It appears you have not yet Signed Up with our community. To Sign Up for free, please click here....



Cancer: Prostate Message Board

  • Radio Therapy

  • Post New Thread   Reply Reply
    Thread Tools Search this Thread
    Old 08-06-2019, 03:59 PM   #1
    helgi
    Newbie
    (male)
     
    Join Date: Jul 2017
    Posts: 9
    helgi HB User
    Radio Therapy

    Hi my psa has gone up for the third time. My doctor has referred me to a radiologist. Apparently, if he feels I need radio Therapy it would be 5 times a week for 5 weeks. My question, besides whether I need the therapy is, should I book time off work, if so, for how long?

    Thanks in advance for everyones help, greatly appreciated!

     
    Reply With Quote
    Sponsors Lightbulb
       
    Old 08-10-2019, 08:46 AM   #2
    IADT3since2000
    Senior Veteran
    (male)
     
    Join Date: Nov 2007
    Location: Annandale, VA, USA
    Posts: 2,187
    IADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB User
    Re: Radio Therapy

    Hi again helgi,

    It appears your doctor has suggested that radiation (in fact a kind of radiation known as SBRT - Stereotactic Body Radio Therapy, an unhelpful name meaning, essentially, fewer but somewhat more intense sessions of external beam radiation), might be a good course for you, but have you had a biopsy? A rising PSA is not enough to jump to therapy. Also, a radiologist interprets information from scans, such as a multiparametric MRI (mpMRI), bone scan, CT scan, etc., but does not manage delivery of therapy. The doctors who oversee delivery of radiation therapy are known as "radiation oncologists."

    Could it be that your doctor is referring you for an mpMRI, which, these days, is often used to see if a biopsy is needed?

     
    Reply With Quote
    Old 08-10-2019, 07:38 PM   #3
    helgi
    Newbie
    (male)
     
    Join Date: Jul 2017
    Posts: 9
    helgi HB User
    Re: Radio Therapy

    Quote:
    Originally Posted by IADT3since2000 View Post
    Hi again helgi,

    It appears your doctor has suggested that radiation (in fact a kind of radiation known as SBRT - Stereotactic Body Radio Therapy, an unhelpful name meaning, essentially, fewer but somewhat more intense sessions of external beam radiation), might be a good course for you, but have you had a biopsy? A rising PSA is not enough to jump to therapy. Also, a radiologist interprets information from scans, such as a multiparametric MRI (mpMRI), bone scan, CT scan, etc., but does not manage delivery of therapy. The doctors who oversee delivery of radiation therapy are known as "radiation oncologists."

    Could it be that your doctor is referring you for an mpMRI, which, these days, is often used to see if a biopsy is needed?
    I don't know anything about a biopsy. I had one of those before my protectomy. Hope I don't have to have another biopsy, it was worse than the surgery, lol. I guess I'll find out more info. at the end of the month.

    Cheers

     
    Reply With Quote
    Old 08-12-2019, 12:04 PM   #4
    IADT3since2000
    Senior Veteran
    (male)
     
    Join Date: Nov 2007
    Location: Annandale, VA, USA
    Posts: 2,187
    IADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB User
    Re: Radio Therapy

    Hi again helgi,

    OK, now Iíve got it: you have had a prostatectomy and your PSA has been going up afterwards. I did not realize that you had already had treatment. And no, you don't need another biopsy!

    I see in your previous scan that you had a PSA of 0.016 in, I assume, the month of May, when you posted about the bone scan. Would you mind sharing where your PSA is now (and when tested)? That would tie into the question whether you need the therapy. A PSA of 0.016 would not warrant treatment if your PSA were stable, but it is now clear that there is a rising trend. Modern research has proven that patients with a rising PSA that is 0.04 or 0.05 will eventually hit the traditional ďofficialĒ PSA recurrence threshold after surgery of 0.2, and there is a fairly strong chance that patients who have hit 0.03 will have an official recurrence. A very widely used guideline now states that a recurrence has also occurred after two subsequent increases after a detectable PSA; by that guideline you now have a recurrence. A key number is how fast your PSA is doubling (PSADT). With a very long doubling time, you might be able to delay radiation, or perhaps not ever have to have it if your PSADT is extremely long, per my laymanís impression.

