PSA 3.12 after 3/17 radical prostatectomy. Future treatment thoughts?

[happycamperguy]

I'm new to Advanced Prostate Cancer, moving "up" from Prostate Cancer Network due to recent pathology results after da Vinci radical prostatectomy (RP) on March 17 in Spokane, WA, with Dr. Raymond Lance, who had more than 2,000 da Vinci RPs under his belt. I feel very good about this choice. Surgery was successful, and my incontinence is minor. 3/17 surgery went well.

My late Oct. 17, 2019 PSA had been up to 74.3. My Oct. 2019 prostate biopsy revealed Gleason 7 (mostly 4 + 3). Thanks to all of you who provided feedback at that time.

POST-SURGERY PATHOLOGY REPORT: Pathology revealed 90% of prostate had cancer, with one tumor beginning to break out, so report said "positive margin." Pathology report said "Gleason pattern at positive margin = Pattern 5."No cancer in seminal vesicles removed and, to Dr. Lance's surprise, no cancer in 21 removed pelvic lymph nodes. Pathology report said "Surgical Pathology Stage pT3a, pN0." (Does this mean Stage 3A?).The 3/17 surgery pathology report said "Gleason's Score 5 + 4 = 9."

Doc said he removed 1 and 1/2 neurovascular bundles, but preserved pedendal never that preserves continence.

Yesterday (4/29/2020), my PSA was down to 3.12 six weeks after RP. Still higher than it should be, I believe. I meet again next week with Dr. Lance, Any perspectives on beam radiation treatment (RT), ADT or other treatment or scans going forward?

My surgeon Dr. Lance said, in February pre-surgery, he trusted only 2 Radiation Oncologists (RO) in Spokane to perform RP follow-through radiation treatment, plus perhaps Dr. Guy Jones in Richland, WA.I'm aware there is a Varian Edge system with IMRT/IGRT in Richland with Dr. Guy Jones, but have not yet had a consult with him; looks like that's an option. Spokane appears to only have Varian Truebeam and Cyberknife, but no Varian Edge. Your thoughts on RT hardware/ROs?

So I'm Looking for a capable RO as local as possible. I live in Walla Walla WA, about 3 hours from Spokane and about 1 hour from Richland-Kennewick-Pasco ("Tri-Cities"). Many hours from Seattle. Of course, I seek to minimize travel with COVID-19 all around.

Note I chose da Vinci surgery because brachytherapy would have damaged my Medtronic insulin pump. I am diabetic. Thanks in advance!

[Tall_Allen]

I'm not sure why you say "surgery was successful"- it clearly wasn't.

Positive margin means that the surgeon left some of the cancer inside of you. The cancer beginning to break out is something else; it's called "extraprostatic extension" (Stage pT3a) and is an additional risk factor. And of course, your persistent PSA tells you that you need adjuvant radiation.

You can get an Axumin PET scan, which will tell you if the cancer has left the immediate area of the prostate. If it is negative, you can go ahead with adjuvant radiation. If it is positive, Zytiga or docetaxel would be a good next step.

You should have a shot of Firmagon immediately after the Axumin scan. That will prevent progression of the cancer and may kill off the cancer that was released into your bloodstream by the surgery. After a couple of months of Firmagon, you can switch to a multi-month shot of Lupron. With the hormone therapy, you can safely put off the radiation (if still warranted) until you've had time to regain continence.

You may want to consult with a medical oncologist in addition to a radiation oncologist.

[Boacan in reply to Tall_Allen]

My situation after RP (01/06/2020) is similar (stage pT3a / pN0) but with slightly better post-op pathology, i.e. clear margins & clear nodes/seminal vesicles. However, a small focal EPE was noted but within the margins. Therefore, stage pT3a. Post-op pathology also identified PNI along with “one focus” lymphovascular invasion. Gleason 3+4 with only 10 percent of prostate with cancer. Pre-surgery PSA was 6.1 and post-op PSA on 02/25/2020 and again on 04/24/2020 <.01 undetectable. MO and urologist recommend continued monitoring PSA at 3 month intervals and moving to 6 months after 1 year if still undetectable. I value your opinion and wonder if I should continue active surveillance or consider consulting with an RO? I’ve followed many of your posts and read many of your articles but wanted to know your thoughts on the above. Best regards.

[Tall_Allen in reply to Boacan]

I think they gave you good advice. Your situation is very different from the OP's. You can wait for 3 consecutive uPSA rises orif a PSA= 0.1

[happycamperguy in reply to Tall_Allen]

Thanks, Allen. I’ll digest your information to better understand it all. Thanks for pointing me in these directions. Do you know where I can get an Axumin PETscan in Washington state?

[Tall_Allen in reply to happycamperguy]

try this:

axumin.com/imaging-center-l...

[HopingForTheBest1]

Ask your doctor about getting genetic testing. It could determine effective treatment for you.

[PGDuan]

Hi, my situation was somewhat similar. Ths Axumin scan is a good idea. For me, RALP showed no margins and no positive lymph nodes so we were first told the surgery was successful (PSA around 11 , GS 4+3 when I started). Then...post-surgery PSA of 4.0. Subsequent Axumin scan showed 2 local “avid”lymph nodes, so then onto 18 months of ADT + Zytiga. Undetectable for the past 16 months and hoping for a long or permanent ADT vacation soon. Take care, good luck.

[Concernedwife24]

My husband has a similar pathology report but is t3bn1. It was in seminal vesicle. Waiting for first PSA.

We are thinking of going for all the treatment out there. Radiation and hormones. But if my husband's PSA is over 1 I will insist on the new pet scan to see if it has spread anywhere specific. If it has radiation might be too late and maybe chemo will be better. Still haven't discussed all these ideas with the doctors. Good luck and prayers.

[petercraig2]

Hello happy camper,

I had surgery and PSA was still 3.2 afterwards. All scans at the clinic showed nothing I went to Charite in Berlin and had GA-68 PET-PSMA scan which showed cancer in two lower abdominal lymph nodes.

They recommended surgery or what they call cyberknife which I believe is focused laser therapy here. Met the radiologist in Canada who told me in no uncertain terms that full abdominal radiation was the only solution he would offer. Patronizing and condescending with phone calls at home I eventually buckled under the pressure.

Following surgery I had regained full bladder control and was cycling, running and active in doing the physical exertions I enjoy. Following radiation I lost bladder control and despite Kegals I'm still struggling nearly two years later.

I regret not being more resolute and being more determined to find the place that would do SBRT radiation therapy which is focused, small number of sessions at higher intensity with very good outcomes over many years.

So have been on estrogen patches for 2 1/2 years now and PSA has gone from 12.4 to <.008 or unmeasurable and testosterone <.01 or non-existent with no significant issues.

Best of luck to you.

[j-o-h-n]

My only comment is STAY happy!!!

Good Luck, Good Health and Good Humor.

j-o-h-n Friday 05/01/2020 2:25 PM DST

[ranger69]

Hi Happy CamperI have been seeing Dr. Lance and he has referred me to Summit Cancer Care for Cyberknife treatment. He referred me to Dr. Kelly. Was this Dr one of the ones he mentioned of the three that he trusted?

[happycamperguy]

Ranger69 Dr. Lance only mentioned Dr Jones in Richland. Dr. Jones left the practice. Not sure who replaced him. Tri-Cities Cancer Center has good Varian hardware. Maybe ask Dr. Lance where Dr. Jones went? Or who the other two Dr. Lance trusts.