Some radiation questions

jimschlemmer · Regular Joined: 28 Apr 2008 Posts: 22 Location: troy, ny

Hi.

I'm contemplating having a robotic RP. I am concerned that my post-op pathology might not be good. Thus, I'm considering what treatments might be best following the RP, with EBRT being the one that seems appropriate. I was wondering if anybody could point me in the direction of information describing the outcomes of patients who waited to see if their PSA had trended higher vs. those that hit it right away with radiation. I was told by a radiation oncologist that the later was shown to be more effective at treating the disease.

My second question pertains to going with brachytherapy and/or EBRT in preference to RP. Is there any data on prostate problems down the road after RT? Can you still get BPH or prostatitis? Is there any reason to think that your chances of getting PCa in a different location are any different than with somebody who hasn't had PCa therapies? It seems that at least with EBRT you might well zap any nascent cancer elsewhere in the prostate, thus resetting the prostate clock, so to speak.

Thanks,

-Jim

Replicant · Moderator Joined: 01 Nov 2006 Posts: 744

This article: http://tinyurl.com/4jwto4, just out from Johns Hopkins researchers, might help answer your question. It shows that a strategy of waiting until PSA rises before initiating salvage RT is an effective strategy with positive margins and/or extra capsular extension, but not always with seminal vesicle invasion.

The authors cite an earlier study, http://tinyurl.com/3mvou2 , which stated "because of the potential confounding factors, direct comparisons of ART and SRT are problematic; however, ART is extremely effective and offers the surest approach for maintaining biochemical control."

You might also be interested in the following:

Adjuvant Radiation Vs. Salvage Radiation For Prostate Cancer Recurrence - AUA 2006 - Society Of Urologic Oncology Meeting
http://www.medicalnewstoday.com/articles/43871.php

My own two layperson cents: the only difference between ART and SRT is timing. If you closely monitor PSA after surgery and start RT before PSA hits 0.5 (optimally) or 1.0 (more realistically) your odds are about as good as they get. Of course, if the cancer is systemic neither ART nor SRT will cure you. It's always a bit of a crap shoot when it comes to where the cancer is located.

Bear in mind that although radiation (my experience is with IMRT) is much gentler in regards to collateral damage than EBRT of a decade ago, it still brings with it the chance of side effects like proctitis, bladder irritation, increased incontinence, and increased ED (on top of whatever the surgery did). And although protons can be used for salvage and are known for low side effects, anecdotally I know of a case to the contrary. A member of the WebMD discussion board did protons as SRT just before I did salvage IMRT. At first I had the side effect (proctitis) and he had none at all. But 10 months after, his incontinence worsened and last I checked, he was getting collagen injections for it without much relief. Both of us, by the way, have apparently achieved biochemical control with undetectable PSAs. So be mindful about side effects when considering RP followed by immediate radiation. I'm not saying don't do it, just make sure you know what you're potentially getting into. There are side effects and you cannot eliminate the risk no matter how carefully you plan.

Good luck!
_________________
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

jimschlemmer · Regular Joined: 28 Apr 2008 Posts: 22 Location: troy, ny

Thanks, replicant.

I've been following your posts carefully as you seem to be walking in what may very well be my shoes.

WRT the new nomograms at Sloan that you posted a link to, do you think they represent too rosey an outlook for somebody intending to have the "work" done locally?

My feeling is that with a robotic RP the skill of the surgeon is probably not as curcial as with seed therapy, at least in terms of removing the cancer. The surgeon I'm considering has done the robotic RT about 200 times, we're told. We meet with him tomorrow.

I appreciate all your comments about side effects of various RT treatments and thanks a lot for those paper links. At my current stage I'm more focused on what approach is likely to be more effective in ridding me of the cancer, though I know that this is not an easy thing to determine and though I may have other thoughts if I'm suffering side effects later.

-jim

jimschlemmer · Regular Joined: 28 Apr 2008 Posts: 22 Location: troy, ny

Also, are there difficulties in targeting with IMRT? Did you get CT or MRI scans to determine your capsule shape?

Does RT make subsequent abdominal surgeries problematic? I've of course read that if you do RT first then RP is very difficult but I'm unclear as to whether that's just for prostate surgery or all surgeries in the area.

