Rationale for blind radiation to the bed of the prostate

[drjg]

Wife would like to ask what the rationale is for SRT without a biopsy or any kind of imaging.

My psa went from .08 on 1/17/22 after almost 3 years of undetectable psa.. Most recent

psa was .21 on 8/5/22. Urologist encouraged to have radiation therapy to the bed as original gleason score was 8 on multiple cores of biopsy. Had less than 1 mm positive margin during original surgery date in November of 2018.

Any help is appreciated.

Jerry

[Tall_Allen]

Biopsy or imaging doesn't help. The microscopic infiltration of cancer cells into the prostate bed is always where the cancer goes to next. A biopsy or imaging can easily miss it.

Prostate bed and 4 months of ADT is probably enough at your PSA:

prostatecancer.news/2022/05...

[Lewis22 in reply to Tall_Allen]

I read your response two days ago to drjg which I found both direct and concise which is characteristic of the majority of your posts. I downloaded the link and found it to be informative and hopefully a positive supportive longitudinal research document given my recurrence and treatment. However, similar to the vast majority of men with biochemical recurrence, I remain extremely anxious about the result of the next PSA test. I know I need to continue testing BUT it is such an ongoing struggle not to be continuously focussing on the forthcoming result to the extent that life just seems to pass me by due to the need to internalise my fears about the future. However, if I was going to reply to myself, I would say that it is essential to focus on the positive, worrying is a pointlessly activity and that the PSA test is only a blood test. Stay as healthy as you can and whatever will be, will be! Good advice but can I actually follow my own advice?

[Tall_Allen in reply to Lewis22]

It is all well and good to give yourself advice like that, but I've found it impossible to stop the relentless rumination of thoughts and emotions. In my case, I found it so annoying that I went for psychotherapy. It helped a lot. I learned techniques, especially mindfulness, for dealing with it. It took about 3 months of daily practice for mindfulness to become habitual. Instead of trying to dismiss or avoid troubling thoughts, I try to be more aware of them and examine them closely while paying attention to my breath. The troubling thoughts and feelings never go away, they just resolve much more quickly when I intentionally and calmly pay more attention to them. I know it sounds counter-intuitive, but it works. I suggest you enroll in a class. It's easier to practice in a group, and it takes a few months.

[Lewis22 in reply to Tall_Allen]

Thanks for your thoughtful reply. I understand what you mean when your refer to mindfulness and, in a sense, I am practising a form of mindfulness in my response to you highlighting my concerns about the emotional impact of PSA testing. In some respects, I am “intentionally and calmly paying more attention” to my feelings as you have outlined. However, I respect your suggestion regarding enrolment in a class to learn more about mindfulness. Not sure, though, how I can get more information about this. I live in London and I think most of this type of support will be accessible only in private medicine. To date, my treatment since 2014 has been with the NHS at University College London Hospital under Professor Emberton and his team. Nevertheless, I will see what the private sector can offer. Thanks!

[Tall_Allen in reply to Lewis22]

Try googling "Mindfulness" and "London" I'm sure there are many workshops available in London.

[Justfor_]

Blind irradiation is a big no-no for me. Have posted my reasoning in detail. If interested pls check my relevent post. Also, my Bicalutamide maneuvers may be of interest to you.

[Hawk56]

I had surgery in March 2014 (clinical history attached), BCR in December 2015 after PSA became detectable at .2 in September 2015 followed by .3 around 90 day after that in December. My radiologist wanted to do radiation to the prostate bed only, 39 IMRT, around 70.2 Gya. My urologist supported that decision.

At the time, data from various clinical trials that I read was emerging though not yet into clinical practice, that including the PLNs and short term ADT may be a better treatment option. I recall seeing data from Mayo that most times when BCR failed, there was already PCa in the PLNs.

I asked my radiologist and urologist about this and they dismissed it, saying no long term data supporting it. My instinct said that's the route I should go but I acquiesced to my medical team. We took labs 90 days after completing the SRT to the prostate bed and PSA had increased to .7, another 30 days and it was 1.0...

I looked at my medical team and swore that never again in this journey would I acquiesce to my medical team when I felt there were more aggressive options. That was the case when I went to Mayo, a local urologist at a NCCN where I live who was Chief of Urology there said he would only use monotherapy, ADT, not triplet therapy, didn't even want to consider imaging. I fired him and did the triplet therapy. That was four years ago, no treatment since.

As to the imaging, at your PSA, most statistics I see say a 30% chance of locating any site of PCa. So, as TA says, does the decision to image change the treatment decision...?

If you agree with your urologist, SRT to the prostate bed only, then imaging may not be necessary since it does not change the treatment decision

If you disagree and want to consider the option to extend the treatment field to the PLNs and include short term ADT, 6-18 months, there are several considerations:

At your PSA, the imaging may not locate any PCa and thus not change the treatment plan. Under this outcome, imagining might not make sense if you believe that a 30% or less chance is not worth the investment (depending on insurance, deductibles, co-pay...).

If you are ok with the 30% probability of locating sites of recurrence and the imaging does show any sites of recurrence, the radiation treatment plan may change somewhat with boosts and wider treatment margins around those sites. In this case, imaging may be the "right" decision.

There is another option in play, if you want to increase the "statistical odds" of imaging locating the recurrence you could let your PSA rise to .5 or higher then image. The dilemma there is the higher you let the PSA rise, the lower the effectiveness of the traditional SRT to the prostate bed only.

Just my thoughts based on my clinical history.

Kevin

Clinical History

[Teufelshunde]

Just finished up SRT due to BCR about a year ago. It was prostate bed and LN. At U of Chicago seems that is SOC. Since PSA only 0.28 and GaPSMA showed nothing, ADT was optional and Dr Morgans (Northwestern at that time) thought no need as all the studies at that time showed no big advantage at my PSA. My RO didnt care. Did Bicalutamide for 30 days before and then stopped. PSA now undetectable.