    Modern research on the effectiveness of radiation has also demonstrated that having radiation fairly early is a lot more effective than later radiation, after the PSA has risen to the single digits. (That said, in my very unusual course of overall treatment, my PSA was about 20 when I commenced my fourth round of ADT to drive my PSA down prior to radiation, dropping to 1.9 and falling about a month prior to RT, and 1.44 shortly after starting radiation.) My laymanís understanding is that it is good to have ďsalvageĒ radiation (meaning radiation following after surgery to hopefully achieve a cure or at least set the cancer back) when the PSA is around 0.5 or lower, and Iím thinking that treating at lower PSA levels works even better. I can provide a lead to research on that if you wish.

    However, radiation oncologists like to wait until the patient has basically recovered from the temporary side effects of surgery, which is commonly within the first year after surgery when most recovery of urinary function will have occurred. On the other hand, studies indicate that, if sexual quality of life is important to the patient, delaying radiation to allow more recovery after surgery is helpful. My impression is that, generally, delaying radiation to enhance sexual effectiveness until the PSA is anticipated to hit about 0.5 (or maybe even higher) would be smart, but, again, Iím a layman, and this would be a subject for discussion with the radiation oncologist if sexual QOL is important to you and if you still need more time to recover after surgery.

    A key question for you and your radiation oncologist will be whether to have an additional dose of radiation (done at the same sessions as the dose to the prostate bed) to the pelvis; that can now be done safely, and it increases the odds of success. I had a case that was still considered high-risk by the time I had radiation, and I had a pelvic dose; my PSA has remained at an extraordinarily low level ever since my radiation 6 ľ years ago. I am not sure if a pelvic dose would now be standard if you are a recurring patient but might be considered to have a relatively low-risk recurrence; Iím confident a pelvic dose would at least be seriously considered if you had a more average or higher-risk recurrence. In either event Ė no pelvic dose or a pelvic dose, technology known as SpaceOAR is now available (just within the last two to three years of wide availability) to protect the rectum from radiation; while the side effect burden from modern, well-done radiation is very low, SpaceOAR lower the risk of rectal side effects even further.

    Another key question is whether ADT should be done along with (including prior to, during, and after) the radiation. My laymanís understanding is that this is a good idea that is supported by research. I am not sure how low the ADT would be, but Iím thinking it would be six months or more, depending on the facts known about the recurrence.

    As you may have read in other posts, the old and cheap diabetes drug metformin is looking greatly promising for all patients, including non-diabetic patients, to both increase the odds of success with radiation and to partially counter some of the side effects of ADT. While metformin has undesirable side effects for a small proportion of patients, doctors know how to gradually increase the dose up to the full dose to check for side effects, and then fall back to a very well tolerated dose if the patient needs it. I can provide more information if you need it. If I were having radiation now, I would want to be taking metformin, but the evidence is not yet rock solid as clinical trials are in process and results will not be known for years.

    About the need for time off work: My impression is that you will be able to work at least some of each day during which you are having radiation. Typically, patients experience fatigue that is helped by naps after they get well into the radiation therapy. Also, while and shortly after the period of your radiation sessions, you will probably want to be near a bathroom. You are slated for technology that uses fewer radiation sessions but somewhat higher doses (commonly known as SBRT), and I am not personally familiar with that. I had what used to be standard: around 38-40 sessions of radiation at 2 Gy per session (plus a pelvic dose), and Iím thinking the side effects during treatment are probably a bit more burdensome for the SBRT type of radiation delivery. I was retired at the time I had my radiation (2013), but could have worked part of each day, which I believe is typical. In fact, one morning, coming in for my 9 AM radiation session, I was surprised to see my medical oncologist, whom I had been seeing for more than a decade, exiting from the radiation room, all gowned up. He too was getting radiation for prostate cancer; he was getting it at the start of his day and then going up from the basement of the building to his fourth floor office to see patients. I hope you get some responses about being able to work from men who have had SBRT or their loved ones.

    I hope this helps. Jim

     
    Reply With Quote
    Old 08-13-2019, 08:42 AM   #5
    helgi
    Newbie
    (male)
     
    Join Date: Jul 2017
    Posts: 9
    helgi HB User
    Re: Radio Therapy

    Thank you, I realy appreciate your time.

    Cheers

     
    Reply With Quote
    The following user gives a hug of support to helgi:
    IADT3since2000 (08-13-2019)
    Old 08-13-2019, 11:04 AM   #6
    helgi
    Newbie
    (male)
     
    Join Date: Jul 2017
    Posts: 9
    helgi HB User
    Re: Radio Therapy

    Quote:
    Originally Posted by IADT3since2000 View Post
    Hi again helgi,

    OK, now Iíve got it: you have had a prostatectomy and your PSA has been going up afterwards. I did not realize that you had already had treatment. And no, you don't need another biopsy!

