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  • 16-Months Post-RP Decisions to Make (Long & Detailed)

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    Old 01-08-2020, 04:52 PM   #1
    OldTiredSailor
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    16-Months Post-RP Decisions to Make (Long & Detailed)

    My robot assisted RP was August 23, 2018. Final pathology was G7 (3+4), SM+, EPE (SM & EPE were collocated, smaller than 2mm, and G6). My 6-week µPSA was 0.022 and it declined to 0.018 at 18-weeks (early January 2019).

    I’ve had a µPSA test every 3-months since the January 2019 test and it has steadily, but slowly, increased 0.023, 0.028, 0.035, 0.050 on January 6, 2020. The John Hopkins PSA Doubling Time calculated off my data from Jan 2019 to Jan 2020 is 9-months, which is getting short enough to be of some concern.

    That is a very steady growth trend over the last 12-months and can be EXACTLY characterized with a polynomial (2nd power) trend line, which shows me reaching a 0.100 PSA value in October 2020. The polynomial growth indicates that the growth rate is accelerating so I have no reason to expect good PSA news in the future.

    When my surgeon and MO (urologist who specializes in prostate cancer treatment) both told me, about a year ago, that SRT was pretty much inevitable for me I committed to making a decision BEFORE my post-RP PSA reached 0.1 ng/ml.

    I guess now is the time for that commitment to radiation therapy but I do have some BIG questions:

    Is this REALLY the time to commit to SRT?
    My Decipher RP score was 0.47, which is just 0.01 points above their Low Risk group. I did NOT have that information when I talked with the surgeon and MO.

    When I apply my pathology report and Decipher score to the Dalela nomogram (2017 Clinical Oncology) I see less than a 4% change of Clinical Recurrence in 5-years and less than 8% chance in ten years with NO radiotherapy.

    Those risks decrease to <1% in 5-years and <2.5% in 10-years IF I do have radiotherapy. So going with SRT will reduce my chance of experiencing BCR from 1 in 12 to 1 in 40. Is that reduction in risk worth the potential side effects from SRT?

    Clinical Recurrence is defined as post-RP fossa biopsy finding PCa OR post-RP advanced imaging finding PCa.

    That 11 in 12 chance (92%) of NO 10-year metastisis while avoiding radiation therapy seems pretty inviting to me as I sneak up on age 73.

    What type of Radiation Therapy should I choose?
    Should I choose Proton Therapy? It is offered in both Orlando and Miami, either one of which is less than a three hour drive for me. I would stay there during weekdays but drive home on for the weekends.

    Are the side effects of Proton that much less than EBRT or IMRT?

    Do I want to use a center of excellence or a local radiation provider?
    Mayo in Jacksonville (140 miles) or Moffitt in Tampa (95 miles) can deliver my radiation therapy but are they that much better (how to define that?) than the 21st Century Oncology facility, which is just 15-minutes from home? Will a center of excellence provide more accurate, more effective, and (most important to me) fewer side effects?

    How soon should I begin radiation therapy?

    Den et. al (2015 Clinical Oncology) studied 188 post-RP with pT3a or worse pathology (ME!) OR men with post-RP surgical margins (That is ME!). The endpoint of the study was clinical metastisis. This study combined CAPRA-S scores with the Decipher score (GC). The low-risk GC group had a score < 0.4 and the low risk CAPRA-S group had a score < 3 while I am in the Average Risk CAPRA-S group with a score of 5.

    These results are very interesting from my "what to do now?" perspective!

    Den defined ART as post-RP radiotherapy begun with PSA <0.2 and SRT as ≥0.2.

    Here is what the Den study found (specific to my situation):
    Quote:
    When comparing patients treated with ART versus SRT, the 5-year incidence of metastasis was 7% versus 21%, respectively, for patients with CAPRA-S= 5.
    That tells me I have 3x less chance of PCa metastisis IF I begin RT with a PSA < 0.1, which, given my current trend, would be sometime before late fall 2020. But, Decipher tells me I already have a very low chance of metastisis with NO RT.

