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Thread: Adjuvant Radiation Study

  1. #1

    Adjuvant Radiation Study

    https://www.ascopost.com/News/60308

    As with most these, with out knowing the G score mix it hard to draw a conclusion.
    YOB 1957

    DX 12/18, GS 8, 4+4 6/12 cores, LL Apex 100%, LM Apex 60%, LL Mid 50%, LMM 40%, LL Base 5%, LM <5%, Right side negative.

    3/6/19. Pathology - Grade Group 4 Intraductal Carcinoma
    T3aNO, 1 mm EPE, GS8, 21 mm uni-focal tumor involved 10% of prostate.

    7 Nodes, SV, SM, PNI, and BNI were negative.

    LVI and Cribriform pattern present.

    Decipher .86 High Risk.

    Post Surgery PSA
    3/25/19 .03. (28 days)
    4/25/19 <.03. (58 days)
    5/25/19 <.02. (88 days)
    9/10/2019. <.02. (198 days)

    3 Part Modality Treatment

    2/25/19 Robotic Laparoendoscopic Single Site Surgery outpatient Cleveland Clinic,

    ADT - started 6/19, end date 6/21.

    ART - Completed 9/26/19. (78 Gy, yes, I glow in the dark)

  2. #2
    From Duck2's report

    The 10-yr survival for biochemical recurrence was 82% in the adjuvant group and 61% in the observation group (hazard ratio [HR] 0.26 [95% confidence interval {CI} 0.14–0.48], p < 0.001), and for overall survival 92% and 87%, respectively (HR 0.69 [95% CI 0.29–1.60], p = 0.4).
    Of interest is that even with SM+ and/or EPE+, 6 out of 10 of the observational group did not encounter BCR in the first 10 years. Granted, some will in the years to come, but this does point out that we need to know the outcomes from trials currently underway as to whether in these cases, ART is greatly superior to eSRT for overall survival. If it is not, then perhaps roughly half of men in this category can avoid overtreatment simply by waiting to see if they develop BCR. (Since the study period was April 2004 and October 2012, I assume most of the SRTs were not early, let alone very early.)

    The enrollment in this study wasn't high, but IMO the improvement in OS by ART wasn't overwhelming. Again, it's certainly possible that ART was of greater value in the higher G scores (or perhaps in today's parlance, those with higher genomic risk).

    Djin
    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
    I could not gain access to the "Full Text," to see their criteria to initiate ART.

    Of interest and befuddlement is the statement:

    "An increase in the PSA value usually precedes the recurrence of prostate cancer, and in this study, the patients with a maximum PSA of 0.4mg/L were determined to be disease-free."

    Does this mean that all in the ART Group were "disease-free" at the time of initiating ART???

    In the U.S., nearly all of us would have initiated SRT upon their post RP PSA reaching 0.20

    MF
    Last edited by Michael F; 10-17-2019 at 07:04 PM.
    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 91 Months Post Op: Mean = 0.022 (22x uPSAs: Range 0.017 - 0.032) LabCorp: Ultrasensitive PSA: Roche ECLIA
    Continence = Very Good (≥ 99%)
    ED = present

  4. #4
    Generally the indications for adjuvant RT are any two of the following adverse pathologies:

    Pre-RP PSA ≥ 20
    Gleason score ≥ 8
    Pathology stage ≥ pT3b
    More than four cores with primary grade 4

    ... and even at that, approx half of the men who decline ART remain progression free for ten+ years (though that may be due to early death from other causes). Typical recurrence is 3-8 years.

    Most of my information is dated pre-genomic testing, or without such testing. I don't recall just when gene testing became mainstream, but no one ever mentioned it to me.
    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

  5. #5
    Quote Originally Posted by RobLee View Post
    Generally the indications for adjuvant RT are any two of the following adverse pathologies:

    Pre-RP PSA ≥ 20
    Gleason score ≥ 8
    Pathology stage ≥ pT3b
    More than four cores with primary grade 4

    ... and even at that, approx half of the men who decline ART remain progression free for ten+ years (though that may be due to early death from other causes). Typical recurrence is 3-8 years.

    Most of my information is dated pre-genomic testing, or without such testing. I don't recall just when gene testing became mainstream, but no one ever mentioned it to me.
    I haven't come across that particular set of guidelines, but a case-by-case evaluation might be best in the current "transition" period. D'Amico was adamant recently that G9 and 10 men with even ONE of SVI+, EPE+ or SM+ be told that adjuvant treatment is an integral part of their primary treatment. While SVI+ is pT3b, EPE+ alone is pT3a, and SM+ alone is usually pT2. Recent studies have emphasized the quite different natures and behavior of G patterns 4 and 5, so I think we'll see G8 with 9 and 10 distinguished more in recommendations often going forward.

