Dad has his mapping on Friday for salvage radiation 16 January. His persistent PSA post surgery in June was 0.08 ( from 14) and in December 0.17. In December he started ADT in advance of salvage radiation for 6 months. He will have 33 sessions at 66gy. I question 66gy believing that higher dosages are more effective but the radiologist was adamant that this was optimum for his situation without unnecessary radiation. His scans were good with rectum and bladder perfect so they considered this "easy mapping". Should I be further challenging the dosage for 68gy/70gy in your opinion or should I accept their professional opinion as the experts in their field in a top London hospital?
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The dosage of salvage radiation and duration of ADT is a controversial area. Some excellent ROs believe that with low PSA, ADT is not necessary at all. Note Dr. Sandler's (Cedars Sinai) comments in the following article:
Dr. Sandler (who is unquestionably one of the most knowledgeable ROs in the US) also gives only 66 Gy with boosts to known cancer (i.e., site of the positive margin). Other top ROs believe more is better - Dr Zelefsky (MSK) and Dr King (UCLA) routinely give 72 Gy:
if I sound like I am talking out of both sides of my mouth - I am. I do understand the point made by your Dad's RO - his cancer burden is probably low, you have a good guess as to where the cancer is (at the positive margin), with GS 4+3, his cancer is not likely to be radioresistant, and lower doses lower the risk of toxicity. But I also understand the feeling of giving it all you can:
Thank you Tall_Allen once again for your excellent thoughts. I know its a grey area which makes it's hard to know what's best. I Guess I'm aware that this is potentially a chance of cure and a last chance at that so I just want to know that we are making the right decision at 66gy. I will encourage my father to have another conversation with the radiologists and his own radiation oncologist who is highly regarded and just listen to their explanation and take their advice. I think challenging is good as long as it's fair. I'm certainly not questioning their ability but I do also think we have the right to query...!
It's your dad. Do whatever he agrees to. If you are uncomfortable with the recommendation, seek alternative recommendations. That said, I wonder if the NHS permits this. I understand that "second opinions" are a no-no in the NHS.
We are private not NHS. We will have another chat with the radiologist for clarity and go with what they suggest I think. I don't want to create further anxiety for him.
Wow, I feel like you are my daughter talking about me. I too am scheduled to start salvage radiation around 14 January. Yes, 66gy is what my ro is using for 38 treatment days, for a total of 660gy. I received my first ADT shot on 21 December, and my PSA has climbed to .55 from .29 after RP in Mar 2018. I’ll be watching your post and replies. Especially Tall Allen’s response.
I did a similar course in summer 2016. I pushed for more and I might have gotten a couple more gy. But the science is vague and there is no way to really know if it will help. Also, there are side effects. I think it is a gut, personal choice that he needs to make as he will deal with the side effects. I will say my last psa was undetectable, so I'm happy. Best
Great to hear you're doing so well! Thank you for your contribution. I feel content with 66 upon the differing views and have to trust their expert opinion when the science is grey the optimum levels. We start Wednesday so I think he's ready to just start now really. Sooner it starts the sooner it's over!
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