    Finally, Cox proportional hazards demonstrated that patients with higher GC scores who received ART had an 80% reduction in risk (HR, 0.20) compared with patients who received SRT

    The really SIGNIFICANT bit of data for me is found in Figure 3D, which shows that post-RP men with GC (Decipher ME=0.47) > 0.4 who started their radiotherapy with:

    PSA < 0.1 had a 100% chance of being metastisis free at 10-years

    PSA ≥ 0.1 and ≤ 0.5 had only an 85% chance of being metastisis free at 10-years

    PSA > 0.5 had only a 70% chance of being metastisis free at 10-years

    All the above seems to tell me to begin my SRT sometime before October this year!

     
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    Old 01-08-2020, 08:13 PM   #2
    DjinTonic
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    Re: 16-Months Post-RP Decisions to Make (Long & Detailed)

    Hiya OTS. Before getting into the important weeds of your question, don't you think it wise to repeat your last PSA test? We know (at least I do) that there can be outlier results. I would suggest a 30-day repeat for two reasons. If it's unexpectedly lower, you have more reason to question your results or perhaps the rate of rise. And if it's essentially the same or a tad higher, you have confirmation of the likely accuracy of your current level, and perhaps more data about the rising trend. Just a thought.

    Have you discussed with your docs or given thought to either (1) fossa-only vs. whole-pelvis RT? and (2) what benefit might there be from one of the PSMA-PET scans, even at your low PSA? How many lymph nodes were removed at your RP?

    Djin

     
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    Old 01-09-2020, 03:59 AM   #3
    Prostatefree
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    Re: 16-Months Post-RP Decisions to Make (Long & Detailed)

    Sooner is better if you are going to do it. Hesitating is what got you in this jam. You can't trust your head in this. This is all predictable.

    I suggest you include hormone therapy. Your PSA was on the rise from the git go. The assumption is its still local, but there is a chance its not and ADT has some permanent effect beyond the radiation field.

    Simple isn't easy.

     
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    Old 01-09-2020, 06:05 AM   #4
    Steve135
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    Re: 16-Months Post-RP Decisions to Make (Long & Detailed)

    OTS I have to agree with Prostatefree! Hesitating isn't the right call! In my personal experience when my PSA moved just plus it was call for alarm! My first PSA move from my bench mark 1.5 to 2.0 This was call for alarm to my URO 6 months later 2.4 and biopsy revealed high grade gleason 8 in multi areas! After RP 1.4 years later my PSA, <0.1 to 0.1 it should have been cause for alarm. URO waited 3months, PSA went to .4 and two weeks later .5 on my first BCR. Second BCR uPSA went from 18 months at 0.006 and moved to 0.030 call for alarm right... no? 3 months later 0.235 two weeks later 0.320 two weeks later 0.340 this second BCR had me changing from URO to MO and it took almost three months with no drugs due to the switching doctors and approvals!
    I don't know why some have there PSA go up and down during testing but I have never had my PSA doi anything but up! When it moves just 0.001 its going to be a problem with me. And it moves so fast insurance can't keep up with request for approval of meds!
    I've been on ADT since 2/17 with short break do to insurance! Believe me every day I wake up I know I'm on ADT with each new drug its gets worse!
    But the doctors felt that that break in meds allowed to pet scan to see the bone mets earlier?
    steve d

    ____________________
    Diag. 56 DOB 2/59 PSA 01/14 2.0 6/15 2.4
    Biopsy 6/15 5 Gleason Score 8
    RP 10/15 Path 54g 5x4.2x2.8cm 4+3=7 Tumor location quadrants Bilateral
    Extra-capsular extensions present,SV no invasion
    Vascular invasion none, PNI ,Multicentricity multifocal
    Margins NP lN's 5 neg pT3a,N0
    PSA 10/16 0.1 02/7/17 0.4 02/15/17 0.5
    Pet Scan 2/17 Neg PSA 03/17 0.6 Axumin trial 17.4mm BCR rt. SVB Casodex + Trelstar
    04/17 SRT (42)
    08/17 PSA 0.1 Last 6 uPSA 0.006 uPSA 2/19 0.030 2nd BCR 5/19 0.235 5/19 03.2 6/19 0.34 7/19 0.06 8/19 0.08 9/19 0.056
    10/190 0.08 11/19 0.07 12/19 0.07 12/30 0.06
    7/19 Trelstar, Xtandi, Zoledronic Acid
    12/19 (3) SBRT Iliac bone liasion

