When to do Salvage Rad?

[ElRanchoDePoisonIvy]

62 years old. RP 2/2022. PSA 0.06 10/2022, 0.09 2/2023 My MO and 3 ROs advise me completely differently. One RO says SRT now. Another says wait for 0.2. Another says any time between 0.3 and 0.7. MO says 1.0+ is fine. Urologist says wait as long as possible for surgery to heal. Any advice from you gentlemen?

[cujoe]

ElRancho - In my opinion that decision should be based on the results of the final biopsy (from the prostatectomy). My biopsy was poor, so I requested early IMRT at 3 months vs the 6 month "healing period" usually recommended. The 6-month recommended period is supposed to allow for recovery of both continence and erectile functions. RT is usually said to "fix" level of incontinence, so how well you have recovered might be a consideration for timing.

This is updated version of the document I used to argue for and make the decision for early Adjuvant RT. Read it with your final biopsy results in hand and in consideration of how well you recovery of continence and erectile function are progressing. That will help you in any discussions with your medical team about the advantages of Adjuvant RT vs waiting for a PSA rise and doing RT at that time - called "Salvage RT". (Nice term, huh?)

Adjuvant and Salvage Radiotherapy after Prostatectomy: ASTRO/AUA Guideline (2019)

auanet.org/guidelines-and-q...

Also, here is a 2021 European paper that might help you with you decision:

Radiation Therapy After Radical Prostatectomy: What Has Changed Over Time?

ncbi.nlm.nih.gov/pmc/articl...

Good Luck. Stay Safe & Well,

Ciao - K9

PS - In re-reading your post, I see that your prostatectomy was a year ago, so your healing period is well past. You would now be considering RT based solely on evidence of any beneficial effects in reducing cancer burden; i.e., Salvage RT(now) vs Adjuvant RT (earlier). Once again, your biopsy results should be your guide; i.e., non-organ confined, excap. extension, seminal vesicle invasion, and/or lymph node involvement. For anything other than organ-confined disease, you are trying to stem the possibility of advancing disease to distant metastases. Kill it near the homebase (oligometastatic) rather than dealing with it in distant locations.

[ElRanchoDePoisonIvy in reply to cujoe]

Thanks, I really appreciate your input. I had no seminal vessel involvement but did have excursion into one lymph node which was removed with clean margins. I’ll get a copy of my path report and read the links you sent. Thanks again.

[cujoe in reply to ElRanchoDePoisonIvy]

El Rancho - At the time I had my RALP in 2013, the update version of the ASTRO/AUA Guideline put seminal vesicle involvement (which I had) as a indicator of worse outcomes that lymph node involvement. The guidelines are formulated using a sort of meta-analysis of all relevant clinical research and, as such, has to compile studies of varying size and scope. The nature of risk factors may have changed somewhat in the intervening 6 years for this update. I haven't read the European paper, but is is more recent and the title would suggest a historical perspective that might be helpful for your understanding of the risks-to-rewards of doing Salvage RT now or waiting for confirmed rising PSA trend. (The normal criteria for that is a sequential rise of 3 labs, and I like to add a fourth one to "confirm" the trend.) PSA doubling time is also a critical factor is gauging risk profile for progression. Your 2 labs in the post would suggest a doubling time of around 8 months; i.e., 0.03 over 4 months increase ~ 2 x over 8 months starting from 0.06. IMO, you need more than these two labs to make that judgement, as the next one could indicate an accelerating or decelerating rate of change. Also, your lowest lab post-surgery will be your PSA "nadir" and should be used as a benchmark for treatment response and disease progression going forward - at least as long as you remain hormone sensitive. (Which hopefully, will be indefinitely.)

Another consideration would be to see if you can get a PSMA scan to confirm any wider disease extent, say to other pelvic lymph nodes. If few in number, those can be effectively zapped with SBRT to reduce/eliminate tumor burden. The early diagnostic use of PSMA makes more sense to a lot of patients, as it is a very sensitive scan for hormones sensitive disease - and that is what almost all PCa patients have early in their disease history. Having such a scan early provides a good benchmark for any changes over time.

Once again, Very Best to you as you wrangle with the decision on RT. More questions welcomed, if you have them after reviewing the docs. Keep it safe & well. Ciao - K9

[ElRanchoDePoisonIvy in reply to cujoe]

Thanks again. I had PSMA/PET Dec.’22 but nothing lit up.

