Factors that determine prognosis for Prostate Cancer

[brainman]

Hi everyone. The question of a return of PSA after a total Prostatectomy has come up several times in the last few months and again just today. I did some research and this is what I found:

In an article in the Journal of the American Medical Association reporting on a study done at John Hopkins Medical Center in Baltimore, only prostate cells produce PSA. However, on average it took 8 years for the metastasis to show up and cause any problems. According to the authors of that article, in consultation with your medical team, you have two options:

1. Begin Hormone Therapy
2. Wait until the cancer reappears on scans

There seems to be four factors to consider in making a decision:

1. Is the PSA above 0.2?
2. Was the original Gleason score 8 or higher?
3. Did the PSA return in less than 2 years?
4. How fast is the PSA rising? Is it doubling in less than 10 months?

All of these seem to be negative indicators, that is, depending on the answer to these questions, hormone treatment should begin soon. The link below has all the details including a way to balance the above factors in order to determine how likely it is for you to develop a metastatic prostate cancer.

You can find more detailed information at: http://www.phoenix5.org/Basics/psaPostSurgery.html

Reference: Pound, CP; Partin, AW; Einsenberger, MA; Chan, DW; Pearson, JD; and Walsh,PC. ''New Method to Assess Risk of Advanced Cancer After Prostate Removal,'' Journal of the American Medical Association, Vol.281, pp.1591-1597.

I hope you find this information helpful.

[Replicant]

Hi--

When you write about the two options, you fail to mention salvage radiation.

It is mentioned on the Phoenix5 website, and in the JAMA article "Risk of Prostate Cancer–Specific Mortality Following Biochemical Recurrence After Radical Prostatectomy". (Assuming that's the article to which you refer).

In the JAMA article, men who had complete responses to salvage radiation were considered--for the purpose of the study--cured and were then excluded from the study. So the two choices of wait or start ADT come AFTER the participants had the chance to try radiation.

Somewhere around 50% of men will get at least a durable response of several years--and may potentially be cured--by salvage radiotherapy after having PSA rise after prostatectomy. These days the side effects, though still present, are much milder with the advent of IMRT, image-guided IMRT, and protons.

Dr. Andrew Stephenson is a lead researcher in this field. He recently, along with these estimable co-authors: Scardino, Kattan, Slawin, and Pollak, et al., did a very large study of 1,600+ patients from 1985 to 2005. They did a multivariate study of all the factors that might affect the success of salvage therapy. The article, "Predicting the Outcome of Salvage Radiation Therapy for Recurrent Prostate Cancer After Radical Prostatectomy" (Journal of Clinical Oncology, May 2007), provides a nomogram for patients and doctors faced with a rising PSA after prostatectomy.

I had salvage IMRT done, and as I was considering it, became acquainted with a patient at Loma Linda UMC having proton beam salvage. He had negative margins, I had positive. Both of us had short (3 mos. or so) PSA doubling times. Both of us have seen our PSAs fall back to undetectable levels after radiation.

I'm quite relieved that I was able--at age 44--to have a second chance. I wasn't ready to sit back and wait for metastasis or go on ADT.

On my blog at http://pcabefore50.blogspot.com , I chronicle what it's like to be young and have prostate cancer, and what IMRT salvage was like. I also summarize and link to research on predicting the outcome of salvage.

Thanks for running a great board---I mean this to be informative and not an attack.

[brainman]

No attack felt. Thank you for that clarification. I did not "fail to mention" salvage radiation... the authors of the website your the summary of the study can be found did not mention that significant fact.

Again, thank you for that excellent review and clarification.

I did check out your website. Although normally you can only post links to external sites after being a member for over one month and posting at least 10 significant messages, there is one exception and your link qualifies: links to truly person, cancer related, blogs or websites.

I is good to have someone so well informed as part of this community .

[bcdoo]

Thanks for the information. Is there any pre-emptive action one could take? I had Da Vinci, radical prostectomy 1/22 and the cancer was upgraded to 4+4....the path noted the cancer was stained to the margin. Should I be exploring any proactive measures or wait to watch PSA velocity?

Thanks...this is a great forum for us newbies!

BDOO

[hkkippy]

I am very new to this and I look forward to your counsel.

