Senior Veteran (male)
Join Date: Nov 2007
Location: Annandale, VA, USA
Re: Salvage radiation after Hormone Therapy?
Originally Posted by flyfisher37
I had a radical prostatectomy three years ago in October. There has been undetectable psa on every six month checkup until the last one this past October. It was 0.1. I had a Gleason 8 cancer, and apparently it might have returned after almost 3 years.
My urologist, of course, said we will do another psa test at the end of this month to see what's happening. He mentioned that if it went up, I would be a candidate for salvage radiation of the pelvic area.
However, after my RP, he said that everything was clear. The margins of my prostate gland were clear and all the peripheries were clear as well. But since I had a Gleason 8 cancer, it would seem that perhaps some cancer cells escaped in my blood system. I guess this would mean that they could be anywhere in my body. Because of this possibility, I personlly think that hormone blockade therapy would be the only viable answer. I still think hormonal blockade could be excellent for you (from my layman's perspective and experience with intermittent hormonal blockade), but I have expanded what I think is possible this year to include radiation in some advanced cases, in particular, my own. One of the key doctors in my journey - Dr. Robert ("Dr. Bob") Leibowitz, has vigorously argued the point you mention (that a non-local, systemic approach is essential) for years. While I have never actually consulted Dr. Bob, his view that cancers like mine were systemic (throughout the body) rather than local has influenced me for years. It was from him that I first learned that well over half of men with early stage prostate cancer - men considered excellent candidates for surgery or local radiation, actually have prostate cancer cells in their bone marrow before surgery (83%, Lange, Vessella and team, 2007 paper) and a hefty percentage of such men will have the cells in their blood! (But for other readers, don't get scared here - read on!)
However, a fairly obvious question is why far more than a majority of such men do very well with surgery or radiation, having no recurrence for many, many years if ever? The answer seems to be that many of these wayward, far journeying prostate cancer cells, are not capable of becoming established metastases. Research suggests that they simply die off, with some becoming dormant. Dr. Myers makes this statement in a review of a pertinent study (page 3): "Only a small percentage of men with cancer cells in their bone marrow are destined to develop recurrent disease! If you carefully read the literature on RT-PCR detection of prostate cancer cells in bone marrow and blood, the inescapable conclusion is that a vast majority of these cancer cells fail to develop into bone metastases...."
Dr. Bob was not the only doctor who readily believed that many higher risk cancers were systemic. However, there was a recent study that those of us should know about who are trying to decide whether to invest in radiation or rely on hormonal and other therapies for our recurring and high-risk cancers. Dr. Myers explained it in a recent edition of his Prostate Forum newsletter (Vol. 10, Number 5, published January 2007, "The Process of Cancer Spread & Testosterone Replacement), and he has said that it is one of those studies that is so significant that it is making a big change in the way he practices medicine for his advanced prostate cancer patients. In short, he is now seeing a greater role for radiation where there are indications the disease has spread beyond the prostate and would previously have been thought to be widespread, beyond the range of radiation.
The study cite is Swanson, G.P., et al., Predominant treatment failure in postprostatectomy patient is local: analysis of patterns of treatment failure in SWOG [Southwest Oncology Group] 8794. J Clin Oncol [the Journal of Clinical Oncology], 2007. 25(16): pp. 2225-9. The study compared how patients with locally advanced disease did under surgery alone versus surgery with radiation. The authors found that adding radiation to the prostate bed reduced metastatic disease and recurrence indicated by PSA at all levels of PSA after surgery. Dr. Myers writes, "For the worst patients with a post surgical PSA greater than 1.0 ng/ml, adjuvant radiation therapy, which was done using techniques no longer regarded as state-of-the-art, reduced the risk of distant metastatic disease from 44% for those who had surgery alone to 18% in those who had adjuvant radiation therapy." He later adds: "... I can think of only one explanation. The cancer cells that would eventually lead to the development of distant metastases were at that time [for some period after surgery] present in the pelvis and only later migrated to bone and other sites...."
I have read about some of the side effects of radiation, and I don't like what I read. Urinary and bowel problems seem to be the main issues after radiation. I've already had my share of urinary problems after my RP. ... So this is why I'm not too crazy about having radiation . That makes sense. I don't have the figures handy, but I've heard that patients with urinary and bowel problems after an RP often have worse problems after radiation is added.
So my thinking is, why not just start hormone therapy and see what happens. If it ever gets to the point where I need radiation in the pelvis area or somewhere else, would having the hormone therapy first, affect the effectiveness of the radiation? That makes sense to me. I have heard it's important to do radiation before the PSA rises to more than 1.0 to get the best results, but the hormonal blockade would probably take care of that. At least PSA could be reduced to less than 1.0 with many patients. But that's a question for a doctor who is expert in radiation and hormonal therapy for prostate cancer, not for me.
Well, this is getting rather long, so I'll come back later.
I'm sure that there must be someone out there that has gone through this same scenario and perhaps they will share their experience with me.
Thanks so much......Flyfisher37