Thanks again.

-jim

Replicant · Moderator Joined: 01 Nov 2006 Posts: 744

Thanks for your kind words on my blog.

As far as your surgeon goes, 200 sounds like a good number. Everything I've read says 70 or so is the usual number before a surgeon starts getting results comparable to open surgery in terms of surgical margins. Earlier in the curve, surgeons tend to have higher rates of positive margins. It shouldn't be an issue for someone with hundreds of robotic procedures under their belt.

For salvage IMRT, I no longer had a prostate, so the imaging was to show the prostatic fossa (prostate bed), bladder, bowel, etc. The capsule is gone. After surgery, your innards tend to fill in the void where the prostate used to be, at least to some extent. After I was tattooed (freckle sized tats) I had a 3D planning CT done. With salvage, the radiation IS going to touch the bladder and rectum. The question is, how much? With salvage, you don't know exactly where the cancer is. Is it where the prostate used to be? Are there some cells nestled up against the rectum? The bladder? Those surface areas probably need to get at least some radiation, but not as much as the prostate bed. This is part of the skill of the doctor and radiation physicist. They use some pretty fancy software to assign dosages in a way that looks like a topographical map.

I've never heard that RT would make future surgeries (aside from prostatectomy) more problematic, but that would be a good question for a doctor. I am a little concerned about colonoscopies (once I hit 50) as far as bleeding goes, but my radiation oncologist is not. And of course I'm a little worried about the increased risk of bladder or bowel cancer in the long run. Not only from the IMRT, but I've had multiple CT pelvic scans as well: 1 diagnostic scan before surgery, 1 diagnostic scan at recurrence, the high definition 3D planning scan, and standard x-rays every week during SRT to see if any changes in alignment needed to be made.

There has been some recent news about the prevalence of CT scans, especially in emergency medicine, and the increased risk of cancer.

But--I'm satisfied with my choices and very happy with the outcome so far, and those above risks are just part of the price I paid to fight PCa.
_________________
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

Replicant · Moderator Joined: 01 Nov 2006 Posts: 744

Jim, the nomograms on the MSK page are based on very large multi-institutional studies, so I doubt they present an overly optimistic picture. If anything, they are slightly pessimistic. The reason is that PCa is such a turtle, and therefore studies have to be VERY long and necessarily backwards-looking. So the one for SRT includes many men who had (relatively) primitive EBRT, some who had 3D conformal, then some who have had IMRT. The guys who had early forms of EBRT probably skew the stats to the negative in terms of outcomes.
_________________
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

jimschlemmer · Regular Joined: 28 Apr 2008 Posts: 22 Location: troy, ny

Thanks for all the added info, replicant.

I was reading Walsh last night in preparation for my meeting with the surgeon today. I was struck by how much he emphasized the skill of the surgeon in RP. I guess I was being naive in thinking it was a pretty straightforward operation. I was also struck, yet again, by Dr. Walsh's arrogance and shameless promotion of Johns Hopkins. If he could just dial that down a few ticks I think his message would sink in further.

-jim

jimschlemmer · Regular Joined: 28 Apr 2008 Posts: 22 Location: troy, ny

Replicant,

Did you look into prostate bed seeding? I was corresponding with a guy who went that route and then followed up with chemo. It was kinda tough going and the bed radiation pretty much guaranteed incontinence but he said he wanted to be ultra aggressive after his surgery failed to remove all the cancer. He said that he leaks about a table spoon a day when he does certain things but it's not like he needs to wear adult diapers.

-jim

Replicant · Moderator Joined: 01 Nov 2006 Posts: 744

No, I didn't explore that. I think it's a little out of the ordinary, compared to salvage IMRT. Frankly, it wouldn't have been that attractive to me. After surgery, I'd had enough poking around down there. Smile

As long as the recurrence is localized, IMRT offers a great second chance at a cure. If it's systemic, there's no radiation tx that will cure it.

I'm not saying your friend made a poor choice. For all I know, it was exactly right for him. But not for me.

Don't fret too much at this point. I know you're just covering all your bases, but you don't know what your surgical pathology will be. It could very well be that you won't need any additional treatments.
_________________
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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