surgery was .08. It doubled. Not what I expected.

Ever since my first post surgery psa my urologist has been after me to have radiation, since he considered my scores "detectable." I've met with a radiation oncologist who concurs with that.

Question #1: Does salvage radiation at these levels make sense? I've read somewhere that starting it before your psa reaches .2 is advantageous. In another 3 months I could be there, and I'd rather start early and kill this thing off, if possible.

Question #2: Should I have ADT with this radiation? I've consulted with a prostate medical oncologist at the University of Washington who recommends ADT for a month prior to, and then during the radiation. My radiation oncologist thinks it's unnecessary at my levels and could mask the effectiveness of the radiation and possibly, even, make it less effective.

Any clarity you can give me on these two questions or any other aspects of my situation would be greatly appreciated.
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slides
8/1/08 PSA 5.1
9/2/08 RRP, ECE, Single Focal Margin, Gleason 4+3
10/16/08 PSA .02
12/1/08 PSA .01
3/1/09 PSA .03
6/1/09 PSA .04
9/1/09 PSA .08

Replicant · Moderator Joined: 01 Nov 2006 Posts: 849

1. Yes, in my layperson's opinion. No extreme rush at this point, but it looks like you're in biochemical failure, whether or not it has been officially declared. The important levels I know of are 0.5 and 1.0. Optimal to start at 0.5 or below, and definitely before 1.0, although there are no hard and fast rules. My source for this is Andrew Stephenson's research on salvage radiation success, published in JAMA and the Journal of Clinical Oncology (see my blog for links). There is a salvage radiation success prediction tool on the MSK website nomograms.org that is based on Stephenson's work.

As to your second question, I think there are arguments on both sides of that issue, and maybe it comes down to a case by case basis. Personally, I was glad to have just radiation because of what your radiation oncologist said. If I had had both, I probably would still be in a state of anxiety--did my PSA come down because radiation did the trick or was it a temporary effect of hormone therapy? Since I had radiation alone, and my PSA dropped below 0.1 and stayed there, I don't have that anxiety. On the other hand, I'm well aware of studies that seem to show a benefit to the combination. I'm not advising you either way here. If you are uncertain, maybe scan the most recent literature in PubMed.

There is a salvage radiation success prediction tool on the MSK website nomograms.org that is based on Stephenson's work. I highly recommend taking a look at it.

Best wishes.
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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

slides · Regular Joined: 18 Sep 2009 Posts: 10

Thanks for your speedy reply, Replicant! I've looked at the nomograms, and my medical oncologist has referred me to Stephenson's study about salvage radiation in the Journal of Clinical Oncology, which I've read.

A couple of follow-up questions for you or anyone else.

1. Are you aware of any research or opinions from doctors that suggest that the ADT might actually make the radiation LESS effective in a salvage radiation application? I asked my radiation oncologist, who doesn't think the ADT is necessary with my low PSA, "The ADT can only help, right?" He said, "Yes." And then he got this funny look on his face like he had spoken too quickly and wasn't being completely forthcoming with his knowledge. He said that chemo and radiation are most effective with actively growing cancers (I'd heard that about chemo, not radiation.) and that ADT slows down that growth. He also said there are doctors treating BREAST cancer who believe it's best not to use hormones during radiation. I really like this guy and he was trained in one of the country's top cancer centers, but his opinions on this are at odds with Stephenson.

2. How can I minimize the effect of the radiation on my hemmorhoids? This is a big concern. I have a prescription from a colo-rectal surgeon for Analpram HC to use during the radiation. Poke it in and squeeze, is how I think it's applied. Ever heard of this?

Thanks for your insights. I'm a little nervous about making the right decisions on all this. I meet with the medical oncologist on Tuesday and need to tell him whether or not to pull the trigger on the hormones.
_________________
slides
8/1/08 PSA 5.1
9/2/08 RRP, ECE, Single Focal Margin, Gleason 4+3
10/16/08 PSA .02
12/1/08 PSA .01
3/1/09 PSA .03
6/1/09 PSA .04
9/1/09 PSA .08

Replicant · Moderator Joined: 01 Nov 2006 Posts: 849

I'm not aware of studies that show ADT makes radiation less effective. The original Stephenson nomogram made it seem that way, but that was an error later corrected.

My main concerns would be the ambiguity mentioned earlier and possible side effects, although if you're on ADT for only a short course, maybe those aren't too bad. I don't know. You'll have to weigh the costs and benefits.

As for the hemorrhoids, I'm right there with you, brother. If you read my blog, you'll see that at one point I thought the radiation had irritated them, but in reality I had proctitis, which was much worse -- until I got treated for it. My treatment was Proctofoam, which is a steroidal foam with a topical anesthetic (the same one that's in Anusol). It REALLY cooled things down, just like a fire extinguisher. It came with an applicator. You filled up this little chamber with the foam, and then the applicator tip goes just barely into the rectum (to avoid further irritation), you push the plunger and sigh in relief. Easy and comfortable to apply.

