Wait for a PSA rise or Radiate Now- h... - Advanced Prostate...

Advanced Prostate Cancer

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Wait for a PSA rise or Radiate Now- how did you choose?

JosephineS
JosephineS

Hi folks, as you can see from my profile, my husband has prostate cancer. We are nearing 3 MOs mark after his surgery. We are currently debating next steps. Based on what I have read, advice received in this forum and a consult with an MO, it seems adjunctive radiation is the likely course to follow. My husband is deeply discouraged by potential side affects (albeit short term) and prefers to take action only when he has to. His plan is to wait for a PSA rise and then attack back. My worry is that if we wait, do we increase the risk it will metastasize? For those in similar situations, can you help me understand how you came to your decision? We are meeting with radiation oncologist this afternoon. My only ask of my husband is that he make informed decisions. I am thankful he is at least willing to talk to the radiologist.

25 Replies
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Hi, Josephine, Is his PSA persistent? Were there positive margins? Why do you think you need to proceed at this point?

JosephineS
JosephineS in reply to COG1

Thanks for the quick reply, yes there were positive surgical margins, also ECE and LVI. His Gleason remained 4+3 but did come back with a tiercierary 5 pattern as well. Those are the main drivers of why I think additional treatment may be needed. He hasn’t gotten his First PSA . That is end of the month as his urologist doesn’t believe in looking at that until 3 MOs post surgery which will be 4/30.

The timing of the radiation will not influence the occurence of metastases. There are already cells in the blood stream which can result in mets.

I would wait at least six months after surgery to recover from that. This should result in fewer side effects caused by the radiation. If you are afraid to wait you can have ADT to stop the tumor from progressing.

You can have adjuvant radiation after surgery, this is radiation during three months after surgery. Or early salvage radiation, this is done six to twelve months after surgery. I prefer early salvage radiation. You will usually start with that when the PSA value, without ADT, is between 0.2 and 0.5 ng/ml.

I had a Decipher test done on my biopsy tissue -- it could be run on your husband's surgically removed tissue. My exceedingly high risk Decipher score (0.94) combined with +SM, +EPE/ECE and cribriform being the 4 in my GS7=4+3 led me to chose adjuvant RT along with six months of ADT even though my PSA has been <0.1. Surveillance is a valid choice, as is ART alone. All depends upon your personal risk/reward analysis. Talking with the RO is a good start.

Tall_Allen will probably answer with more information, but here's a start:

urotoday.com/conference-hig...

You can wait for his first PSA before deciding.

Thank you both for your reply. We will have that answer (PSA) very soon. Let’s say it comes back undetectable, what would your recommendation be given his pathology? When we run the pathology through the calculators it seems likely biochemical reoccurrence is likely. This is the driver for me feeling like we still have a shot at a cure if we can kill it before to reorganizes. Is this flawed thinking?

pjoshea13
pjoshea13 in reply to JosephineS

Josephine,

If PSA is 'undetectable', no treatment is required, but one should always act as though biochemical recurrence is possible, IMO. Many men hear that treatment was successful & assume a cure, when recurrence rates are significant - with positive margins there is a 40% chance of recurrence within 5 years [1].

There are many past threads that may be helpful, including those on reducing the risk of mets, controling altered coagulation, reducing inflammation - & many others.

If the treatment was not a success, radiation has to wait until everything has healed. The threads I mentioned are still important, IMO.

-Patrick

[1] ncbi.nlm.nih.gov/pubmed/230...

In my experience it’s best to take things step by step. I find that looking too far down the road can lead to depression. Wait until the first PSA result. The body will not be ready for radiotherapy for 6 months anyway. Hormone treatment can be given before that if needed but there is a cost to the body from all these treatments.

Josephine, As you can now see, ask five people and you will get five different "opinions". In one of your earlier posts, I profiled my treatment experience following surgery with near identical pathology to your husband's. My solitary experience is just that - and does not reflect what pathway you/he should follow.

Most importantly, in that post I linked several guideline documents that discuss in detail what are the issues for the various negative pathology results when considering RT. That document is sorely out of date (2013), but as it was a meta-study of the available research at that time, it correlates individual research that can be difficult for non-research individuals to do on their own. It was invaluable to me in making my treatment decision.

I suggest you go back and review those documents again. Whether your husband's PSA comes back undetectable or not, with the pathology he has, it is very probable that he will have a biochemical recurrence. (As I did.) The question you need to discuss with your medical oncologist(s) is what treatments will reduce the chances of and/or prolong the time to that recurrence.

Good Luck & Be Well - cujoe

Wait for the PSA test result. I had a RP and waited 2.5 years before I followed up with radiation. My PSA slowly rose 6 months after my surgery. I chose radiation when my PSA hit 0.185. 2.5 years after radiation my psa is still undetectable. I am G9 N0x M0x, EPE, SVI.

