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Thread: Zero Club Membership Renewed - SRT Question

  1. #1
    Senior User
    Join Date
    Jul 2017
    Posts
    124

    Zero Club Membership Renewed - SRT Question

    Yes, I had to peek. One month post RALP, PSA was zero. Uro scheduled me for six months later (June 7) for next appt follow-up and PSA. Of course, I had to peek at what my PSA was before then! So at four months post RALP I did a local test, and again zero. Yay!

    Somewhere in all this I did the Decipher test which came back at .78 (high risk) plus, the Grid Report indicated I would be resistant to ADT. My Uro had never used Decipher, but he ordered it at my request. I guess insurance paid for it... or somebody paid for it, as I have never seen anything about any payment given or requested. Odd.

    After seeing the Decipher result, he scheduled me for an appt at the Proton Center (MD Anderson) on the same day as my visit with him (the Uro). (I am a fan of Proton Therapy, and visited with them prior to choosing surgery for my particular "large volume" case.)

    So now, I'm wondering... If my PSA is still zero on June 7 will the Proton folks still want to do radiation (considering everything EXCEPT PSA results would indicate it is likely needed)? Or will they say, let's wait until actual BCR, if/when? And IF radiation (Proton or otherwise) is indicated, what exactly is the "target" since the prostate is gone? Do they just shoot the whole area and hope for the best? Surely not.

    I guess this gets into the area of when is the optimum time to initiate salvage radiation. Before BCR, given my risk category, or after the onset of BCR?

    I will be getting on Medicare in September, so IF SRT is indicated, I'm sure I can wait until then to get started, yes? (Medicare will pay for Proton Therapy, my insurance will not.)

    Thanks to all!

    Always grateful.

    Mike in Kerrville
    Age 63 at Dx
    PSA History
    07/10 - 0.5
    05/12 - 0.5
    08/13 - 0.9
    02/14 - 1.2
    10/15 - 1.3
    07/16 - 3.3
    12/16 - 4.4 with Free PSA 52% (low risk)
    04/17 - 5.03
    08/17 - 3.5
    09/17 - 3.2
    11/17 - <0.01
    2/18 - <0.01
    05/18 - <0.01
    08/18 - 0.01 (CPL says they don't use the "<" any more. ???)
    10/18 - 0.02
    11/18 - 0.01
    01/19 - 0.02
    05/19 - 0.02
    07/19 - <0.02


    Biopsy 07/11/17 PSA 5.02 T1c, revised to T3b after RALP
    Results 07/26/17 - Gleason 4+3 = 7 (two 4+3's, five 3+3's)
    RALP at MDA Oct. 23. Confirmed Gleason 4+3

    Pathology:
    Bladder neck (microscopic) and seminal vesicle involvement + large volume of PC, clear margins
    Bone Scan and CT Abdomen, lymph nodes are clear
    Decipher test result: .78 - High Risk
    Dry after six months post surgery.
    Axumin PET and Pelvic MRI are clean 11/09/18
    Completed 35 Proton treatments at MDA 03/28/19


  2. #2
    Hi Mike. You doc may be thinking about ART (Adjuvant RT) given the Decipher result and your path report. This would be radiation given before BCR, aimed at preventing it from occurring. Think of it as surgery + radiation as your initial treatment. See also

    https://www.cancerforums.net/threads/52573-Criteria-for-RT-after-RP-Adjuvant-vs-Salvage?highlight=adjuvant

    https://www.cancerforums.net/threads/52862-Extraprostatic-extension-(EPE)-and-Adjuvant-Radiation?highlight=adjuvant

    Regarding the Decipher Grid report, while I am Low Risk, mine came back with a terrible score of 1 out of 100 for ADT response! When I mentioned this to my doc, he said two things. First the GRID is still in the research stage and not validated for clinical decision-making. Secondly, while he's always heard that about 10% of men don't respond to ADT, he has never had a patient who did not show at least some response to it, at least initially.

    Djin
    Last edited by DjinTonic; 03-06-2018 at 12:33 PM.
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3-
    7-05-13 TURP for BPH (90→30 g) path neg., then 6-mo. checks
    6-06-17 Nodule on R + PSA rise on finasteride: 3.6→4.3
    6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
    Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, neg. frozen sections, Duke Regional
    SM EPE BNI LVI SVI LNI(16): negative, PNI+, nerves spared
    pT2c pN0 pMX acinar adenocarcinoma G9 (4+5) 5% of prostate (4.5x5x4 cm, 64 g)
    11-10-17 Decipher 0.37 Low Risk: 5-yr met risk 2.4%, 10-yr PCa-specific mortality 3.3%
    Dry; ED OK with sildenafil
    9-16-17 (5 wk) PSA <0.1
    LabCorp uPSA, Roche ECLIA:
    11-28-17 (3 m ) 0.010
    02-26-18 (6 m ) 0.009
    05-30-18 (9 m ) 0.007
    08-27-18 (1 yr.) 0.018 (?)
    09-26-18 (13 m) 0.013 (30-day check)
    11-26-18 (15 m) 0.012
    02-25-19 (18 m) 0.015
    05-22-19 (21 m) 0.015
    08-28-19 (2 yr. ) 0.016
    Avg. = 0.013

  3. #3
    Big Congrats on another "0" Mike! Keep them coming!