[cujoe in reply to ElRanchoDePoisonIvy]

Good man with a good game plan. BTW, did you have a PSA lab around the time of the PSMA scan? Also, are you currently on any form of ADT? And have you been getting Testosterone labs with the PSA ?

[ElRanchoDePoisonIvy in reply to cujoe]

I did get a PSA with the PET. It was 0.08; in the noise range. Haven’t been getting T tested with PSA, but that’s a great idea.

[cujoe in reply to ElRanchoDePoisonIvy]

So, is it safe to assume that you are now nor ever have been on any form of ADT?

[ElRanchoDePoisonIvy in reply to cujoe]

Right. No ADT at this point. And if I do get SRT, I’m tempted to not go for the concurrent ADT. Based on what I’ve read to date.

[cujoe in reply to ElRanchoDePoisonIvy]

I may not be quite up to date on that, but I seem to recall that the outcomes are better with 3-6 mos of concurrent ADT. It was in trials and somewhat controversial at the time I got my 8 weeks of IMRT (early 2014). If I was starting now, the recommendation would likely be for the field to be expanded to included the pelvic lymph nodes, the RT dosage would be boosted, and some duration of ADT would be added. Worth noting that my IMRT only got me about 2 1/2 years before I had BCR#1. If given the choice today, I would go for the full program outlined above, as I now have confirmed metastatic disease in two strings of lymph nodes and that treatment might have been much more effective in reducing the initial post-surgery disease burden and maybe even preventing my current status from developing.

There is a post about the timing of starting ADT with RT that I will find tonight and post back here. It will give you a perspective that might make you reconsider doing a short course of ADT. I headed out for my daily trip to the Y, so it might be late tonight before I get the link posted here. So look for it after 10 PMish EST.

Later - ciao k9

[ElRanchoDePoisonIvy in reply to cujoe]

Got it. Thanks and have a good workout.

[cujoe in reply to ElRanchoDePoisonIvy]

El Rancho,

The posts linked below are about timing ADT and RT, specifically the use of the notorious ADT T-flare to make RT more effective. This discovery essentially turns the table on the once common practice of using bicalutamide (Casodex) to front-run the Lupron T-flare that occurs after an inital lupron injection. The interest in this was started when I sent the paper linked in the MateoBeach post to npfisherman when he was setting up an SBRT treatment to an isolated bone met. The full paper (see my note for full paper link) is filled with detail about the actions involved in this timed-ADT + RT dynamic.

The last link is to a later post I did based on The SANDSTORM review of 12 RTs looking at such ADT-RT sequencing strategies/results.

1. An Update on my SBRT given with ADT experiment... so far....so good... NPfisherman•8 months ago•24 Replies

healthunlocked.com/fight-pr......

2. Testosterone “Flare” (Or Testosterone?) Timing to Optimize Salvage Radiation Therapy - MateoBeach•8 months ago•7 Replies

healthunlocked.com/fight-pr...

Note: the link in MB's above post seems to be incomplete and not working. Here is the link to the full paper:

2-a. Androgen Flare after LHRH Initiation Is the Side Effect That Makes Most of the Beneficial Effect When It Coincides with Radiation Therapy for Prostate Cancer, Nicola J. Nasser, Cancers (Basel). 2022 Apr; 14.

ncbi.nlm.nih.gov/pmc/articl...

3. Sequencing of Androgen-Deprivation Therapy of Short Duration With Radiotherapy for Nonmetastatic Prostate Cancer (SANDSTORM) - ASCO Journal - cujoe•4 months ago•6 Replies

healthunlocked.com/fight-pr...

Worth exploring in some detail, if you decide to do salvage RT. Good Luck and keep us posted on how things are going.

Ciao - K9

Timed ADT + RT

[ElRanchoDePoisonIvy in reply to cujoe]

Wow. Perry amazing stuff here. Thanks.

[ElRanchoDePoisonIvy in reply to cujoe]

Btw, this is a plot I’ve made of lab results. The light blue is lab data, although levels < 0.06 are retroactive guestimates. The red and yellow lines are my guesses of the error bars, going into a growth curve that is entirely guesswork.

Plot

[Justfor_ in reply to ElRanchoDePoisonIvy]

There is a "bumpy" PSA range, but, reportedly at a higher level (0.15-0.18). Mine started lower (0.11-0.15).

