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Old 08-31-2010, 02:29 PM   #3
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Re: PSA Relapse Following Salvage Radiotherapy, can you help?

Hi Jim,

I appreciate your post above. I did my investigation at NCCN as you advised and got an insight of their recommendations for cases like mine. Surely the guidelines confirm HT as my next treatment. However, there is no recommendation on a “trigger” for starting the treatment in asymptomatic cases, neither on a decisive methodology (continuous vz intermittent). It seems that individual cases will require different decisions. That may be the reason for Dr. Choo’s report in insufficiency of trials and data to best treat cases of relapse after major treatments..

In regards to the timing, I quote here a summary of the text, for any one that might be interested in knowing its contents;
(NCCN Guidelines "Prostate Cancer" V.3.2010)
Timing of ADT for Advanced Disease (PSA recurrence or metastatic disease)
1) The timing of ADT for patients whose only evidence of cancer is rising PSA is influenced by PSA velocity, patient anxiety, and the short and long-term side effects of ADT.
2) A significant proportion of these patients will ultimately die of their disease; their prognosis is best approximated by the absolute level of PSA, the rate of change in the PSA level(PSA "doubling time"), and the initial stage, grade, and PSA level at the time of definitive therapy.
3) Earlier ADT may be better than delayed ADT, although the definitions of early and late (what level of PSA) are controversial. Since the benefit of earlier ADT is not clear, treatment should be individualized until definite studies are done. Patients with an elevated PSA (>50 ng/ml) and/or a shorter PSA doubling time (or a rapid PSA velocity) and an otherwise long life expectancy should be encouraged to consider ADT earlier.
4) Treatment should begin immediately in the presence of tumors-related symptoms or overt metastases (category 1). Earlier ADT will delay the appearance of symptoms and of metastases, but it is not clear whether earlier ADT will prolong survival. The complications of long-term ADT have not been adequately documented.

In regards to Optimal ADT, it says;
5) No clinical data supports the use of triple androgen blockade (finasteride or dutasteride with combined androgen blockade).
6) Intermittent ADT may reduce side effects without altering survival compared to continuous ADT but the long term efficacy of intermittent ADT remains unproven.

(Your case proves that intermittent ADT works very well)

Accordingly, in a setting of low PSA velocity<0.75, PSADT>8 moths and asymptomatic, the only trigger would be to soften patients’ anxiety and/or to accept ADT’s side effects. This leads to the consideration of a “long life expectancy”.
I am 61 so I would like to try the earlier ADT, triple blockade.

I have also searched other forums on prostate cancer to get answers for similar third-line treatment cases, but couldn’t find posts related to experienced cases. I got the impression that I should keep posting about my experience so that it may help others on the same boat.

Thanks for the help and interest.