Radical prostatectomy, Gleason score 7 (4+3), PSA persistence, PSA rising, choosing no treatment

[inhaleexhalerepeat]

My father, 72, had his prostatectomy in May 2021, tumor stage T3a, N0. He had positive surgical margins, bladder neck invasion and perineural invasion. His post-surgical psa was 0.4 Aug, 0.437 Sept, 0.6 Oct, 0.723 Nov. His PSMA PET/CT did not identify any specific locations. His oncologist recommends 24 months of ADT (Lupron) and radiation to the prostate fossa due to the positive surgical margins. My father is reluctant to start therapy due to potential side effects of the medicine (ED) along with his ongoing incontinence and bladder leakage. He said he doesn’t want to make a decision right now. I want to make sure he understands what the potential consequences of the delaying the decision too long could mean or choosing to not undergo treatment. His doctor plans to check his psa every 6 weeks. I know everyone is different but based on the information provided, how urgent is it that he makes a decision?

[Justfor_]

The key word retained after my reading is bladder neck invasion. If the spot was well rescted incontinence will last and sRT will make it worse. If not, bladder invasion may be a matter of a couple of years. Serious either way. PSMA scan by 68Ga or 18F DCFPyL does not provide good visibility on the urinary track. 18F PSMA 1007 does better. An interim solution until he makes up his mind is Bicalutamide monotherapy. It will keep his PSA low with almost no SE. Not a brilliant solution but better than nothing.

[Tall_Allen]

It is certainly urgent to do something immediately, although salvage radiation can be delayed. The authors of the following study recommend starting ADT immediately but delaying radiation for 7 months to give tissues a chance to heal:

sciencedirect.com/science/a...

In a way, he is fortunate that there are positive margins. I say this only because it adds to his probability that salvage radiation will be curative. His negative PSMA PET scan means he may be able to get away with prostate bed radiation only. He may want to discuss the following French recommendation for the prostate field size:

redjournal.org/article/S036...

They probably did not spare his bladder neck, so that will delay continence recovery. 7 or more months of ADT will hopefully give him enough time to recover continence.

[inhaleexhalerepeat in reply to Tall_Allen]

Thank you. Do you have an opinion on bicalutamide monotherapy versus lupron?

[Tall_Allen in reply to inhaleexhalerepeat]

Yes. Lupron or Orgovyx is much better.

[lcfcpolo]

Hi. Are you aware if FMRI offer LU177 combined with AC225, like some German hospitals appear to be offering. Thank you.

[Fightinghard]

Agree 100% with Nal. I had same situation a couple years ago. Hit it hard now. ADT and radiation or at least ADT alone

[Hidden]

This is no time to be siting around waiting . IMO ,It could get bad fast without treatment. He needs to put this beast down now . He will be depleted like we all are . Keep him moving and active living healthier than before . My dad had this and died of a heart issue 18 months after an RP . He was 71 . I was 2000 miles away and couldn’t see him . Mom treated him brutally and he decided to check out .

[London441]

It’s disappointing how many men refuse ADT simply because they fear side effects. He clearly needs treatment and ADT is part of it yes. The folklore about the horrors of ADT does not reflect reality if he exercises or is at least willing to.

[rscic]

Positive surgical margins + persistent PSA means there is cancer which has escaped the prostate .... also evidenced by bladder neck invasion. At this point there is a good possibility of curative treatment. ADT + radiation would be possibly curative. Some would radiate the pelvis & not just the Prostatic bed. Waiting 6 months for tissues to heal can be done. My Radiation Oncologist (RO) said the continence you have going into radiation is the continence you will likely end up with .... it usually does not improve after Radiation. Starting ADT now to keep the cancer subdued & waiting up to 6 months or so for bladder function to improve is a possibility, but there are statistical risks as my MO (Medical Oncologist) said in 2019 that there is a study out there which says those who begin Radiation within 90 days of surgery do a little better than those who start months later. I was told I could wait up to 6 months to begin Radiation Treatment (RT) but, in your father's case with invasion of the bladder neck, the recommendation when to begin RT might change.

