Rising post-RP PSA. How long to wait ... - Advanced Prostate...

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Rising post-RP PSA. How long to wait before SRT?

Bcmariposa
Bcmariposa

56 years old, PSA =5.8, RP in July 2018

Gleason 3+4 (although original biopsy said Gleason 9!)

Margins were clear, nothing in lymph nodes. Everything was great with PSA undetectable until October 2019 PSA = 0.02

Since then:

Jan = 0.04

Mar = 0.06

May = 0.10

Have a virtual appointment with MO soon, but should I request to start radiation now ( with Covid concerns still a problem in my area)? Should I get ADT with the radiation? What other questions should I ask?

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"should I request to start radiation now "

Now would be a good time to talk to a radiation oncologist. It was recently found that a PSA of 0.1 or 3 consecutive rises gives results as good as immediate (adjuvant) radiation:

pcnrv.blogspot.com/2019/09/...

"( with Covid concerns still a problem in my area)?"

Consider a hypofractionated course of salvage radiation. A panel of ROs is recommending that during the pandemic.

pcnrv.blogspot.com/2020/04/...

"Should I get ADT with the radiation?"

Unnecessary with PSA that low.

"What other questions should I ask?"

pcnrv.blogspot.com/2017/12/...

MO (at Dana Farber in Boston) is recommending ADT despite my questioning it’s benefits in my case. He said it’s better to hit the cancer with everything early on to have a better chance at a cure. I trust him, but dread the side effects.

You should discuss this with an RO, not an MO. Many MOs are ignorant about this sort of thing, and you have the hammer/nail phenomenon going on. Paul Nguyen would be a good choice.

I made a mistake in my post as Robert_san pointed out. I corrected it now. Please note.

Shouldn't that read ".1 or 3 consecutive rises"? (-- just in case OP did not read down into the pcnrv link)

Yes- I'll correct that - thanks!

I would agree with Tall Allen time to see a radiation oncologist. I was similar age 4+3 but with a positive margin. They wanted to do me after 3 raises and PSA was 0.06 when I had radiation. I pushed them into 6 months ADT because I thought it would have a combination impact. Unfortunately it did not work for me but I thought worth a shot. One question I would ask is whether they intend to do the lymph nodes or not? There are pros and cons. With me they decided not to and only concentrate on the prostate bed because I had a positive margin. At this stage I don’t know whether that was a poor decision because my PSA is only back up to 0.05 which is too low for scans to confidently locate. Very difficult decisions and I wish you all the best

Your PSA is still low. One option would be to go on an ADT drug, i.e. Lupron for a few months then take the radiation treatments. It would give things time to quiet down as far as the coronavirus.

Ask about getting genetic testing. It may be able to determine an effective course of treatment via precision medicine. It has worked for me.

Interesting similarities. I was 54 when diagnosed 3/2006 with PSA 5.8 and Gleason 3+4. RP 5/2006 showed Gleason 4+3 and no exterior involvement. PSA was undetectable for a year. When PSA went to 0.12 and then 0.20, IMRT on local area 12/2007-1/2008 without ADT gave me 7.5 years of undetectable PSA. When PSA again started in 2016 (0.06 but doubling in 6 months) IMRT of additional lymph nodes + Taxotere + Lupron made PSA undetectable again.

My philosophy has been to use every reasonable tool available to fight the war to outlive my parents who made it to 87 and 88. Lupron has been my least favorite treatment.

p.s. If I have any regrets in hindsight with my current knowledge, it would be not getting treatments sooner at original PSA doubling and at biochemical recurrence.

Personal (dissenting) opinion, not advice...

For myself, I would do the ADT (or some form of hormonal therapy) earlier rather than later. I like the advice of hitting the PC early and hard, but if I could only choose one, RT or ADT, I would chooses ADT.

From my reading, I believe most PC is intrinsically systemic and micro-metastases are commonly in our blood/bones well before RP. That doesn't mean they ever do anything aggressive or lethal, but it means systemic treatment earlier might be better (and for me, radiation only to the mets if and when they give pain or problems).

A minority of MOs might agree with me, but of course no ROs would (unless they were already retired and not worried about putting themselves out of business).

From a few studies, random and without context:

"Experience at our institution with SRT demonstrates that this results in good long-term biochemical control. However, toxicity and urinary incontinence rates were high."

"Nearly half of patients with recurrent prostate cancer after radical prostatectomy have a long-term PSA response to SRT when treatment is administered at the earliest sign of recurrence."

[then presumably LESS than half DON'T?]

My experience, may not be yours.

Diagnosed in Jan 14 at age 57. Surgery in March 14, T2CNoMx, GS 8, ECE, SV and margins negative, 10% prostate involved.

PSA <.1 until Sep 15 when it comes in at .2. We tested 90 days later and it was .3.

We did SRT in March 16, 39 IMRT, 70.2 Gya. I asked bout including sort term ADT and including the PLNs, answer, " not enough long term data...!"

90 days after finishing SRT PSA was .7, tested 30 days later 1.0...epic failure.

With my clinical data, GS 8, 18 months to BCR, PSADT and PSAV, it was clear how agressive my PCA was.

Went to Mayo in Jan 17, C11 Choline scan showed four PLNs but no organ or bone involvement. I agree with Dr. Kwon and we start treatment, 24 months of ADT, six cycles of taxotere and 25 more radiation treatments, IMRT, 45 Gya. With the first 3 month ADT and taxotere PSA dropped from 4.8 to .8, with the 2nd taxotere, <.1, T to <7. Both stayed there.

We finished treatment in May 18 as Dr. Kwon agrees that 18 months of ADT is sufficient given my response to treatment. Latest labs have PSA stable, .07.Though those 18 months were no picnic, I managed to live my life, worked, traveled, exercised...Life is great with T!

I feel like I am in AS now, my urologist and I test and consult every four months. We have an idea of what we'll do when it comes back, get multiple readings to gauge PSADT and PSAV, image using C11 Choline, Aximun or PMSA, then informed by that clinical data, make a decision on treatment.

Lessons learned for me.

Aggressive PCa requires aggressive treatment which may not be the standard of care or what I call "population based medicine."

Given the likelihood of micro-metastatic disease, mono-therapy may not be the best decision. My urologist did not want to do surgery for that reason.

Combining treatments and bringing them forward in the disease rather than linear and sequential treatments destined to fail may be better.

Shorten my window for treatment, if it's not curable, instead of 10-15 years, ask if this treatment will work for the next 3-5 years, if so, great because by then newer treatment options will be available.

TA has given solid advice, I'm just giving my experience.

Good luck with your decision.

Kevin

Just think of your spouse... Hit it hard and fast...

Good Luck, Good Health and Good Humor.

j-o-h-n Tuesday 05/19/2020 7:38 PM DST

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