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Thread: Adjuvant Radiation/Oncologist question

  1. #11
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    Austin, TX
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    Quote Originally Posted by njstol01 View Post
    Hi Dan, I look at your latest post with keen interest as I appear to very similar to you- RALP on 3/8/17, Final biopsy data G4+3, 4mm margin, pT2c, nodes and tissues negative. The possibility of salvage radiation was mentioned, however this would hinge on PSA #, which of course have not been done yet. So I see it somewhat alarming (to me being so close to in your shoes) that you are already considering radiation even before your first PSA result. Are you and your doc being too aggressive, or is my uro being too conservative and missing something?
    I'm still early in this process, njstol01. Like many/most/some of the folks here, during the waiting periods between actions (BX - DX, DX - followup, DX- Surgery, etc) the fact I have cancer that feels unresolved preys to some extent on my mind. The degree to which it does of course varies between patients. My bias is toward doing a bunch of reading and research BEFORE I see my medical practitioner in an effort to be "informed" when I do. I didn't really do this before my DX . I blithely followed recommendations without fully understanding the import of biopsy etc (didn't really occur to me that I could have cancer -- I never had a PSA until biopsy was already indicated, agreed, and scheduled based on abnormal DRE by my GP. So during my initial visits I felt I was operating behind the curve -- meet doc, get info, do research, develop question, wait to see doc again later, try to remember question.... Since, I've tried to flip that. That leads me to the ART thing.

    Given my pathology, I'm not panicked or extremely concerned. However, knowing the fact that there is likely some cancer left behind, I started doing the "what's next" research. That led me into the territory of adjuvant radiation therapy. I cannot answer the question about "overly aggressive", and certainly would not make recommendations to others. However, just as surgery was my preferred option under the "just deal with it" bias I have (which can tend toward the aggressive end of the treatment spectrum), considering more/sooner radiation was something to consider. While I didn't see the article that RobLee posted (thanks, good read -- I thought you were supposed to be recovering from AUS, not worrying about me!), what I was seeing (like this article http://ascopubs.org/doi/full/10.1200/jco.2014.58.8525) and stuff in Urology Today or whatever it's called, touted the overall benefits of adjuvant versus salvage radiation. Studies appear to be increasingly pointing this out. Keep in mind that my age, 53, also pushes me toward much more aggressive approaches than I likely would consider/favor were I closer to seventy. My age was a major consideration in moving quickly to surgery, as well.

    Finally, I should mention I am not unaware of the potential coming changes to medical insurance, which could very easily make me nearly un-insurable until I hit medicare in over a decade. Our insurance is due to my wife's employer, which is a small business. I think RP surgery qualifies as pre-existing as relates to recurrence So, if this is the best direction to travel, no reason to wait.

    To summarize, I don't know what this RO will recommend, when such treatments would commence (suggested between Aug - Nov by Uro) or any other details. This is just based on my research and the uro recommendations. It did kinda feel good when my surgeon quoted a lot of the same studies/articles/professional assn recommendations to me on my last visit -- without me first asking about them. We seem to be on the same page approach-wise. I suppose that is one of the reasons I like him so much. I'm gonna go listen to the RO and see what direction he points. Then comes evaluation time. My first post-surgery PSA is around the first of August, and I've been told nothing would happen before that anyway.

    Thanks to all of the input so far. Toss anything back at me if I'm missing anything or you have questions. I'm always willing to share my thought processes as they relate to me.
    Dx 06jan2017, 53yo
    PSA 7
    Gleason 3+3=6, 2 cores from 12,
    L apex 1mm, 14% and 0.5mm 5%
    Grade T2a
    RP Davinci 10 Apr 2017
    Final Pathology: 36 grams (4x3x3cm)
    Tumor 1.8cm greatest dimension, extrapostatic ext. indeterminate
    Primary Grade 4, Secondary Grade 3, Tertiary Grade 5 (5%)
    4mm span positive margin apex
    "Tumor not obviously beyond the prostate" (at margin), but into striated muscle tissue.
    Extraprostatic tissues, 5 lymph nodes, seminal vessicles all no malignancy.
    pT2c, N0, Mx
    Adjuvant RT scheduled: 39 tx at 70Gy Sep-Nov 2017