This is my experience & what I was told back in 2019. I was Gleason 3 (85%) + 4 (15%) = 7 with microscopic extension outside the Prostate Capsule, negative lymph nodes & negative for extension into the seminal vesicles.

IMO give your father the best chance of a cure (ADT + RT) & deal with the side effects later. I would also get Pelvic RT rather than Prostate Bed RT ..... but this is just what I would do.

BTW my RO said, those who have a goal during RT tend to do better than those who do not .... trying to better ones-self is better than just hanging-on.

There are medical solutions for ED & incontinence ..... there is presently no solution/cure for advancement to Stage 4 Prostate Cancer.

For reference I am 70 & say this only because your father is 72 so I understand where he is in life.

[BobbyMac07]

IIn 2016, had the same as your Dad - Radical prostatectomy, Gleason score 7 (4+3), PSA persistence, , but my PSMA PET?CT showed uptake in my pelvic lymph nodes.Went on Lupron and subsequent Salvage Radiation to prostate bed and pelvic lymph nodes.

As TA said, he may get away with prostate bed radiation only?

My PSA undetectable to date.

[MGBman]

Hello. I can't advise you what to do but I can tell you your father's situation is somewhat familiar to my past situation - PSA 35, T3b, 4+3 gleason, perineurial invasion, some bladder neck invasion and some leakage. In January 2015 I had a radical prostatectomy, which also removed my seminal vesicles, as the cancer had escaped my prostate. Very shortly (a couple of months) after my surgery, my PSA began to rise. At the same time I started ADT (Zoladex) for 24 months. A few months (June-July) after my surgery I had 32 external beam radiation treatments. Side effects of the prostatectomy - total loss of any sex (ie I had no "dysfunction", just a 100% loss of sex) and some minor leakage (I wear a small pad 24/7 but it's not a big deal). Side effects of ADT - usual fatigue, hot flashes, loss of strength, etc. Side effects of radiation - beat up my lower intestines and landed me in the hospital for 10 days...one yr later, peeing blood so I had to have a fulguration of my bladder (ie cauterize) a few damaged spots. Since all of that, my quality of life has been very good (less of course the sex part) and I am glad that I had The Big Three (prostatectomy, ADT and radiation) rapidly, as it enabled me to give the cancer a good solid 'punch' and set-back. Seven yrs on my PSA is starting to rise and I will be returning to ADT, using degarelix. Hope this might be of some help.

[teacherdude70]

Side effects of ADT are minor compared to Mets and those treatments. ED can be offset with treatments from a ED specialist and the clear minded decision to be sexual. Hot flushes can be annoying but fun in cold weather. Try looking at the positive and not the negative.

Me: 6 yrs in starting with G9 aggressive. Now treatment include monthly Lupron and twice daily Nubeqa. Doing well, soon will be 74 and active.

Yes we are all different but with a positive attitude life is so much better.

[j-o-h-n]

Greetings...inhaleexhalerepeat....................... Hold your breath.............. BREATHE.....

All of us should have the worry of being 72 and getting a woody. Buy him a blow up doll, she won't mind....(have him go for the treatment(s))...

Good Luck, Good Health and Good Humor.

j-o-h-n Saturday 11/20/2021 6:49 PM EST

[Lieto55 in reply to j-o-h-n]

I was thinking exactly that. 72 and the erector set is working...GOOD ON YA! I had to go back and reread that line. I've resorted to the pump post-surgery at 63. Turns everything into a bit of a military amphibious operation. So I see his point. PCa is a bit like falling down stairs. Each step takes something away, and I try to adapt or build back. But that first step, from normal to "OMG! This is my life?" can be a doozie. It takes a minute to adjust perspective. Some of us don't have that minute and making a clear decision in the fog takes a trust/insight we haven't built up yet. BUT post surgery, with luck, all the options now are somewhat impermanent (compared to surgery). And as had been said, the SE from ADT are a whole lot less than from METs and what they do is hardly ever reversible.