Before starting Bicalutamide

[cujoe in reply to ElRanchoDePoisonIvy]

Looking at the jagged profile of your recent labs, it seems your PSA is mostly bouncing around +/- 0.09 level - and not on a sustained doubling rate rise. Whenever my PSA starts a rise, it usually has a sustained rather rapid doubling rate and quickly reverts to a hockey stick graph.

I would want to watch a lab history like yours closely over time to see if this is a steady state or just the result of lab variations. Having labs done at same place and a consistent time of day, (preferable no later than mid-morning), and being sure to be well-hydrated for each will eliminate most of the controllable noise.

The above recommendations for blood draws is especially important for T labs, as time of day and hydration status can have a major impact on results. Comparing sequential T labs done in the afternoon vs morning have consistently been as much as 50% lower.

If you want to do some self-monitoring of your PSA, T, hormones, etc., LEF and Ulta labs both have reasonably priced walk-in labs to do that. In fact, depending on your location, you may be able to do LEF labs blood draws (via in-store Labcorp services) at your local Walgreens. I use LEF, since the labs are done at the same Labcorp facility used by my PCP. Here are links to both walk-in lab services:

lifeextension.com/lab-testing

ultalabtests.com/

Stay S & W, Ciao - K9

[ElRanchoDePoisonIvy in reply to cujoe]

Thanks, I’ll look into that. I’ve been using Quest, but I’ve heard that Labcorp has a lower detect limit.

[LowT]

Can you provide more comprehensive history and details, path report, etc? I’m assuming your GS of 7 was 4+3. Is that correct?

How many lymph nodes removed, etc.

Never as simple as one number without knowing context to make best decision.

[ElRanchoDePoisonIvy in reply to LowT]

GS 7(4+3). One node removed, clean margins, Dec ‘22 PSMA PET indicated nothing at that point.

[Justfor_]

I keep sRT for later. In the meanwhile, I keep my PSA low (lately too low - correction pending ) via a minuscule dosage of Bicalutamide. Detailed documentation here: healthunlocked.com/prostate...

[ElRanchoDePoisonIvy in reply to Justfor_]

Very interesting. Thanks for the post.

[cujoe in reply to ElRanchoDePoisonIvy]

El Rancho - Justfor & smurtaw are both math analysis whizzes - and should both probably be consulting with Robert Gatenby and team at Moffitt.

moffitt.org/research-scienc...

Based on Justfor_'s linked post, I tried something similar using bicalutamide with the intention of adding dutasteride once I had established a "steady-state" targeted PSA (=<0.05). I hit my target using full dosage of 50mg daily, but made the mistake of cutting the dosage back too much, too quickly and PSA did rather abrupt U-turn. So, I restarted the 50mg per day and once under <0.01 had planned to add in the dutasteride and reduce the bical to every other day (or half tab per day) and check for results in 30 days. I started the dutasteride, but several days later decided I need to stop bical due to progressive gynecomastia

Unfortunately, I did not pre-treat for potential gynecomastia before starting all this and ended up winning the "booby prize". That has resulted in me stopping the bical altogether until I can get RT for the gynecomastia. I have an appointment with a RO next Monday to hopefully set it up. With a quick schedule for the RT, I can then resume my treatment program.

BTW, in my case, I am looking at the B+D as an interim treatment bridge to something more advance around mid-year. So far, I have been a good responder to ADT, but I do not want to overstay my welcome with even this modified version of SOC. I have so far chosen to reject long-term use of ADTs that block testosterone directly, due to personal QOL preferences. That's not a road for younger patients to travel without lots of forethought about the trade-offs and potential consequences involved.

There are quite a few members here who are working at the fringes of SOC. In many cases developing their own versions of SOC or using treatment paradigms that are only currently available in clinical trials. There is growing consensus that some of it may end up in SOC. Interesting stuff, by some real adventurous pioneering patients. Do stay tuned, as you may find some ideas that you can take to you treatment team for discussion.

Glad to have you as a contributor. Keep It Safe & Well,

Ciao - k9 terror

[cujoe in reply to cujoe]

A final footnote: As I quicky scanned the diverse input you got at another HU forum, I noticed the following sentence in one of your replies:

"I've got an 11 y.o. boy and am very motivated to stay healthy long enough to be an active dad as he grows up and see him married to a good woman."

