I was approached for advice from 75 year old family friend who had RRP in 2001 and just became aware that he is in midst of a BCR (see PSAs below) after his PCP who has been ordering PSAs for last several years finally called the recurrence to his attention and sent him to RO.
RO ordered Axumin PET, which, of course, found nothing at his PSA. RO is advising to move quickly with SRT including neoadjuvant ADT.
Friend is in generally good health and is concerned about side effects from SRT. Given very slow PSADT and his age it would seem reasonable to at least consider continuing conservative approach which he has, unwittingly, already been taking for several years.
He asked RO about Decipher but she said Decipher testing is not indicated in the setting of a rising PSA such as his. Given his case, there would not be a clear understanding how to interpret the results and results of the test would not change her treatment recommendations for radiation. This does not sound right to me from everything I have read. I would appreciate insights / advice from anyone about benefit of Decipher in this case and how to get it ordered and paid for by insurance (although he is 75 friend has private insurance through working spouse) or else what it would cost him if insurance will not pay.
I have also advised him to have the surgical specimen sent to Hopkins for detailed read (e.g. extent and Gleason grade of PSMs). If necessary, I wonder if Hopkins would order Decipher for him while they have the specimen?
Original Pathology was done by community hospital and is not very detailed. Final post-op GS was 3+4 with multiple PSMs (base, apex and radial). Original biopsy was only 3+3.
Given PSMs, long time to BCR and very slow PSADT seems likely this could be residual indolent G6.
Recent PSA history…
7/23/12 0.2 (no “<” in EMR but assume it was dropped in transcription from paper chart)
11/5/12 0.2 (no “<” in EMR but assume it was dropped in transcription from paper chart)
1/4/13 0.15
6/22/13 0.15
1/20/15 0.18
2/9/16 0.28
8/3/16 0.29
2/4/17 0.29
2/15/18 0.33
12/10/18 0.36
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RZ13
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I agree with his RO - Decipher won't make one bit of difference. I also don't think he needs a second opinion from JH. Whole mount pathology isn't subject to the same kind of misclassifications that biopsy samples are - and it doesn't matter anyway - his PSA pattern is enough.
He had GS 7 with significant positive margins.
The only question is - how is his health? If he has significant comorbidities, other things may do him in before PC does.
He is in reasonably good health with life expectancy of 15-20 years. He is active with good QoL (although nerve sparing in RRP was failure). The motivation to consider potentially forgoing SRT is avoiding the risk of significant lasting side effects. Is that risk really negligible?
If he had been made aware of BCR four years ago at age 71 I don't think there would have been any question about going ahead with SRT. But given that, for whatever reason, he wasn't made aware till now and he is now 75 and has the benefit of knowing PSADT is 4+years it seems like a closer call -- again unless the risk of significant lasting side effects really is negligible.
The intent of pathology re-read would not be to rule out misclassification but to provide insight on cell pattern at PSMs, which was not noted in original. It's possible only G7 was minimal and fully contained in the specimen.
So, hypothetically, even if all PSMs were G6 and Decipher were low would you say the only rational choice is still SRT + neoadjuvant ADT?
Also, what if Decipher showed high PORTOS , wouldn't that suggest SRT would be unlikely to have any benefit?
I think the chances of his dying of prostate cancer in 10-15 years may be low, but it will rise quickly after that. SRT does have risk of side effects, so he has to weigh those factors. Fortunately, he has had plenty of time to heal since RP, but if he is having urinary dysfunction now, it is likely to get worse.
PORTOS is interesting but requires validation by a prospective, randomized trial:
His Decipher score 20 years ago may be very different from what would have been found now. One of the hallmarks of cancer is continued genomic breakdown - it doesn't stand still even in "dormancy."
Have they kept his prostate tissue that long?
I really don't think it matters about his Gleason score at the margin 20 years ago. The cancer has had plenty of time to progress since then. Since he did have at least pattern 4, his cancer has that genomic characteristic even if it was not yet reflected in cellular architecture 20 years ago. Even if it was GS 6, about half of GS 6's do progress in that time frame:
Thanks. Those are good points. Still, having the additional information about Decipher score and PSMs would seem potentially beneficial - if not as a basis to decide against SRT, depending on what it showed it might also convince him that the cancer risk is too high if he were otherwise inclined to forgo SRT based on the info he currently has (primarily the time-to-BCR and PSADT) and his fear of SRT side effects.