     
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    Old 01-09-2020, 05:14 PM   #5
    IADT3since2000
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    Re: 16-Months Post-RP Decisions to Make (Long & Detailed)

    Hi OTS,

    I am an image uided (TomoTherapy) IMRT, pelvic dose, ADT veteran, now nearly 6 years out from ending supportive ADT and with an extraordinarily low PSA (<0.01) for someone with a well-radiated but intact prostate. Here are my thoughts to complement good advice provided by others.

    Quote:
    Originally Posted by OldTiredSailor View Post
    Is this REALLY the time to commit to SRT?
    Yes, salvage RT soon! As you note later, research has shown a great advantage in hitting the cancer when it is still very small, and about now, or as soon as you can select and arrange it, would be wise.



    Quote:
    What type of Radiation Therapy should I choose?
    Should I choose Proton Therapy? It is offered in both Orlando and Miami, either one of which is less than a three hour drive for me. I would stay there during weekdays but drive home on for the weekends.
    I am convinced that well-done image guided IMRT is going to be virtually equivalent to well-done proton therapy. That's partly because the side effect percentages for both are so low that there isn't much room for improvement. If a drive doesn't bother you and you decide you want proton therapy, the Jacksonville facility has more experience and has posted research showing impressive results.

    I had 39 sessions over eight weeks back when shorter courses of radiation had not yet been proven. Now they have been. There is an intermediate course of 20 sessions, and the shortest is just 5 sessions, usually with 1 day in between. These strategies are known by the acronym SBRT, which basically means a reduced number of sessions, but each delivered with a higher dose than the old plans of about 39-40 sessions, which are also still available.

    Quote:
    Are the side effects of Proton that much less than EBRT or IMRT?
    No, as noted above. These days IMRT patients will probably get SpaceOAR gel to protect the rectum prior to radiation, which should reduce rectal side effects below their already very low rates. There may be a slight advantage for proton beam, especially if the facility can deliver it in an IMRT fashion, an emerging approach.

    Quote:
    Do I want to use a center of excellence or a local radiation provider?
    Mayo in Jacksonville (140 miles) or Moffitt in Tampa (95 miles) can deliver my radiation therapy but are they that much better (how to define that?) than the 21st Century Oncology facility, which is just 15-minutes from home? Will a center of excellence provide more accurate, more effective, and (most important to me) fewer side effects?
    It is important to have a really good facility, but it's possible that your local facility is really good. They probably have not published results, but you could ask and then review them. My impression as a mid-Atlantic guy is that Florida has a number of good prostate cancer support and education groups. You could ask around, including your doctors, or you could check the Us Too website at https://ustoo.org/Support-Group-Near-You and enter Florida (7 groups) . You could attend meetings and/or talk to the leader to get leads and information. You can also go to PubMed at www.pubmed.gov and search for - prostate cancer AND radiation AND Florida . I just did that and got a list of 311 papers that involved Florida, most likely based on the affiliation of at least one of the authors. By clicking on the paper and then clicking affiliations, you can see the authors and where they practice. I just checked the first few, and the third one listed happens to have an author from 21st Century Oncology at Ft. Myers (https://pubmed.ncbi.nlm.nih.gov/25413392 , an SBRT study). Okay, lets adjust the search to - prostate cancer AND radiation AND 21st Century Oncology . Hmmm, 47 hits! Impressive! I'm thinking you have a winner there. You might also try the helpline at www.pcri.org .


    Quote:
    How soon should I begin radiation therapy?