Our most prolific poster here at FPC, smurtaw, is in a similar parenting situation. Nothing serves to make one a better advocate for one's health than wanting to be present in the lives of your kids as they grow up. It sounds like you are doing your homework now on the best way to make that happen.

Keep it that way! Paz - K9

[ElRanchoDePoisonIvy in reply to cujoe]

Thanks for the wisdom. There’s still a lot for me to learn. But I wish I knew half of what I know now before I started down this road.

[cujoe in reply to ElRanchoDePoisonIvy]

Most all us fall into that category. Had I the knowledge after my first neddle biopsy that I do now, I would have rushed to a center of excellence for treatment and might well be cancer-free now. Rearview mirror gazing is not where we need to be focused now, but rather on today and the road ahead. Many of us come to forums like this to try to help others make better decisions than we did. Sometimes it actually works. With 3 ROs on the job, you are at least being comprehensive in your decison-making. When you see that kid graduate and get married you'll know you got it right.

Ciao - K9

[Cyclingrealtor]

ElRancho -

Was your psa only .08 at the time of PSMA PET? If that low your micro mets may be driving your psa level.

From the reading I have done most doctors will not order the scan unless .2 or higher. In my case I had to request my RO to order another psa because at the time of referral I was only .1 and within 7 weeks went to .3 and to .4.

With the $26,400 PSMA PET scan we discovered a single deep right iliac lymph node after 8 months after RP. That led to Lupron and ebrt in the summer of 2022 and added abiraterone last month in January 2023.

The articles I was reading on renalandurologynews.com/hom... indicated hitting the prostate cancer as soon and as hard as you can. Several great articles there.

Keeping advocating and fighting the fight! Your Cancer Brothers are behind you!

[Ramp7]

At time of surgery I had a low PSA=4.0. Path report was not good. T3b. PSA undetectable after surgery. I waited a year when PSA was 0.1, then had radiation. It kept it at bay for about 10 years. Just my 2 cents.

[StayingOptimistic]

I did mine at psa .07. I think there was a study that says it’s better to do it at .05. It will give better results. I am not sure though if it was SRT or adjuvant RT. I did not get good results from it whatsoever. They did the bed only, no pelvic, no adt for me. Patients now do the whole pelvic with 6 months adt. If I had to do it all again, I would not do it but this ofcourse because I did not get anything out of it.

[ElRanchoDePoisonIvy in reply to StayingOptimistic]

Thanks. Good luck out there.

[ElRanchoDePoisonIvy in reply to StayingOptimistic]

Do you mean 0.7 or 0.07? Because most of the ROs I’ve talked to don’t show much interest in doing RT below 0.3. Except one guy and he wanted to do it at 0.1.

[StayingOptimistic in reply to ElRanchoDePoisonIvy]

Mine was ( .07). My RO at MSK recommended it. After about 4 months , it went up to .10

[Channelhomec]

I WOULD NOT WAIT YOU HAVE UNFAVORABLE GLEASON 4>3 YOU DEFINITELY HAVE SOMETHING GOING ON I HAD 0.06 BOUNCED AROUND FOR 6 YERS THEN HIT 0.14 DID THE SALVAGE STILL HOLDING BELOW 0 .1 >HAD MY SURGERY 2013 wished I did salvage at 0.06 one yr after surgery

[ElRanchoDePoisonIvy in reply to Channelhomec]

Yeah, I’m starting to see less and less reason to wait. If it was tending down, then maybe. But that’s likely wishful thinking.

[dlste353]

Not being in the medical field I am certainly not qualified to suggest anything. I can only tell you my experience.

My PSA was 0.01 six weeks after surgery, but then started creeping back up. Although it appeared from the scans that it was all contained, the surgeon found the beginning of invasion in one lymph node. Because of that, my uro, my MO and my RO saw no reason to wait. I started ADT at a PSA of 0.05 and radiation two months later.

You are correct though; you should be completely healed and hopefully have no incontinence. I remained completely dry thought 37 sessions.

If you chose to wait, you might ask what the chances are of the cancer spreading while you are waiting.

[j-o-h-n]

Welcome to ELRanchoDeProstateCancer

Good Luck, Good Health and Good Humor.

j-o-h-n Friday 02/24/2023 7:19 PM EST

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

Es Rauncho Es cancer

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

IS SI.............

Good Luck, Good Health and Good Humor.

j-o-h-n Friday 02/24/2023 9:02 PM EST