Age 70, RP on 2/14/19, PSA before surgery 5.3, gleason 4+3=7, extra-capsular ext, vesicles LN and margins negative; PSA after RP 3/16/19 .008 6/18 .008 10/14 .009 2/12/20 .041 7/9 .085 10/9 .125 PSADT 6 mths. I have had mild incontinence since RP 2 pads/day. Life expectancy 10yrs.
I am faced with options of SRT with approximately 44% chance of success and worsening of incontinence which really bothers me , or trying something like intermittent ADT.
Any insights greatly appreciated. Thanks
If you are saying that you have 10 years life expectancy due to significant comorbidities, lifelong ADT is certainly an option. But if you are just using actuarial tables, you may have have 20+ years
I have run your PSA numbers (only the four latest measurements 0.009 to 0.125).
Regression coefficients: Lin = 99.5%, Log = 96.6%
I would take two actions before deciding:
1) Confirmatory PSA, two weeks after latest, say at the 23rd of this month. Your (min) Lin rate of rise of 0.0096/month, is comparable to the precision of the test at these levels, translating to confirmatory test will be conclusive (3.6% for a fortnight minimal rise). If the test comes out at a lower value of 0.125 -%5 = 0.119 or less than something wrong has happened.
My best estimate is that it will come out at 0.145 +/- 5% with the same lab or +/-15% with another lab (lower values indicate milder linear rise, higher values more aggressive exponential rise).
2) Arrange to take a PSMA PET/CT scan. The average uninformed doc will tell you that this is a waste of money as probably nothing will show up at such a low PSA level. Totally wrong-fire such a doc on the spot! Firstly, there is a low possibility 30-50% that something will show up which will enlighten you regarding the odds of an early sRT. If distant metastases are identified sRT will only offer you SE and possibly additional comorbidities. Secondly, lack of any findings still has its information value. Check this recent (July 2020) paper:
"A positive PSMA PET/CT predicts more aggressive disease progression in patients with biochemical recurrence after radical prostatectomy"
Why intermittent ADT? If you are concerned about side effects I would recommend casodex, it's an older ADT drug with less side effects. Stay on it and milk lt for all it's worth, no intermittent treatments.
Thank you for that information and option.
Darolutamide should have a much better side effect prile with improved response compared to Casodex.
Greetings,
I agree with Justfor. Go slow, investigate PSMA PET scans, dismiss negative docs who are not curious and supportive about possible treatments they don’t offer at their facilities, look into proton beam therapy centers near you for your possible radiation treatments and read Wassersug’s book about ADT treatments, their side effects and alternative ADT options. Seek some assistance with muscle strengthening for the incontinence. It can improve with specific physical therapy. Tall Allen is right about avoiding pessimism concerning longevity predictions. I have friends who are G 9-10 and are still alive and functioning well after RP, RT and ADT for more than twenty years. It is a shitty disease, but you’re going to be around and bitching about this nasty life twist for a long time.
Jeff
Thanks for your support, I am moving to Phoenix to be around family and to try and get with the Mayo Clinic there.
Hi jjpeabody,
Good decision. I have a friend who did exactly that. He was diagnosed more than twenty years ago. Back then, he did RT with seed implants, and moved to Scottsdale so he could get further treatment at Mayo. He’s still alive and making do with the SEs of the disease. Darwin said that those who survive are not the fastest nor the smartest. They are the ones who can adapt. Read and research about PCa and follow your own good counsel. Good luck, my friend.
Jeff
Love....bitching about this shitty disease. But if you don't like what you hear from one MD and even if you do, seek out a second opinion. Thanks to Covid and telemedicine I was able to hear from four different physicians. Make sure you consider an NCCN Prostate Cancer Center of Excellence.
ADT is certainly a consideration. You medical oncologist may consider the addition of abiraterone+ Prednisone as well. You might speak with GU nuclear medicine specialist and discuss PSMA or DCFPYL PET scan. While usually these scans require some PSA elevation. But, I did a PSMA PET with a PSA of .4 and a lesion was seen in the seminal vesicles.
If you are considering radiation ViewRay MRIdian which uses live MRI to constantly monitor SBRT and avoid radiating nearby organs. As the beam constantly adjusts, margins beyond the area of treatment and exposure to other structures fiducials and SpaceOAR are not required. Definitely a step beyond proton beam and CyberKnife. I recently completed a 5 treatment course at UCLA without side effects. Watch the video at ViewRay.com
Hi mperloe,
I agree with you concerning the benefits of telemed. I've used it to consult with two RO with whom I would have never considered getting on an airplane and going to see for a consult. I think if Medicare, the docs and the hospitals don't kill the program eventually, telemed will change the face of geezer care. I like sitting in front of a Zoom screen looking right into the face of the doc I'm scheduled to talk with about my shitty disease and ask my questions. I've found that I get 100% attention - nobody dipping in with something to ask the doc, something for him to sign, and I go down my list of questions. We can see the "PCa rock-stars" for our situations. It is terrific while it lasts.
Jeff
Jeff, you skipped over what is an important piece of advice. Your suggestion to make a list is great. I suggest sharing by email or portal a few days before your visit.
Hi MPerloe,
That’s right. I did that, however my wife warned, “don’t bury the poor doc with all those questions....” so when I sent the questions a few days before my scheduled meeting, I kept worrying that they’d cancel the appointment. They didn’t, and I got a lot of information.
Jeff
Likelihood of post-RP radiation? 
Post RP
PSA and NLR after RP. What to make of these numbers?
biochemical recurrence after RP. +post leukemia 
Rising PSA after RP June 2018