    A couple of questions:

    - Did MDA order this latest PSA test ("done locally") or did you have it done on your own?

    - Does MDA offer Proton Therapy for recurrent PCa?

    My novice "sense" is: if your PSA remains "0" at your June 7 MDA meeting, then thoughts of any salvage procedure will be put on hold. (A "Why try to fix it if it ain't broke?" scenario!)

    How's the rest of your RP recovery going?

    Good luck!

    MF
    PSA: Oct '09 = 1.91, Oct '11 = 2.79, Dec '11 = 2.98 (PSA, Free = 0.39ng/ml, % PSA Free = 13%)
    Referred to URO MD
    Jan '12: DRE = Positive: "Left induration"
    Jan '12: Biopsy = 6 of 12 Cores were Positive: 1 = G7 (3+4) and 5 = Gleason 6
    Referred to URO Surgeon
    March '12: Robotic RP: Left: PM + EPE. MD waited in surgery for preliminary Path Report then excised substantial left adjacent tissue(s) down to negative margins and placed 2 Ti clips for SR guidance, if needed in future.
    Pathology: Gleason (3+4) pT3a pNO pMX pRO c tertiary pattern 5 / Prostate Size = 32 grams / Tumor = Bilateral: 20% / PNI: present
    3 month Post Op standard PSA = <0.1 ng/ml
    1st uPSA at 7 months Post Op = 0.018 ng/ml
    uPSA remains "stable" at 84 Months Post Op: Mean = 0.021 (20x uPSAs: Range 0.017 - 0.026) LabCorp: Ultrasensitive PSA: Roche ECLIA
    Continence = Very Good (≥ 99%)
    ED = present

  4. #4
    Hello Mike: Congrats on the good numbers, nice to see and bodes well at this point in time. My first question is given your status as pT3b, why is your doctor not checking u every 3 months at this point in time? Are u having the uPSA test? I would have the uPSA test and plan any possible SRT around what my PSA scores are showing. Anything above 0.03 on the uPSA scale is highly indicative of BCR, ( at least for high risk) and of course you could wait to see the trend. The best time to start SRT is early!! I would not wait much longer than .1...that is when I pulled the trigger. In your case, the target will be the prostate bed, along with what is known as the boost. ( local LN). That is really all they can do at this point. Good luck and keep us posted, MM
    DOB:Feb 1958
    PSA: 9/15: 5.9
    DRE: Negative
    Biopsy: 10/1/15. Second Opinion University of Chicago. +9 of 12 cores. G6: 5 cores, G7 ( 4+3) 4 cores
    10/12/15: -CT scan/BS
    Clinical Staging: 10/28/15 T2c
    ( RALP) UC 12/29/15

    Final Pathology Report; Jan. 6 2016

    -15 lymph nodes
    G9 ( 4+5)
    +EPE
    +LVI
    +Right SV -Left SV and vasa deferentia,
    PI present
    PM
    pT3bNO
    uPSA 2/9/16 0.05
    uPSA 3/23/16 0.11
    Casodex 4/1/16-8/5/16
    Lupron 4/15/16-5/15/18
    SRT 6/14/16...8/5/16 38Tx
    uPSA 8/10/16---8/22/19 <0.05
    Feb. 2017 Loyola Chicago
    11/15/2018 AUS 800 Implanted
    12/18/18...T Levels...Free T 42.8...Total T...262

  5. #5
    You are going to have to show them some PSA before any more treatment is conducted...In any case, it won't be proton as the field of fire has become too large...
    PSA at age 55: 3.5, DRE negative.
    65: 8.5, DRE " normal", biopsy, 12 core, negative...
    66 9.0 DRE "normal", BPH, (Proscar)
    67 4.5 DRE "normal" second biopsy, negative.
    67.5 5.6, DRE "normal" U-doc worried..
    age 68, 7.0, third biopsy (June 2010) positive for cancer in 4 cores, 2 cores Gleason 6, one core Gleason 7. one core Gleason 9. RALP on Sept. 3, 2010, Positive margin, post-op PSA. 0.9, SRT , HT. Feb.2011 PSA <0.1 Oct 2011 <0.1 Feb 2012 <0.01 Sept 2012 0.8 June 2013 1.1, Casodex added, PSA 0.04 10/2013. PSA 0.32 1/14. On 6/14 PSA 0.4, "T"-5. 10/14 PSA 0.6, T-11. 1/2015 PSA 0.106. 4/15. 0.4, 9/15 1.4, 3/16 Zytiga, 0.04, 5/17 1.4 may switch to Xtandi. 3/1/2018. PSA now 54, chemo will begin next month. 7/19, PSA 2000 starting Lu-177 tomorrow..77 years old now..

  6. #6
    Ditto on what MichiganMan said. If you're T3b with SVI that puts you into the very high risk category. The first link provided by Djin leads to a discussion from just a few months ago... actually my post right after Djin's is where we get into the risk categories. This is one treatment protocol that I did not question at all. In fact I spent the first year post RP preparing for ART.

