Exceptions to "early salvage" radiation treatment for recurrence after prostatectomy

[Tall_Allen]

Sometimes, it is unsafe to wait for a biochemical recurrence; sometimes, it is safe to put it off.

prostatecancer.news/2021/10...

[Jmr11820]

Thanks for this. On a somewhat related note, do you still advocate for no ADT for men who chose ART with a very low PSA… below .05? I am DECIPHER high risk and did not have hormone therapy with my ART with a PSA OF .03. Some of the DECIPHER studies in the past year or so suggest otherwise. Thanks for keeping all on this forum current with PC news.

[Tall_Allen in reply to Jmr11820]

I haven't seen that, but I am open to it if you have seen such a study. Do you know which studies?

[Jmr11820 in reply to Tall_Allen]

From Decipher on Twitter…….recommended by the NCCN to guide specific treatment decisions,” said Elai Davicioni, Ph.D., Veracyte’s senior vice president, scientific and clinical operations, urologic cancers. “The NCCN’s designation is unique to Decipher Prostate RP and underscores the extensive clinical validation and clinical utility data behind the test. We believe this recommendation will ultimately enable more men to receive the treatment they need, while reducing unnecessary therapy.”

The new NCCN recommendations are based on results of the NRG Oncology Phase 3 randomized controlled trial, RTOG 96-01. This study, which followed patients for a median of 12 years, demonstrated that Decipher risk results were associated with hormone therapy benefit, with Decipher high-risk men receiving greater absolute benefit from hormone therapy compared to Decipher low-risk men. In the subset of patients who received hormone therapy in addition to early salvage radiotherapy,

[Tall_Allen in reply to Jmr11820]

NRG/RTOG 9601 showed that recurrent patients with PSA less than 0.6 were harmed by adjuvant ADT. It only treated patients with PSA>0.2.

[rscic in reply to Jmr11820]

Last I heard (2019) ADT with ART is somewhat controversial ..... different MO's have different opinions.

[Tall_Allen in reply to rscic]

Not controversial for those with adverse pathology as defined in the article.

[rscic in reply to Tall_Allen]

At least in 2019, some ART without ADT was given to some of the patients with a Gleason score = 8-10, and Stage T3 pathology ..... I cannot speak to today ..... so apparently some MO's did & some did not give ADT .... at least in 2019.

[Tall_Allen in reply to rscic]

There are always doctors who do not provide the standard of care. That doesn't make them controversial, just ignorant.

[rscic in reply to Tall_Allen]

This was a Dr. Nicholas Vogelzang, a renowned medical oncologist and cancer researcher ..... WE are all ignorant compared to a researcher of his status. Again, this was 2019.

[Tall_Allen in reply to rscic]

I seriously doubt that Nick Vogelzang would have withheld ADT from ART from men with Gleason score = 8-10, and Stage T3 pathology. He might have waited for PSA to be detectable (salvage, not adjuvant), however.

[rscic in reply to Tall_Allen]

This was a pre-surgical Gleason score of 8-10 ... which I assumed the article was referring to. He did not (at that time, 2019) want to wait for Salvage RT. Unless I am missing something, with a Pre-surgical Gleason Score of 8-10 & T3 Pathology it now seems Adjuvant RT was a good decision. He considered ADT but decided not to utilize it, possibly because there was only microscopic penetration of the capsule, though I do not know that & he did not comment on it. If I remember correctly, the large study comparing Adjuvant & Salvage RT did not come out until late summer or fall of 2019. This is what happened. Treatment is an evolving process & this paper may ultimately demonstrate that. The fact this occurred in 2019 might influence what decisions were made then.

[Tall_Allen in reply to rscic]

No, the article was after pathology. Why would he use the biopsy results when he could use the post-surgery results?

[rscic in reply to Tall_Allen]

A mistake here on my part ..... Pre-Surgical PSA was 9+ ..... Gleason was 3+4 = 7 (85% G3 & 15% G4) ..... microscopic penetration of the Prostate Capsule.

RECOMMENDED after Prostatectomy:

Adjuvant RT without ADT .... ADT was considered

Again this was 2019

My interest in your post was because in 2019 the large study came out recommending Salvage RT over Adjuvant RT. Your Post seems to further qualify this where some situations seem to do better with Adjuvant RT ..... looks like progress to me .... Thanks for posting!!

[tallguy2]

Thanks for posting this!

[Gemlin_]

In the article you define "adverse pathology" as: positive lymph nodes, or Gleason score = 8-10, OR Stage T3 or T4. But I don't think I agree that all T3s should have ART, they could safely do SRT if PSA returns. So isn't high Gleason AND T3 a better inclusion criteria? (I was T3, no radiation, and still undetectable after 7 years.)

[Jmr11820 in reply to Gemlin_]

Did you ever have a genomic test, DECIPHER or otherwise, to access your risk of metastasis? I was DECIPHER high risk which was the reason I sought RT sooner than later. 7 years… congratulations!

[Gemlin_ in reply to Jmr11820]

Thanks! Yes, I live in Sweden and we use another test, called STHLM3. You can read about it here in english sthlm3.se/sthlm3-testet/ The doctor recommended me to monitor the PSA after the surgery and wait with radiation. Still waiting after 7 years! 😀

[Jmr11820 in reply to Gemlin_]

Undetectable is defined as < .1 in your case?

[Gemlin_ in reply to Jmr11820]

Yes, they do not report anything lower than 0.1 here even though the labs measure much lower. They say that it only causes unnecessary anxiety and has no clinical value to report lower values. Different i US I understand. You guys know your PSA down to 0.003.

[rscic in reply to Gemlin_]

Article reads as follows:...... "adverse pathology" defined as:

positive lymph nodes, or

Gleason score = 8-10, and

Stage T3 or T4

So, it looks like your logic "high Gleason AND T3 a better inclusion criteria" was their thinking as well.

[Tall_Allen]

You are right! Thanks for catching that error on my part.

[rscic]

My MO (a prominent Prostate Cancer researcher) said to me at the time of the Early Salvage RT vs Adjunct RT trial (came out in 2019 as I recall) he felt more research needed to be done before changing his practice ..... this may be one of those caveats to that research. His comment was "Mistakes have been made in the past" & he wanted to see more/better defined evidence .... it appears his thoughts were correct .... we shall see how this develops.

[slpdvmmd]

The concept of biochemical recurrence probably needs to be reevaluated given the improvement in imaging provided by PSMA PET/CT. I was initially labeled biochemical recurrence but PSMA PET redefined the extent of my disease.

[Tall_Allen in reply to slpdvmmd]

Biochemical means on a PSA test, not on imaging.

[j-o-h-n]

"Sometimes it is unsafe to wait for a biochemical recurrence - sometimes it is safe to put it off."

BTW sounds like my arguments with my wife.

Good Luck, Good Health and Good Humor.

j-o-h-n Wednesday 10/20/2021 9:30 PM DST