    I see in your previous scan that you had a PSA of 0.016 in, I assume, the month of May, when you posted about the bone scan. Would you mind sharing where your PSA is now (and when tested)? That would tie into the question whether you need the therapy. A PSA of 0.016 would not warrant treatment if your PSA were stable, but it is now clear that there is a rising trend. Modern research has proven that patients with a rising PSA that is 0.04 or 0.05 will eventually hit the traditional ďofficialĒ PSA recurrence threshold after surgery of 0.2, and there is a fairly strong chance that patients who have hit 0.03 will have an official recurrence. A very widely used guideline now states that a recurrence has also occurred after two subsequent increases after a detectable PSA; by that guideline you now have a recurrence. A key number is how fast your PSA is doubling (PSADT). With a very long doubling time, you might be able to delay radiation, or perhaps not ever have to have it if your PSADT is extremely long, per my laymanís impression.

    Modern research on the effectiveness of radiation has also demonstrated that having radiation fairly early is a lot more effective than later radiation, after the PSA has risen to the single digits. (That said, in my very unusual course of overall treatment, my PSA was about 20 when I commenced my fourth round of ADT to drive my PSA down prior to radiation, dropping to 1.9 and falling about a month prior to RT, and 1.44 shortly after starting radiation.) My laymanís understanding is that it is good to have ďsalvageĒ radiation (meaning radiation following after surgery to hopefully achieve a cure or at least set the cancer back) when the PSA is around 0.5 or lower, and Iím thinking that treating at lower PSA levels works even better. I can provide a lead to research on that if you wish.

    However, radiation oncologists like to wait until the patient has basically recovered from the temporary side effects of surgery, which is commonly within the first year after surgery when most recovery of urinary function will have occurred. On the other hand, studies indicate that, if sexual quality of life is important to the patient, delaying radiation to allow more recovery after surgery is helpful. My impression is that, generally, delaying radiation to enhance sexual effectiveness until the PSA is anticipated to hit about 0.5 (or maybe even higher) would be smart, but, again, Iím a layman, and this would be a subject for discussion with the radiation oncologist if sexual QOL is important to you and if you still need more time to recover after surgery.

    A key question for you and your radiation oncologist will be whether to have an additional dose of radiation (done at the same sessions as the dose to the prostate bed) to the pelvis; that can now be done safely, and it increases the odds of success. I had a case that was still considered high-risk by the time I had radiation, and I had a pelvic dose; my PSA has remained at an extraordinarily low level ever since my radiation 6 ľ years ago. I am not sure if a pelvic dose would now be standard if you are a recurring patient but might be considered to have a relatively low-risk recurrence; Iím confident a pelvic dose would at least be seriously considered if you had a more average or higher-risk recurrence. In either event Ė no pelvic dose or a pelvic dose, technology known as SpaceOAR is now available (just within the last two to three years of wide availability) to protect the rectum from radiation; while the side effect burden from modern, well-done radiation is very low, SpaceOAR lower the risk of rectal side effects even further.

    Another key question is whether ADT should be done along with (including prior to, during, and after) the radiation. My laymanís understanding is that this is a good idea that is supported by research. I am not sure how low the ADT would be, but Iím thinking it would be six months or more, depending on the facts known about the recurrence.

    As you may have read in other posts, the old and cheap diabetes drug metformin is looking greatly promising for all patients, including non-diabetic patients, to both increase the odds of success with radiation and to partially counter some of the side effects of ADT. While metformin has undesirable side effects for a small proportion of patients, doctors know how to gradually increase the dose up to the full dose to check for side effects, and then fall back to a very well tolerated dose if the patient needs it. I can provide more information if you need it. If I were having radiation now, I would want to be taking metformin, but the evidence is not yet rock solid as clinical trials are in process and results will not be known for years.