    Immediately following my RP I was informed that I would need ART, and my RO was quite insistent that it was very important. Also, my PSA a month after RP was declared "undetectable", which to my surgeon's standards meant that it was <.1 ... That wasn't good enough for me, nor for my Uro. Subsequent PSA's were run using ultrasensitive and was always .02 - .03 for the subsequent months, including the time while on HT.

    It turned out that this lab used <.02 as the cutoff for undetectable, so I kind of get the feeling that the term undetectable doesn't mean much anymore. Nor does the term "zero". My latest PSA is 0.00, and I'm still a bit skeptical. I want to know if it was somewhere between 0.001 and 0.005 and was rounded down to "zero".

    I think what I've read is that 50% of T3b's may be overtreated, meaning they didn't really need RT. But how can you be sure that you fall into that 50% or the other 50% that ultimately would have required treatment. All studies point to earlier radiation is better than waiting for a PSA threshold. Regarding SRT without prior adverse pathology, even the "three consecutive rises" in PSA is useless if they don't test at least every three months.
    Late 2012: PSA 4, age 62 all DRE's 'normal'
    Early 2014: PSA 9.5, TRUS biopsy (false) negative
    2015: PSA's 12 & 20, LOTS of Cipro ... Mar'16: PSA 25, changed Urologist
    Jun'16: MRI fusion biopsy, tumor right base, 6/16 cores: 2ea 15-40-100% G8(4+4)
    Aug'16: DVRP,
    "broad cut" 11 LN-,-SM, 53g 25% involved, multifocal EPE, PNI, B/L SVI, pT3b

    Jan'17:
    began Lupron ADT, uPSA's ~.03
    May'17: AMS800 implanted, revised 6/17
    Aug'17: 39 tx (70 Gy) RapidArc IGIMRT
    Jan'18-July 2019: PSA's <0.008, T~12
    Apr'18: Dx radiation colitis, Oct'18: Tx sclerosing mesenteritis
    "Everyone you meet is fighting a battle you cannot see"

    Mrs: Dec 2016: Dx stage 4 NHL/DLBCL,
    Primary Bone Lymphoma
    spinal RT boost+6X R-CHOP21+6X IT MTX via LP. Now in remission
    Read our story at CancerCoupleBlog

  7. #7
    Senior User
    Join Date
    Feb 2017
    Posts
    147
    Hey, Mike, sounds like you're a potential candidate for adjuvant radiation, which I finished first of the year. Generally, from what my Uro and RO told me, IF they are gonna recommend/do adjuvant radiation, they usually wait about six months to schedule it in. Usually target doing it in the last half the year after surgery. This is to allow the body maximum time to heal, gaining 100% continence and as much erectile function as possible before beginning. Usually, the radiation will "freeze" in place the state you have when you begin it (or at least they will tell you that. Since adjuvant is recommended based on clinical/pathological features rather than PSA, additional PSA readings or rises are not really a factor. In my case, I was recommended and planned the radiation without regard to PSA -- they just did one right before the radiation (at six months) to have a baseline. So I wouldn't worry too much about that unless you are considering waiting until a confirmed BCR before proceeding with radiation. In that case, the routine PSA screenings and such are very relevant. Sounds to me like June would be a "normal time" to check in on continence and related side effects and assess for adjuvant.

    Good Luck!
    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 Oct - Dec 2017
    PSA: 1/17/2017 (pre surgery)=7 8/17/2017=0.04 10/17/2017=0.06 2/18/2018=0.02
    5/22/2018=<.01

  8. #8
    Senior User
    Join Date
    Jul 2017
    Posts
    124
    Thanks all! Excellent information and food for thought.
    Age 63 at Dx
    PSA History
    07/10 - 0.5
    05/12 - 0.5
    08/13 - 0.9
    02/14 - 1.2
    10/15 - 1.3
    07/16 - 3.3
    12/16 - 4.4 with Free PSA 52% (low risk)
    04/17 - 5.03
    08/17 - 3.5
    09/17 - 3.2
    11/17 - <0.01
    2/18 - <0.01
    05/18 - <0.01
    08/18 - 0.01 (CPL says they don't use the "<" any more. ???)
    10/18 - 0.02
    11/18 - 0.01
    01/19 - 0.02
    05/19 - 0.02
    07/19 - <0.02


    Biopsy 07/11/17 PSA 5.02 T1c, revised to T3b after RALP
    Results 07/26/17 - Gleason 4+3 = 7 (two 4+3's, five 3+3's)
    RALP at MDA Oct. 23. Confirmed Gleason 4+3

    Pathology:
    Bladder neck (microscopic) and seminal vesicle involvement + large volume of PC, clear margins
    Bone Scan and CT Abdomen, lymph nodes are clear
    Decipher test result: .78 - High Risk
    Dry after six months post surgery.
    Axumin PET and Pelvic MRI are clean 11/09/18
    Completed 35 Proton treatments at MDA 03/28/19


 

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