I started getting the bad proctitis during the last several days of treatment. At first I thought it was hemmorhoids, so I went to my GP. That was a mistake. He gave me a very painful rectal exam, said "you've got radiation proctitis" and prescribed the foam. My radiation doctor subsequently said I should have come straight to him, as he would not have subjected me to the exam and would have just given me the foam!

I used the Proctofoam for a few weeks. It cured the inflammation.

Your doctor may not want you to use ANY topical medications during treatment. (I mean, they may not want you showing up with a rear end full of ointment). So just stay in touch with them.

Oh--I also had some diarrhea, loose stools, gas, etc. which irritated me, but it was worth it in the end (ha ha, a pun--you knew one was coming!)

Bottom line? (There I go again!) I wouldn't let hemorrhoids prevent me from getting salvage radiation.
_________________
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

slides · Regular Joined: 18 Sep 2009 Posts: 10

Thanks again, Replicant! It was especially helpful hearing about the "roids" and your SRT.

BTW, I didn't mention this in my signature, but I've recovered nicely from the surgery, especially with a little help from some ED meds. I'm 59 and just had a new granddaughter born this week. I told my radiation oncologist that I wanted to be there to dance at her wedding! He said I'm in the top 10% of patients he's seen for my treatment and he thought I'd make it!
_________________
slides
8/1/08 PSA 5.1
9/2/08 RRP, ECE, Single Focal Margin, Gleason 4+3
10/16/08 PSA .02
12/1/08 PSA .01
3/1/09 PSA .03
6/1/09 PSA .04
9/1/09 PSA .08

mkane09 · Posted: Sat Sep 19, 2009 5:04 pm Post subject: SRT

Slides, my last year has been remarkably similar to yours. DaVinci RP 9-17-08, blah, blah, blah (read my signature), leading to SRT in April/May. I had some severe proctitis/hemorrhoids with bleeding and a lot of burning. The Proctofoam helped some, but I got better relief soaking in the Jacuzzi with Epsom salts. I STILL have days of burning/bleeding, although they are getting fewer and fewer. Eating nuts of any kind is out, popcorn is out. But, I am riding my motorcycles and horse, so I guess it could be much worse. Good luck!

mkane09
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PSA 6.48, biopsy Gleason 3+4, robotic prostatectomy 9/17/08, pathology Gleason 4+5, pathologic stage T2c, positive margins, first post-op PSA 10-15-08 0.10; 2nd post-op PSA, January, 2009 0.18; SRT completed May 22, 2009. 1st post-radiation PSA, 8-4-09, <0.06. PSA 12-22-09 <0.06

slides · Regular Joined: 18 Sep 2009 Posts: 10

mkane09, thanks for the advice. Did you have Androgen Deprivation Therapy in conjunction with your salvage radiation? And, did your radiation oncologist expect your psa to go down to undetectable after radiation? Or, is that still possible in the coming months?
_________________
slides
8/1/08 PSA 5.1
9/2/08 RRP, ECE, Single Focal Margin, Gleason 4+3
10/16/08 PSA .02
12/1/08 PSA .01
3/1/09 PSA .03
6/1/09 PSA .04
9/1/09 PSA .08

mkane09 · Posted: Sun Sep 20, 2009 4:16 am Post subject: Re: Advice on SRT

No ADT. My rad oncologist was very pleased with my first post-radiation PSA (<0.06). I'll be happy if it just stays there....for another 20 years or so.

mkane09
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PSA 6.48, biopsy Gleason 3+4, robotic prostatectomy 9/17/08, pathology Gleason 4+5, pathologic stage T2c, positive margins, first post-op PSA 10-15-08 0.10; 2nd post-op PSA, January, 2009 0.18; SRT completed May 22, 2009. 1st post-radiation PSA, 8-4-09, <0.06. PSA 12-22-09 <0.06

slides · Regular Joined: 18 Sep 2009 Posts: 10

Thanks, mkane09! I'm still up in the air about the ADT, but inclined to do it, reluctantly. I meet with the medical oncologist on Tuesday, so we'll see!
_________________
slides
8/1/08 PSA 5.1
9/2/08 RRP, ECE, Single Focal Margin, Gleason 4+3
10/16/08 PSA .02
12/1/08 PSA .01
3/1/09 PSA .03
6/1/09 PSA .04
9/1/09 PSA .08

slides · Regular Joined: 18 Sep 2009 Posts: 10

Just a quick update... I took the big plunge on Tuesday. After spending an hour with a medical oncologist I let him give me a 3 month Lupron injection. Kind of an emotional moment, knowing that I was also commiting to start my salvage radiation in about a month.

I like both my medical oncologist and radiation oncologist. They had spent time over the last few days emailing each other about the role ADT could play in SRT. I like doctors who are willing to do that kind of thing for that patients, "off the clock" so to speak.

Both of them think there's a good possibility this thing might be beaten, with my low psa right now. I hope so.

I'll keep you posted!
_________________
slides
8/1/08 PSA 5.1
9/2/08 RRP, ECE, Single Focal Margin, Gleason 4+3
10/16/08 PSA .02
12/1/08 PSA .01
3/1/09 PSA .03
6/1/09 PSA .04
9/1/09 PSA .08

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