    The really SIGNIFICANT bit of data for me is found in Figure 3D, which shows that post-RP men with GC (Decipher ME=0.47) > 0.4 who started their radiotherapy with:

    PSA < 0.1 had a 100% chance of being metastisis free at 10-years

    PSA ≥ 0.1 and ≤ 0.5 had only an 85% chance of being metastisis free at 10-years

    PSA > 0.5 had only a 70% chance of being metastisis free at 10-years

    All the above seems to tell me to begin my SRT sometime before October this year!
    Yes. Research, including this study, has consistently shown that earlier is better. You are in the sweet spot now. Waiting until October would not be terrible, but would likely not be as good as now. That does not mean your radiation has to start very soon. Most likely your doctor will want you on a course of ADT to boost the radiation effects, and you could start that anytime, within days or a week or two. That will knock the cancer down and put you in great shape for the radiation.

    Here are a couple of more things to consider:

    Just Prostate Bed or Whole Pelvic Radiation

    Djin already mentioned this. Some research is showing that whole pelvic, in addition to a focus on the prostate, is substantially beneficial, at least for some patients. That's what I had: 78 Gy to the prostate (would be lower to the prostate bed for you, of course), and 46 Gy to the pelvis. You could look into the latest research on PubMed.

    Metformin

    This old and dirt cheap diabetes drug, with a very long track-record including safety, has proven useful against a number of cancers, and while not yet demonstrated in a clinical trial (now underway), there is very encouraging preliminary evidence, plus an understanding of the way it works, in support of radiation. For instance, check: https://pubmed.ncbi.nlm.nih.gov/23287698 , with striking graphics showing much better results for radiation patients on metformin. It has also proven beneficial in countering some of the side effects of ADT; see https://pubmed.ncbi.nlm.nih.gov/21933330 .

    Good luck,

    Jim

    - - - - - - - - - - - - - - - - - - - - - - - -
    Diagnosis Dec 1999 PSA 113.6 (first ever), age 56
    Gleason 4+3=7 (J. Epstein, JHU), all cores +, most 100%; "rock hard" prostate with ECE - stage 3, PNI, PSADT determined later 3-4 months; technetium bone scan and CT scan negative; prognosis 5 years.
    Later ProstaScint scan negative except for one suspicious small area in an unlikely location. ADT Lupron as first therapy, in Dec 1999, then + Casodex in March 2000, then + Proscar and Fosamax in Sep 2000. Rejected for surgery January 2000; offered radiation but told success odds were low; switched to ADT only vice radiation in May 2000, betting on holding the fort for improved technology; PSA gradual decline to <0.01 May 2002. Commenced intermittent ADT3 (IADT3) with first vacation from Lupron & Casodex. Negative advanced scans in 2011 (NaF18 PET/CT for bone) and 2012 (Feraheme USPIO for nodes and soft tissue). With improved technology, tried TomoTherapy RT, 39 sessions, in early 2013, plus ADT 3 in support for 18 months (fourth round of IADT3), ended April 2014. Continuing with Avodart as anti-recurrence shield. Current PSA remarkably low at <0.01; apparently cured.. Supportive diet/nutrition, exercise, supportive medications during this journey, as well as switches in antiandrogen, 5-ARI, and bone drugs.


     
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    Old 01-09-2020, 05:41 PM   #6
    Insanus
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    Re: 16-Months Post-RP Decisions to Make (Long & Detailed)

    I would have pulled the trigger a long time ago. Keep procrastinating and the cancer will be outside the radiation field.

     
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    Old 01-09-2020, 09:26 PM   #7
    HighlanderCFH
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    Re: 16-Months Post-RP Decisions to Make (Long & Detailed)

    I agree. If there is any decent chance of a recurrence, the sooner the better for salvage treatment.

     
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    Old 02-16-2020, 02:13 PM   #8
    IADT3since2000
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    Re: 16-Months Post-RP Decisions to Make (Long & Detailed)

    Hi again OldTiredSailor,

    Your replies here and elsewhere have helped me rethink how early salvage radiation should be performed, and I'm backing away from what I posted below and moving to your viewpoint of waiting to start SRT until your PSA is about to hit .1. You have probably already done the mental work, but I wanted to hit a few key points.