    About the need for time off work: My impression is that you will be able to work at least some of each day during which you are having radiation. Typically, patients experience fatigue that is helped by naps after they get well into the radiation therapy. Also, while and shortly after the period of your radiation sessions, you will probably want to be near a bathroom. You are slated for technology that uses fewer radiation sessions but somewhat higher doses (commonly known as SBRT), and I am not personally familiar with that. I had what used to be standard: around 38-40 sessions of radiation at 2 Gy per session (plus a pelvic dose), and Iím thinking the side effects during treatment are probably a bit more burdensome for the SBRT type of radiation delivery. I was retired at the time I had my radiation (2013), but could have worked part of each day, which I believe is typical. In fact, one morning, coming in for my 9 AM radiation session, I was surprised to see my medical oncologist, whom I had been seeing for more than a decade, exiting from the radiation room, all gowned up. He too was getting radiation for prostate cancer; he was getting it at the start of his day and then going up from the basement of the building to his fourth floor office to see patients. I hope you get some responses about being able to work from men who have had SBRT or their loved ones.

    I hope this helps. Jim
    sorry I forgot my PSA results:

    - Aug 2018 .008
    - Dec 2018 .010
    - April 2019 .016
    - July 2019 .023

    Thanks again.

     
    Reply With Quote
    Old 08-14-2019, 12:53 PM   #7
    IADT3since2000
    Senior Veteran
    (male)
     
    Join Date: Nov 2007
    Location: Annandale, VA, USA
    Posts: 2,187
    IADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB User
    Re: Radio Therapy

    Quote:
    Originally Posted by helgi View Post
    sorry I forgot my PSA results:

    - Aug 2018 .008
    - Dec 2018 .010
    - April 2019 .016
    - July 2019 .023

    Thanks again.
    Hi again helgi,

    Those PSA results to help clarify your situation, as I understand it as a layman. In essence, as a recurring patient, it helps to know if you have a mild, middle-ground or higher-risk type of recurrence. I took a look at the PSA doubling times, using a program from a major cancer center. (Iíll put the details below, should you be interested in them.)

    The bottom line is that I think that expert doctors would believe that your doubling time is likely settling down to a PSADT of about 5.6 to 5.7 months. (Longer PSADT is of course more desirable than shorter PSADT.)

    The significance: My take is that you have a middle-ground recurrence, which one source refers to as ďbasic,Ē as contrasted to lower (mild) and higher (aggressive) risk. (One source considers a PSADT of 3 months or less to be life-threatening, and your PSADT is thankfully virtually double that dangerous threshold.) Your PSADT suggests that odds of success with a PSADT of about 5.6 to 5.7 months for just seeing what happens if nothing is done Ė ďobservationĒ Ė are not good, because your doubling time is not greater than 12 months, which indicates substantial risk of failing to control the cancer adequately with just observation. The fact that your PSADT is less than 8 months, coupled with the absence of enlarged lymph nodes (assuming that a scans for nodes, seminal vesicles and extra capsular extension were or/would be negative), suggests that you have that basic type of recurrence. Information I personally trust indicates that treatment should include IMRT radiation to the prostate fossa (where the prostate was before removal, also known as the prostate bed) but also to the pelvic lymph nodes and be boosted with ADT. Just radiating the fossa is probably not going to do the job in your situation, as I understand it as a layman. I can provide references to studies regarding a basic type recurrence if you wish.

    A possible alternative for patients with a basic type recurrence is to skip radiation and use ADT plus the chemotherapy drugs Taxotere (docetaxel) and estramustine instead (https://www.ncbi.nlm.nih.gov/pubmed/17135641); to me, as a layman, that seems a bit ďout there,Ē but there is some research to back it up. I suppose, based on that research, that some doctors will be using IMRT including a pelvic dose, plus ADT, plus Taxotere and estramustine. Iím also thinking that a patient could try that approach, and then, if it does not provide adequate cancer control, add radiation; but this is my laymanís supposition, and an expert doctor might have excellent evidence and reasons to consider that strategy to be nuts.


    The details of my calculation of your doubling time: using the centerís program and multiplying all values for all calculations by 1000 because the centerís program does not cover very low values, and assigning a date of the first of the month to all, I first included the first two values, which produced a time of 12.5 months. Next I added the third value, which brought the time down to 8.0 months. Then I added the fourth value, which brought the time down to 7.1 months. With an obvious decrease in time as results were added, I then subtracted the first value, August 1, 2018 of 8 (.008), which resulted in a PSADT of 5.6 months. Finally, I also subtracted the second value, December 1, 2018 of 10 (.010), which resulted in a PSADT of 5.7 months. This leads me, as a layman, to think that your true PSA doubling time is approximately 5.6 to 5.7 months. I think Iíve done this right, but you might want to run it by a urologist or oncologist who is savvy about prostate cancer.