Just a quick note to let you know how timely your response was. I was in the consult room with my husband when notification came through and we had a few minutes to wait. I have read the materials your provided and reread your response. I completely agree. Armed with this refresher the Radiation oncologist suggested we are still looking at a cure with early salvage radiation. He encourages the first PSA and if not undetectable (different from the .2 call to action) early salvage is his recommendation. He will also present my husband’s case to the tumor board to ensure his colleagues at University of Chicago are in agreement with the approach. It was a good meeting and informative. I am not so much in a hurry but more looking for answers as to why some men choose salvage radiation while others choose not to undergo such treatment. My goal for my husband is cute or at the least durable remission for 10+ years. God willing we get there and are wise enough to choose a path the ensures that goal is bet. Thanks as always for your timely and thoughtful responses.

Shooter1
Shooter1 in reply to JosephineS

I'm also aiming for ten years. First told 12-18mo. max. Well beyond that now and still kicking, just not as high.

cujoe
cujoe in reply to JosephineS

Perfect Plan of Action. Good Luck & Be Well - cujoe

That’s what I like to here Shooter! Keep up the good fight!

Please read this blog, the good news that yor husband has G 7 which is not as bad as G >8

This patient cured form PC after Salvage radiation.

pcabefore50.blogspot.com/

I had radiation of the prostate bed about 3 months after my prostatectomy. Evidently, some cancer cells had already escaped as six months later my PSA started rising again. Did an MRI Scan and it had metastasized to my ribs and left shoulder. Stage 4 within a year. Fighting since with various meds. So, he should radiate. Everyone is different though. I have three friends that have had a prostatectomy with no problems and PSA stable. So, who knows. The radiation isn’t all that bad. I think mine was five days per week for six weeks. You experience fatigue toward the end, but when your finished a week later your fine and good to go. There is usually a reason they are recommending the radiation. Good luck and hope everything goes well!!!

As long as there are no co-morbidity involved, stay aggressive and don’t let the bastard dictate. It’s his life, and side effects can be managed. After DX went to RO and first sign of metastatis, MO and chemo-hormone trial for six months. Worked out from me. Ex Gleason (4+3).

Hi josephine, my dx very similar. 4+3 t2bn0m0. Six weeks post RP PSA was .06...six months later 0.23...twelve DAYS later 0.027. According to the best trials out there the treatment plan is radiation to the prostate bed and lower lymph nodes while adding a six month ADT. The decision was not easy but none of my fears have materialized. Now on week five of seven. hope this helps...have to get after the beast.

This is so highly personal and individual. Depends on age, personality, comfort with taking risks, etc. MY situation is similar to his: 4-1/2 months after surgery for a G8 tumor with questionable margins. I am 75 with an otherwise good expectation for longevity. My PSA remains undetectable. I am choosing to watch and wait; in fact, seeing my oncology team this week. I rejected RT+ADT at the outset, telling the oncology team that the side effects of the treatment they recommended were unacceptable to me, and would not permit me the quality of life that I want and need. I am a physician still in active practice. THEIR metric is survival and I honor them for that. THEY, however, do not have to live with the side effects of their treatment. We all read on this site the sometimes callous and uncaring attitudes of oncologists toward their patients' travail as they _endure_ the treatment. Not for me. Again, totally personal. I will wait and see and deal with the anxiety of not knowing. If my PSA starts to rise, as there is a 36% chance it will, I will reconsider.

Check out Proton Radiation...it was side effect free for me, 38 treatments without issues...

carlo8686
carlo8686 in reply to theopolis

Me too. 39 treatments and good. Now the lupron stopped everything in its tracks. Finished radiation on the 18 th of this month just a little burning.

And my comment is:

Good Luck, Good Health and Good Humor.

j-o-h-n Tuesday 04/23/2019 11:52 AM DST

Always tough decisions to be made. Sorry you are in this situation. My situation was also similar: G7 (4+3) in 2014. Decided on robotic assisted radical prostatectomy and the pathology confirmed the G7(4+3) along with positive margins, one seminal vesicle involved and extra capsule extension for stage T3b. First PSA was <0.1, but we did consider adjuvant radiation. The Decipher DX (older version) showed a score just over the Low Average risk of recurrence in 5 years. Based on that result, the decision was made not to do adjuvant radiation. The decision was made jointly with the urologist so no blame can be assessed. My PSA began to slowly rise after 17 months. Decided on salvage radiation and 6 months of Lupron when PSA hit 0.3. It has now been 2 years and still undetectable. The only rule about PC is that almost every case is different. Make your best educated decision and never look back. Wishing you and your husband the best.

A PSA can go up maybe 0.1 or 0.2 in 3 months. My PSA was 1.2 for many years, then went to 3.0 and stayed there for 1 year. Then went up to 7.0 and a month later was at 18. After another month it was at 72.0 so I had radiation and started Lupron injections. If you put these tests on a graph you will see the the PSA went up exponentially. That is what triggered the start of therapy. I stayed on Lupron for 6 1/2 years and now my cancer is gone! I think early diagnosis helped even though I had metastases in the bone.

A good discussion point is micro-metastases. Once into the vascular or lymphatic system, my understanding is that systemic treatment is needed. Success depends on size of tumor burden and body strength. Best discussion with a MO, however a RO should be versed as well.

Finially ask, “Doc if you were in my shoes with my degree of disease, what would you do?”

GD

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