pT3B Newby

[Engman713]

Hi,

My post RP PSA has been 0.3 (6 wks), 0.3 (5 months) and just rose to 0.4 (8.5 months). My current plan is to wait 3 more months to see if PSA rises/doubles. My MO at MD Anderson (Houston) has presented two possible paths if PSA continues to rise (of course hoping it will go down):

1. If PSA rises to 0.5, enter ADT trial; or

2. If future flucuclovine PET CT shows locally confined recurrent disease without distant metastasis, salvage radiation therapy may be beneficial and provide a chance for prolonged remission if not with curative intent.

Any comments or thoughts on this plan are greatly appreciated.

[spinosa]

I'd go with number two, immediately if not sooner. My RO told me .4 is the cut-off - you've gotta find out if salvage radiation would be of benefit or not.

[Tall_Allen]

I don’t understand why you’re waiting. SRT right away!

[Engman713 in reply to Tall_Allen]

Thanks. My MO did say that some ROs would do radiation at 0.4. He seems to be saying that SRT is a decision that can impact quality of life (toxicity, worse incontinence, etc.). I do have some incontinence/leaking that is slow to get better. He also seems to be waiting for PSA doubling time. He said SRT could kill some residual pc cells but not all cancer stem cells that might have traveled away from the prostate bed. MO says if PSA rises further, he wants to consider Zytega and/or apalutamide to attack the resistant cancer stem cells. I'm going to get a consult with an RO to see that they have to say.

[Hidden in reply to Engman713]

Your RP failed.time for whole pelvic radiation, not spot radiation

[Tall_Allen in reply to Engman713]

Good idea to talk to an RO immediately.

[tallguy2 in reply to Tall_Allen]

I agree!

[Justfor_]

0.3 post RP is persistant PSA, serious stuff. One decimal point resolution PSA test every 3 months, in your case, is a "criminal act". Anyway, confirm current PSA value with a second lab at a 2 decimal point resolution. If it matches the latest 0.4, i.e. 0.36 to 0.45, proceed right away with a modified plan 2. Book a PSMA PET/CT. During the few weeks that you will have to wait for your turn ask your MO to put you on Casodex (Bicalutamide). It will temporarily halt/slow-down any progression and may help the PSMA detection by stimulating cancerous cells to put out more PSMA. The rest as per your description.

[Engman713 in reply to Justfor_]

Thank you. I'm going to get a consult with an RO. I don't think PSMA PET is available in my area nor will my insurance cover it (BCBS). Axumin (flucuclovine) PET seems to be the only one available for me and I just had one (no signs of metastasis at least what the Axumin PET could see). I need to look into where you can get a PCMA PET.

[Timmer1967]

My situation was somewhat similar and I chose SRT. My treatment has all been done at Mayo in Minnesota. Unfortunately, SRT was not curative for me and next month I will be reviewing next steps with Dr's. Please continue to post regarding the path MD Anderson advises you to take as it gives others insight into what top treatment centers promote. Best wishes for you on your treatment journey.

[Justfor_ in reply to Timmer1967]

I wonder whether you had a PSMA PET/CT prior to deciding on sRT?

[Timmer1967 in reply to Justfor_]

No, just a rising psa. I did have lymph node involvement (discovered at time of rp), so it perhaps made the decision more obvious.

[Justfor_ in reply to Timmer1967]

It's never too late, you can take it now. Thanks for responding.

[Engman713 in reply to Justfor_]

No. Flucuclovine PET CT which was clean (or at least did not see anything). Hoping PSMA PET gets approved in my area. I did a PSMA PET trial at MD Anderson a month before my RT which only lit up my prostate area.

[Cooolone]

Early action provides the best results in regard to persistent PSA/recurrence. It's unnerving sometimes to think to wait so that a better diagnosis can be made via PSA results and or imaging.

But the question should be if it will change the outcome in regard to prospective therapy? If no, then why wait? If the testing might provide deviant paths then there may be value... I'm wondering if any DNA testing has been done as well and what the pathology was from the RP.

[Engman713 in reply to Cooolone]

Thanks. 10/30/2021 surgery pathology showing pT3b pN0 (0/18), margins negative with +SVI. +EPE +perivascular soft tissue, + LVI, +PNI, high grade PIN.

[Justfor_ in reply to Engman713]

Same here, except for EPE (R0). RP 25 months ago, still witnessing very very very slow contency improvement. In terms of nightly toilet visits I am better than before RP. I have 20+ PSA counts interleaving two labs and out of them a confident view of my PSADT. My 2021 PSA has been 0.11 to 0.15, 0.03 lab to lab systematic offset. When I hit 0.2 it will be PSMA PET/CT time, probably to be followed by sRT. Your MO is right about late toxicities, there are many members here that have witnessed them. The predominant opinion is taking irradiation lightly following a logic that goes like: "You are going to have it sooner or later as there is nothing else to be offered at this stage. So why wait?"

[Fightinghard]

SRT asap. Might get lucky enough to kill the PCa or at least slow it for years

Talk to a good radiation oncologist for input

[Engman713 in reply to Fightinghard]

Thanks. I'm going to do that.