    Good luck thinking through all this.

     
    Reply With Quote
    Old 08-14-2019, 01:00 PM   #8
    helgi
    Newbie
    (male)
     
    Join Date: Jul 2017
    Posts: 9
    helgi HB User
    Re: Radio Therapy

    Quote:
    Originally Posted by IADT3since2000 View Post
    Hi again helgi,

    Those PSA results to help clarify your situation, as I understand it as a layman. In essence, as a recurring patient, it helps to know if you have a mild, middle-ground or higher-risk type of recurrence. I took a look at the PSA doubling times, using a program from a major cancer center. (Iíll put the details below, should you be interested in them.)

    The bottom line is that I think that expert doctors would believe that your doubling time is likely settling down to a PSADT of about 5.6 to 5.7 months. (Longer PSADT is of course more desirable than shorter PSADT.)

    The significance: My take is that you have a middle-ground recurrence, which one source refers to as ďbasic,Ē as contrasted to lower (mild) and higher (aggressive) risk. (One source considers a PSADT of 3 months or less to be life-threatening, and your PSADT is thankfully virtually double that dangerous threshold.) Your PSADT suggests that odds of success with a PSADT of about 5.6 to 5.7 months for just seeing what happens if nothing is done Ė ďobservationĒ Ė are not good, because your doubling time is not greater than 12 months, which indicates substantial risk of failing to control the cancer adequately with just observation. The fact that your PSADT is less than 8 months, coupled with the absence of enlarged lymph nodes (assuming that a scans for nodes, seminal vesicles and extra capsular extension were or/would be negative), suggests that you have that basic type of recurrence. Information I personally trust indicates that treatment should include IMRT radiation to the prostate fossa (where the prostate was before removal, also known as the prostate bed) but also to the pelvic lymph nodes and be boosted with ADT. Just radiating the fossa is probably not going to do the job in your situation, as I understand it as a layman. I can provide references to studies regarding a basic type recurrence if you wish.

    A possible alternative for patients with a basic type recurrence is to skip radiation and use ADT plus the chemotherapy drugs Taxotere (docetaxel) and estramustine instead (https://www.ncbi.nlm.nih.gov/pubmed/17135641); to me, as a layman, that seems a bit ďout there,Ē but there is some research to back it up. I suppose, based on that research, that some doctors will be using IMRT including a pelvic dose, plus ADT, plus Taxotere and estramustine. Iím also thinking that a patient could try that approach, and then, if it does not provide adequate cancer control, add radiation; but this is my laymanís supposition, and an expert doctor might have excellent evidence and reasons to consider that strategy to be nuts.


    The details of my calculation of your doubling time: using the centerís program and multiplying all values for all calculations by 1000 because the centerís program does not cover very low values, and assigning a date of the first of the month to all, I first included the first two values, which produced a time of 12.5 months. Next I added the third value, which brought the time down to 8.0 months. Then I added the fourth value, which brought the time down to 7.1 months. With an obvious decrease in time as results were added, I then subtracted the first value, August 1, 2018 of 8 (.008), which resulted in a PSADT of 5.6 months. Finally, I also subtracted the second value, December 1, 2018 of 10 (.010), which resulted in a PSADT of 5.7 months. This leads me, as a layman, to think that your true PSA doubling time is approximately 5.6 to 5.7 months. I think Iíve done this right, but you might want to run it by a urologist or oncologist who is savvy about prostate cancer.

    Good luck thinking through all this.
    Once again, thank you for all your thoughtful information. I really appreciate all your time, all the best.

    Helgi

     
    Reply With Quote
    The following user gives a hug of support to helgi:
    IADT3since2000 (08-14-2019)
    Reply Reply




    Thread Tools Search this Thread
    Search this Thread:

    Advanced Search

    Posting Rules
    You may not post new threads
    You may not post replies
    You may not post attachments
    You may not edit your posts

    BB code is On
    Smilies are On
    [IMG] code is Off
    HTML code is Off
    Trackbacks are Off
    Pingbacks are Off
    Refbacks are Off




    Sign Up Today!

    Ask our community of thousands of members your health questions, and learn from others experiences. Join the conversation!

    I want my free account

    All times are GMT -7. The time now is 07:44 AM.





    © 2019 MH Sub I, LLC dba Internet Brands. All rights reserved.
    Do not copy or redistribute in any form!