  2. #12
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    Mar 2017
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    Thanks for the detailed response Dan. Yes, nothing wrong about researching your options.....that's why we're all here! In my case, surgery went great and everything is pretty much back to normal. Obviously I do not want to go down the radiation path unless really needed, which I guess the post operative PSAs will largly determine. So, hopefully I'm not taking a too laid back approach!
    Age:59
    Family history: Father Dx PC ~ age 60 brachytherapy; colon cancer surgery ~age 70 (deceased heart failure ~ age 80); Brother age 67, PSAs low (<2)
    June 2013 PSA: 4.20 DRE: Normal
    Nov 2015 PSA: 5.51 DRE: GP noted smooth, slight enlargement. Biopsy suggested.
    Mar 2016 Biopsy: 2/12 cores positive; G3+3
    Nov 2016 PSA: 8.76
    Dec 2016 Biopsy: 1/12 core positive right lateral apex; G5+3
    3/08/17 daVinci RALP; Pathology: 34 grams, tumor present 13/37 cassettes, Margins involved 4mm distance 6:00-9:00 apex margin; G4+3, stage pT2c; Extraprostatic extension, seminal vesicle, 11 lymph nodes (7R, 4L) all negative
    Cystograms 3/23 and 3/30 suggested small leak, speculated probably contrast agent in bulbourethral duct
    3/30/17 Catheter out (22 day!)
    4/29/17 Ran/walked half marathon in 2hr 39 mins!
    Jun/17: PSA 0.01

  3. #13
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    Feb 2017
    Location
    Austin, TX
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    Update for any interested parties. Met with the RO yesterday. Since I couldn't figure out any better way of selection/validation, I just kinda talked to him and got comfortable with his background, experience, and current case loads. He's been at a teaching hospital, in positions of oversight/supervision and practicing for more than a decade before coming back here (near home). As academic, he was a contributor to numerous journals, etc, on radiation topics and some prostate specific ones. And he's got a full schedule of mostly all prostate patients. So anyway, he's now my guy for certain.

    We went over my pathology and other stuff and determined that adjuvant is the best path forward. Apparently, the margins and such described on my pathology are classified as significant and, he said, mean that from a prospective treatment/decision point of view, I am classified as if my final pathology was t3. Essentially, there is likely cancer outside the prostate, but at the apex where there is no "capsule". Thus, there are no pathological findings stipulating the extraprostatic grading, but the size of margins make it very likely it's there. Question is more of extent, which cannot be known right now. The studies of which he is aware, some of which he was involved with, suggest about a 20% improvement in the risk profile going forward, especially in the next five years for BR, from adjuvant. He also cited studies out to 25 years or so showing improvements to mortality/metastases from adjuvant. This is slightly different than what I had found and "reassuring" in a way. As in all of my treatment considerations, age played a large role in the recommendations. He repeatedly noted that the expected (and study supported) benefits from the adjuvant radiation are expected to appear in the longer term -- that is, more than 10-15 years down the road. Up to 15 years or so, there is little or no demonstrable advantage in things that matter (overall mortality and metastases free survival). Though the reduction in five year biochemical recurrence is consistently present.

    Based on all of this, I am now scheduled for 39 sessions of adjuvent radiation, 70Gy, beginning on 9-12 ending Nov 3. This assumes first post surgical PSA on 8-14 is undetectable. If not, well, welcome to hormone treatments. Otherwise, I can avoid hormone therapy for now.
    Dx 06jan2017, 53yo
    PSA 7
    Gleason 3+3=6, 2 cores from 12,
    L apex 1mm, 14% and 0.5mm 5%
    Grade T2a
    RP Davinci 10 Apr 2017
    Final Pathology: 36 grams (4x3x3cm)
    Tumor 1.8cm greatest dimension, extrapostatic ext. indeterminate
    Primary Grade 4, Secondary Grade 3, Tertiary Grade 5 (5%)
    4mm span positive margin apex
    "Tumor not obviously beyond the prostate" (at margin), but into striated muscle tissue.
    Extraprostatic tissues, 5 lymph nodes, seminal vessicles all no malignancy.
    pT2c, N0, Mx
    Adjuvant RT scheduled: 39 tx at 70Gy Sep-Nov 2017

 

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