    Quote:
    Originally Posted by IADT3since2000 View Post
    ... Yes. Research, including this study, has consistently shown that earlier is better. You are in the sweet spot now. Waiting until October would not be terrible, but would likely not be as good as now. That does not mean your radiation has to start very soon. Most likely your doctor will want you on a course of ADT to boost the radiation effects, and you could start that anytime, within days or a week or two. That will knock the cancer down and put you in great shape for the radiation.
    ...
    In short, research is showing that patients get very good results if radiation is started by the time the PSA hits .5. Your research refines that further, down to pulling the trigger at .1. I reread chapters in "The Key to Prostate Cancer", specifically Chapters 32 (Radiation for Indigo [meaning recurring patients], pp. 255-260, Dr. Christopher Rose, MD), and 33 (Indigo - Cancer Relapse or Pelvic Node Disease, by Dr. Mark Scholz, pp. 261-272). These chapters make the point that earlier radiation does a better job at eliminating the cancer than later radiation, but that the longer the gap between surgery and radiation, the better the avoidance of sexual and urinary side effects, apparently up to the point that there is full recovery after surgery. With your doubling time, I'm joining you in thinking you can safely wait until a PSA of .1 before doing salvage radiation.

    I'm puzzled about the role that ADT in support of radiation plays in this scenario, because:
    (1) ADT would reduce a high PSA to .1 (or a lot lower) if needed;
    (2) ADT is usually used in conjunction with RT except for very mild recurrence, as I understand it; and
    (3) part of the course of supportive ADT is typically given before RT is started. (My own shot at a cure with RT, with no prior RP and therefore not salvage, began with a PSA of about 20, reduced by ADT to 1.9 a month before starting RT.)

    Therefore, supportive ADT would seem to give patients a safety net for achieving the low PSA level desirable for radiation even if their PSA had risen above .5.


    Jim

    - - - - - - - - - - - - - - - - - - - - - - - -
    Diagnosis Dec 1999 PSA 113.6 (first ever), age 56
    Gleason 4+3=7 (J. Epstein, JHU), all cores +, most 100%; "rock hard" prostate with ECE - stage 3, PNI, PSADT determined later 3-4 months; technetium bone scan and CT scan negative; prognosis 5 years.
    Later ProstaScint scan negative except for one suspicious small area in an unlikely location. ADT Lupron as first therapy, in Dec 1999, then + Casodex in March 2000, then + Proscar and Fosamax in Sep 2000. Rejected for surgery January 2000; offered radiation but told success odds were low; switched to ADT only vice radiation in May 2000, betting on holding the fort for improved technology; PSA gradual decline to <0.01 May 2002. Commenced intermittent ADT3 (IADT3) with first vacation from Lupron & Casodex. Negative advanced scans in 2011 (NaF18 PET/CT for bone) and 2012 (Feraheme USPIO for nodes and soft tissue). With improved technology, tried TomoTherapy RT, 39 sessions, in early 2013, plus ADT 3 in support for 18 months (fourth round of IADT3), ended April 2014. Continuing with Avodart as anti-recurrence shield. Current PSA remarkably low at <0.01; apparently cured.. Supportive diet/nutrition, exercise, supportive medications during this journey, as well as switches in antiandrogen, 5-ARI, and bone drugs.

    [/QUOTE]

     
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    Old 02-16-2020, 03:42 PM   #9
    IceStationZebra
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    Re: 16-Months Post-RP Decisions to Make (Long & Detailed)

    This is what scares me...

    My doctor seems so flippant about post RP testing. He only wants to use regular PSA testing using a single digit.

    He said my stats show only a 2% chance I die due to this Pca. However, like you I had a 3mm positive margin and my decipher score was low risk .37. All of my results were G6. Despite that I expect to have recurrence.

    I expect like you that I will get recurrence slowly. If I go with my surgeon's plan I wouldn't know it for quite some time and only after it exceeded .1 which
    Takes time to plan and get on top of the radiation away.

