Learning about salvage therapies

[hogwell]

Hello... I'm new to this group.

It's now been 10 years since my RP. My post-RP pathology was 3+4 with clear margins and no lymph node cancer.

Now my PSA has started rising in the last couple of years. PSA has gone from .02 up to .07 2 months ago, and now it's at .12. Doubling time is decreasing from 24 months to 6 months, as of this test.

I will check PSA again in 3 months.

So, now it seems I'm looking at possible salvage or secondary treatments of some kind.

I'd like to get up to speed on the options so I have some knowledge when presented with options from the doc.

How to start learning? The list of meds to learn about is daunting (Zytiga, Xtandi, Avodart, Lupron, Apiraterone, etc. etc.) Is there an overview somewhere of secondary treatments and when they are appropriate?

Also, what about radiation to the prostate bed. Is this still recommended as a first step, like it was 10 years ago?

Any thoughts? I'm sure many others have been in this position several years after their primary treatment.

Thanks for any advice...

[Shooter1]

two ways...adt and other drugs or radiation. Oncologist would probably advice ADT such as lupron and Xtandi later on, radiologist would probably advice radiation. With your PSA as low as it is, you have time to see more dr.s and get second opinions before worrying to much.

[Tall_Allen]

Salvage radiation is best done sooner rather than later:

pcnrv.blogspot.com/2016/09/...

Because of your long time to biochemical recurrence, there is a good chance that salvage radiation will be curative:

riskcalc.org/ProstateCancer...

The prostate bed is probably all that's needed at your low PSA. Unfortunately, even the best PET scans aren't likely to show anything, so you have to just assume it's there. you probably don't need adjuvant ADT at your low PSA either. All of this should be discussed with a radiation oncologist (not a urologist or a medical oncologist).

[hogwell in reply to Tall_Allen]

Thank you for these very interesting links...

Early SRT does seems like it should be considered in my case, assuming my next PSA

keeps rising, possibly above 0.2.

In the blog post, it's especially interesting that "The time in months since completion of prostatectomy had no bearing on any of the outcomes."

Also, that PSADT does not seem to be factored into these studies.

Adjuvant ADT before RT also seems to be a good thing to consider.

(Of course, this maximizes SE's... it's hard to want to dive into this.)

[Tall_Allen in reply to hogwell]

PSADT is not validated for PSAs below 0.1 ng/ml (and requires at least 3 readings for PSAs above tat). RTOG 9601 found no advantage to adjuvant ADT in men whose PSA was below 0.7. See Dr Sandler's comment:

pcnrv.blogspot.com/2016/08/...

[Crabcrushe in reply to Tall_Allen]

Is there a list of pda cutoffs per treatment available?

Thanks in advance...

Grasshopper

[Crabcrushe in reply to Crabcrushe]

"Psa", not "pda". Retrieving my laptop tomorrow; Scout's Honor.

[Tall_Allen in reply to Crabcrushe]

No list - earlier is better, and below 0.03 is too early.

[Crabcrushe in reply to Tall_Allen]

Well, I'm cool in that .94's my lowest.

Thanks!

Charlie

[Gemlin_ in reply to Tall_Allen]

Allen, you wrote that with long time between RP and BCR there is a good chance that SRT will curative. How much is the probability for cure improved with time? Are there studies that have looked at the relation between "time from RP to BCR" and "the probability that SRT will be successful"?

[Tall_Allen in reply to Gemlin_]

This nomogram includes the effect of the length of time between prostatectomy and BCR:

mskcc.org/nomograms/prostat...

[hogwell in reply to Tall_Allen]

This nomogram only goes up to 6 years post-RP - too bad, more data needed?

[Gemlin_ in reply to Tall_Allen]

Thanks Allen, I know that nomogram. The nomogram gives the probability that salvage radiation therapy will be successful 46% if BCR at 12 month and 44% if BCR at 72 month. (If I use my own data and hypothetically compare 12 month vs 72 month for BCR = 0.2.)

Thats why I started to believe that the time between prostatectomy and BCR have no (or even worse) bearing on of the outcome of SRT.

Have you seen any studies with relevant discussions about this question?

[Tall_Allen in reply to Gemlin_]

Like all nomograms, they rely on the data used to build it, and they may be quoting data for a combination you are specifying based on just one or two people. Some nomograms tell you what the sample size is. Try this one:

riskcalc.org/ProstateMortal...

[cujoe]

Hogwell,

I recommend any post-RP patients considering adjuvant or salvage radiation study the following document from the AUA. And while it was produced some time ago in 2013, it still provides a good framework for understanding the risks/rewards for RT under the various negative findings of a final biopsy, etc. Since you are 10 years out, some of this may not apply to your specific situation, but it will definitely allow you to be better informed when you and your MO/RO discuss the RT options. There is additional link at the bottom to a more recent 2017 document from AUA that should also be useful to you.

Adjuvant and Salvage Radiotherapy After Prostatectomy: American Society of Clinical Oncology Clinical Practice Guideline Endorsement

Abstract is here:

ascopubs.org/doi/abs/10.120...

Downloadable PDF of full text with charts is here

ascopubs.org/doi/pdf/10.120...

AUA 2017: Identifying the Optimal Candidate for Early Salvage Radiation Therapy after Radical Prostatectomy for Prostate Cancer: A Long-Term Multi-Institutional Analysis

urotoday.com/conference-hig...

Good Luck & Be Well - cujoe

[hogwell in reply to cujoe]

Interesting links... again recommending early SRT rather than waiting for PSA to rise.

OTOH, I've seen several guys on this site who had no benefit from radiation and moved on to ADT to control their situation better.

[Break60]

Radiation kills just the mets radiated whereas ADT gets all mets in your system but it’s not curative.

[j-o-h-n]

Greeting to the Chicago fire. I am the one who's in charge of sparky our mascot Dalmatian. All the guys here are volunteer fireman that know how to handle their hoses. Pay attention to them since they're very sincere and extremely helpful members. So to become a bona fide volunteer we ask that you answer the following questions: Your age? Your location? Your treatment center? Your doctor(s) name(s) and expertise? This info helps our brave members help you. All this information is voluntary and confidential. If you wish not to answer then you will be assigned the duty of walking sparky four times a day.

p.s. I had the salvage radiation.

Good Luck, Good Health and Good Humor.

j-o-h-n Thursday 02/21/2019 5:08 PM EST

[hogwell in reply to j-o-h-n]

Thanks for the Reply... I went ahead and put a new separate post up with more of my info.

[j-o-h-n in reply to hogwell]

Thank you and

Good Luck, Good Health and Good Humor.

j-o-h-n Thursday 02/21/2019 6:00 PM EST

[monte1111 in reply to j-o-h-n]

Pretty easy to handle 3 inch hoses.

[j-o-h-n in reply to monte1111]

You hit the hammer right on head.

erect, that is...

By George, it's his birthday.

Good Luck, Good Health and Good Humor.

j-o-h-n Friday 02/22/2019 5:08 PM EST

[Crabcrushe in reply to j-o-h-n]

You guys have more dignity to waste valuable time on penis jokes.

[Crabcrushe in reply to Crabcrushe]

-than-

Kindle