    I'm not clear why one would adhere to a biopsy finding (4 or more cores with primary 4 or 5) when one has a post-RP estimate of the percent tumor involvement (along with a definitive G score). With my G9 final score -- but 5% involvement and pT2 staging -- I don't think my uro would have advised adjuvant if my biopsy had hit 4 lesions instead of the 2 it found. When PCa is thought to be prostate-confined with no SM+, it's hard to resist waiting on ART if the PSA is cooperating after RP.

    I assume the PSA >20 criteria represents a likelihood of mPCa.

    I don't know if genomic testing is mainstream yet or is still in the catching-on stage, but along with G score and confirmed extent findings (imaging and post-op pathology), it is a valuable piece of information about your particular cancer that go beyond general population statistics.

    With genomics, uPSA, and the newer PET-CT imaging, together with the upcoming results of the ART vs. early/very early SRT trials, I expect guidelines for adjuvant therapy will change, leaning more toward waiting for PSA trends, if adverse features and risk factors permit.

    And as far as SRT goes, with pT2, if I encounter BCR, I will want to do everything to find out if my recurrence is local and/or distant. I don't want SRT to the pelvis if nothing is there and, on the other hand, a lesion in a long bone needs RT. In other words, "Don't taste my fossa, Bro!"

    Djin
    Last edited by DjinTonic; 10-17-2019 at 04:25 PM.

  6. #6
    Much of what I post is my recall of things I've read here and there, which is why I "always" include qualifiers such as generally, often, and usually.

    In the past I have been called out to provide studies to support my statements, but even before Lupron brain, I've never kept "detailed files" of what I've read. But I did state that my knowledge is dated, and much has changed in recent years. I do have the tendency to speak mostly of my own experiences when offering advice to others. After all, that is the only knowledge I have to draw on. My urologist tells me that I should spend less time researching prostate cancer online, which does not help to expand my knowledge base.

    Now I remember that the "two or more" including the "more than four cores" had been the criteria to differentiate high risk and very high risk. The rest were indications for adjuvant ADT with RT. I do tend to conflate some things, but I'm pretty sure that neither PSM nor EPE alone are ever justification for adjuvant therapy.
    Last edited by RobLee; 10-18-2019 at 01:30 PM. Reason: added final recall

  7. #7
    Top User garyi's Avatar
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    Quote Originally Posted by RobLee View Post
    Much of what I post is my recall of things I've read here and there, which is why I "always" include qualifiers such as generally, often, and usually.

    .....I do have the tendency to speak mostly of my own experiences when offering advice to others. After all, that is the only knowledge I have to draw on. My urologist tells me that I should spend less time researching prostate cancer online, which does not help to expand my knowledge base.
    LOL, Rob...Those personal experiences that you and other people post, are most valuable, in my opinion. They, and the studies that folks, and especially Djin make available, are a powerful tool when talking to urologists and oncologists. Sadly, many ill prepared physicians are intimidated by involved and informed patients. Too bad, cause we need to be our own best surrogates.
    72...LUTS for the past 7 years
    TURP 2/16,
    G3+4 discovered
    3T MRI 5/16
    MRI fusion guided biopsy 6/16
    14 cores; four G 3+3, one G3+4,
    CIPRO antibiotic = C. Diff infection 7/16
    Cured with Vanco for 14 days
    Second 3T MRI 1/17
    Worsened bulging of posterior capsule
    Oncotype DX GPS 3/17, LFP risk 63%, Likelihood of Low
    Grade Disease 81%, Likelihood of Organ Confined 80%
    RALP 7/13/17 Dr. Gonzaglo @ Univ of Miami
    G3+4 Confirmed, Organ confined
    pT2 pNO pMn/a Grade Group 2
    PSA 0.32 to .54 over 3 months
    DCFPyl PET & ercMRI Scans - 11/17
    A one inch tumor still in prostate bed = failed surgery
    All met scans clear
    SRT, 2ADT, IMGT 70.2 Gys @1.8 per, completed 5/18
    Radiation Procitis, and Ulcerative Colitis flaired after 20 years
    PSA <.006 9/18, .054 11/18, .070 12/18, .067 2/19, .078 5/19, .074 7/19, .081 9/19, .116 11/19
    We'll see....what is not known dwarfs what is thought to be fact

 

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