    Quite frustrating.

     
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    Old 02-16-2020, 03:48 PM   #10
    Insanus
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    Re: 16-Months Post-RP Decisions to Make (Long & Detailed)

    Results Of 1566 patients, 1195 with prostate-specific antigen levels of 0.1 to 0.5 ng/mL received ESRT and 371 patients with prostate-specific antigen levels lower than 0.1 ng/mL received ART. The median age (interquartile range) was 60 (55-65) years. After propensity score matching, the median (interquartile range) follow-up after surgery was similar between the ESRT and ART groups (73.3 [44.9-106.6] months vs 65.8 [40-107] months; P = .22). Adjuvant RT, compared with ESRT, was associated with higher freedom from biochemical failure (12-year actuarial rates: 69% [95% CI, 60%-76%] vs 43% [95% CI, 35%-51%]; effect size, 26%), freedom from distant metastases (95% [95% CI, 90%-97%] vs 85% [95% CI, 76%-90%]; effect size, 10%), and overall survival (91% [95% CI, 84%-95%] vs 79% [95% CI, 69%-86%]; effect size, 12%). Adjuvant RT, lower Gleason score and T stage, nodal irradiation, and postoperative androgen deprivation therapy were favorable prognostic features on multivariate analysis for biochemical failure. Sensitivity analysis demonstrated that the decreased risk of biochemical failure associated with ART remained significant unless more than 56% of patients in the ART group were cured by surgery alone. This threshold is greater than the estimated 12-year freedom from biochemical failure rate of 33% to 52% after radical prostatectomy alone, as determined by a contemporary dynamic nomogram.

     
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    Old 02-16-2020, 04:58 PM   #11
    DjinTonic
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    Re: 16-Months Post-RP Decisions to Make (Long & Detailed)

    Insanus neglected to cite the source he quoted from:

    Comparison Between Adjuvant and Early-Salvage Postprostatectomy Radiotherapy for Prostate Cancer With Adverse Pathological Features. [2018]

    This study also has:

    "Discussion
    In men with locally advanced T3N0 prostate adenocarcinoma, the role of immediate postoperative RT after RP was investigated in 3 randomized clinical trials.3,5,6,7,8,9 All 3 trials demonstrated a progression-free survival outcome for immediate radiotherapy over observation, but only SWOG 8794 demonstrated an FFDM and OS improvement.3,9 A meta-analysis of these 3 trials found that 10-year FFBF, FFADT, and FFDM were superior with immediate RT than a wait-and-see approach, but there was no difference in OS in this combined analysis.10 There were several potential limitations in these trials. First, survival was not a primary outcome, and the studies were therefore underpowered for this end point. Second, fewer than half of patients who recurred in the observation arms received SRT, as salvage therapy utilization was not prespecified in the trials.5,9,31 Third, roughly one-third of patients in the immediate RT arms had low-detectable PSA levels before starting RT and therefore technically received ESRT.3,7 Approximately 20% to 40% of men in the observational arms of these trials never had disease recurrence, indicating the possibility of overtreatment with ART in this patient population."

    This definitely isn't a one-size-fits-all guideline! The study concludes with the advice for at-risk patients: get a Decipher test and an advanced scan.

    Djin

     
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    Old 02-17-2020, 05:34 AM   #12
    IADT3since2000
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    Re: 16-Months Post-RP Decisions to Make (Long & Detailed)

    Thanks Insanus for focusing on this study, (https://pubmed.ncbi.nlm.nih.gov/29372236, free full text at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5885162/), which tests the notion that “early” salvage radiation can safely be deferred to .1, as OldTireSailor has noted in the study he cites, or .5 as suggested in “The Key to Prostate Cancer.” Thanks DjinTonic for raising context issues.

    I’m thinking key sentences, from Insanus’s excerpt from the abstract, are: “Sensitivity analysis demonstrated that the decreased risk of biochemical failure associated with ART remained significant unless more than 56% of patients in the ART group were cured by surgery alone. This threshold is greater than the estimated 12-year freedom from biochemical failure rate of 33% to 52% after radical prostatectomy alone, as determined by a contemporary dynamic nomogram.”