I am opposed to tests done for information purposes. They are only worth doing if they provide a basis on which to make a decision. His PSA pattern is reason enough no matter what the tests show. Even if his tissue from 20 years ago show low risk, which is likely, it is meaningless. The tests just get in the way and cause anxiety.
IMO, he is extremely fortunate to be where he is at 18 years post-op; especially since he has received no adjuvant therapy. This scenario would be a dream for many of us...just sayin! My urologist wasn't too concerned about me until my PSA rose above 1.0. I consider myself to be one of the very lucky guys since I'm also 75, 14 years post-op, had recent sacral lymph node surgery, and I'm currently doing transdermal estradiol therapy with successful results.
To my mind he would be better spending his money on a PSMA scan - I'm not sure about the US, but very high quality PSMA is available at Peter Mac in Melbourne Australia for US$530; Decipher on an RP specimen costs US$3400 for non-US residents, so frankly he could fly here buisness class and still be ahead!!
The PSMA scan has a reasonable shot at telling him what they should be shooting at - but it seems likely that he has a reoccurrence in the area of the positive margins i.e. the prostatic fossa (where the prostate was removed). He is by no means to old to consider SRT, and the side effects shouldn't be a countervailing consideration if he uses an experienced RT. He has a pretty good shot at a cure and even if not, then at knocking it back down for so long as it will make no difference to him.
It's not moving fast - and although he has left it a little later than the emerging optimal window for SRT (thought to be a PSA of 0.1 - 0.2), most men who had SRT prior to the last few years had PSAs higher than his and many achieved success. If he does go ahead with SRT he could consider a short (ca. four to six month) course of ADT to "compensate" for his PSA, although under recent SRT guidelines, he probably needn't do so.
I am starting 2 years of ADT tomorrow (that's the aim, anyway) and SRT a couple of weeks later, with a PSA of 0.12. While I am one of the 25% having a high PORTOS and it's true that has afforded me some comfort about the whole SRT thing, my PSADT is just 3.5 months and Decipher says I have a 48% chance of metastatic progression within 5 years - it doesn't just measure PORTOS! We haven't been able to find anything on the PSMA scan so will be shooting blind - I'd happily swap situations with your friend any day!
I had the 68Ga PSMA scan done at Peter Mac 20 months ago for US$600...was $ 2750 at UCLA and Medicare wouldn't cover it. My RT airfare from Thailand to Melbourne was $730 so the scan and ticket ended up being half the price of the UCLA scan alone. Only problem with the scan is that it normally doesn't identify tumors <4 mm.
I have read studies that said some people benefited from SRT and others had it accelerate the time to DM in patients who had it done compared to the cohort that did watchful waiting. Side effects are not insignificant. I am facing the same decision. The study said that Decipher scores were predictive. Even the ones that had radiation did not have an overall survival benefit, but some of those that did had the permanent side effects. in several of the studies people faired better with longer OS by not doing SRT.
Leave this alone...your PSA Velocity is still very slow. I am 0.27 and am feeling well after 19 years RP.We can't always listen to your doctors.......you are money to them...are they concerned about quality of life at 75?Just something to think about. Good Luck.
My friend has decided he'd like to get an expert 2nd opinion on what to do / not do from a risk-based perspective. His insurance will apparently pay for travel as well as the consult.
He was thinking of going to Hopkins. Although Hopkins is not really known for radiation they have a Multidisciplinary Clinic where he could talk to both radiation and medical oncologists during a day-long session.
The first thought I had was for him to go see Anthony D'Amico from Dana-Farber.
Any other suggestions of where to go / who to see for expert advice on his situation? He is in Chicago area.
Update on this. My friend just returned from his consult at Hopkins.
The RO he saw told my friend that if he were 10 years younger recommendation may be different but, given his age and very slow PSA doubling rate, RO did NOT recommend SRT at this time.
RO advised my friend to monitor PSA every six months and follow up if kinetics change. He also said that if PSA reaches 1.0 within 2-3 years he'd recommend a PSMA PET scan at that time.
RO apparently also mentioned SBRT as an alternative to IMRT, but my friend didn't seem to have a lot of details on that.
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