I had a Radical Prostatectomy in August 2008 at age 68 with a Gleason of 8 (3+5). I subsequently had four PSA tests and all were undetectable. In late January I had another test and it showed a PSA of 0.2. My Urologist retested me again and I will learn the results on Wednesday (2/11) and we will go from there. He mentioned radiation (five days a week for four weeks or waiting three months and retesting. Any thoughts, suggestions, advice. Thank you very much.

PS. My wife is recuperating from knee replacement surgery and we are basket cases at this point.

[Replicant]

Don't panic.

Your doctor is suggesting that you may be a candidate for salvage radiation. That's a second chance at a cure.

I think getting re-tested is fine. If your PSA shows any further rise, I would move forward with consultations in regards to radiation. If your PSA holds steady, it probably won't hurt to wait. You would want to get started before your PSA hits 1.0, as research shows men who start before 1.0 do better than those who are on the other side of the mark.

Whether or not salvage radiation does indeed cure someone of PCa depends on whether or not the cancer is still localized to the area where the prostate was. If it is still localized, chances of a durable response to radiation are excellent. If it is not localized, but systemic, radiation won't cure.

Overall, the odds of success are generally thought of as 50/50. But if you have your complete history at hand, you can use the salvage nomogram at nomograms.org to get a better idea of the odds.

I had a prostatectomy in 2006, and my PSA started rising soon afterward. I had radiation last year. In my case, I was ready to go for salvage radiation even if my chances were 1 in 10, maybe lower. My odds were better, but far from a sure bet. It seems to have worked. Only time, lots of time, will tell.

You needn't fear the treatments themselves. They are completely painless, devoid of any sensation except perhaps boredom for a few minutes each day. Side effects are possible, but for most men they are mild and temporary. My blog at http://pcabefore50.blogspot.com details my experiences with salvage radiation, and links to research I found useful.

There are others on this board, besides me, who have found themselves in your situation.

Sometimes I go to Catholic Mass with my wife, in spite of my agnosticism. I find something the priest says at the end reassuring. I'm not sure if it's part of the standard "script" followed by priests, but in his benediction, he asks for freedom from undue anxiety.

That is what I wish for you. Freedom from undue anxiety. Hope.

There's plenty of reason to be hopeful. We would all like to be done with the fight after surgery, but some of us find that we have to climb back in the ring for another round. The good news is, lots of us WIN the 2nd round!

Best wishes.

[hkkippy]

Thank you very much. Your note was very reassuring.

[Hawk]

I am one of those others that found myself being called back for round two

I have had 32 of 40 treatments with very minimal side effects.

I am mainly interested in your dose. IF we are talking external beam photon radiation. Typically you would get radiation every weekday for closer to 8 weeks. Studies have shown that a dose of 70 Grays (translates to 7000 Rads) is clearly better than a dose of 60 Gray (6000 Rads). Memorial Sloan-Kettering Cancer Center doses at 72 Gray.

Some local Radiation Oncologists dose down around low to mid 60's which would not make me happy. Fortunately mine was open to input and upped the dose upon my request that referenced my consultation at Sloan-Kettering.

[hkkippy]

I will report back on Wednesday after my appoointment. You guys are great and thank you very much.

[Replicant]

When you report back after your appointment, it would be a good idea to start a new topic. Best wishes.

[TC at HW]

Brainman's post is and excellent guide to doing salvage hormonal therapy. I do respect much of what comes out of JHU and always consider their excellent program's reputation. Replicant makes a great case for radiation in a salvage scenario.

My story is about adjuvant therapies. With data is pending at Stanford and Harvard university's studies, I chose that rout. While I was a Gleason 7 (4+3), my high risk factors were my age (44 at Dx), my stage after RP ~ T3b (using AJCC 2002) and my pre-op PSA of near 20. We acheived an undetectable nadir after surgery, however, nomagrams and case study were against me considering a life expectancy of more than 30 years. My intent on using adjuvant therapies was avoid metastatic disease until well after year 8. My action was to take on radiation and hormonal therapy prior to an increase in PSA. I fully understand that the improvement in the Stanford/Harvard studies is only 27%, but I felt my age might work for me.

May peace be with you all...

Tony

[ertweryt]

I have to say that the psa is a very important fact.

PSA levels of prostate-specific antigen for Prostate cancer patients in its operation, if with unusual increasing in the first few months ,which probably means that the extent of their cancer have been very serious, and therefore they have to accept the high-intensity treatment as soon as possible to improve their chance of survival.

seems to be negative,but have to pay close attention to it

peter