    What these sentences reveal is that the adjuvant (early after surgery based on a PSA of <.1) radiation group and the salvage (based on a PSA of .1 to .5) radiation group are groups of patients who have substantially different risk levels: the adjuvant group contains many patients, estimated at from 33% to 52%, who were very likely cured by surgery alone and therefore were never (at least at the 12 year point) going to recur, develop distant metastases, or die of prostate cancer (affecting overall survival), while all (or a very high proportion, not stated) of the salvage patients were extremely likely not cured by surgery. This makes the study another apples-to-grapefruits comparison, though an interesting and thought-provoking one from these leading and highly respected institutions.

    The authors state that their sensitivity analysis filtered out the unequal risks statistically, with the remaining result still statistically significant, but I’ll bet the key differences (12 year recurrence, distant mets and overall survival) are a lot less dramatic after that filtering than the unfiltered results in the abstract. As the authors note, if 56% of the patients in the adjuvant (ART) group had been cured by surgery alone, which is not known, the differences would basically disappear (become insignificant statistically). While 56% is at the upper end of what is likely, even a somewhat lower figure would decrease the raw differences featured in the abstract.

    (Another very important issue is the timeframe. The patients in the study were treated at 10 academic medical centers between January 1, 1987, and December 31, 2013. During much of this time – the early years – radiation dosing was too low to be effective for a substantial proportion of patients for primary radiation therapy, and I suspect the same was true for salvage radiation. Also, imaging was much inferior to what it is now. Thus, if modern methods were used but also magically achieved a 12 year follow-up, results in both groups would be even better.)

    I liked this study, but I’m thinking it still leaves the door wide open for men who want to wait before pulling the trigger on salvage therapy, especially if they pull the trigger closer to a PSA of .1 than .5.

    Jim

    - - - - - - - - - - - - - - - - - - - - - - - -
    Diagnosis Dec 1999 PSA 113.6 (first ever), age 56
    Gleason 4+3=7 (J. Epstein, JHU), all cores +, most 100%; "rock hard" prostate with ECE - stage 3, PNI, PSADT determined later 3-4 months; technetium bone scan and CT scan negative; prognosis 5 years.
    Later ProstaScint scan negative except for one suspicious small area in an unlikely location. ADT Lupron as first therapy, in Dec 1999, then + Casodex in March 2000, then + Proscar and Fosamax in Sep 2000. Rejected for surgery January 2000; offered radiation but told success odds were low; switched to ADT only vice radiation in May 2000, betting on holding the fort for improved technology; PSA gradual decline to <0.01 May 2002. Commenced intermittent ADT3 (IADT3) with first vacation from Lupron & Casodex. Negative advanced scans in 2011 (NaF18 PET/CT for bone) and 2012 (Feraheme USPIO for nodes and soft tissue). With improved technology, tried TomoTherapy RT, 39 sessions, in early 2013, plus ADT 3 in support for 18 months (fourth round of IADT3), ended April 2014. Continuing with Avodart as anti-recurrence shield. Current PSA remarkably low at <0.01; apparently cured.. Supportive diet/nutrition, exercise, supportive medications during this journey, as well as switches in antiandrogen, 5-ARI, and bone drugs.

     
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    Old 02-17-2020, 01:11 PM   #13
    Michael F
    Member
    (male)
     
    Join Date: Dec 2019
    Location: Greater Atlanta
    Posts: 52
    Michael F HB UserMichael F HB UserMichael F HB UserMichael F HB User
    Re: 16-Months Post-RP Decisions to Make (Long & Detailed)

    The OP continues to ask the same questions over and over at shorter intervals than his precise every 3 month uPSA schedule. OTS is very intelligent and has done thorough research into his issues. It is doubtful that he hopes to find a different answer.

    Unfortunately, the prognostic crystal ball has not completed Phase III testing!

    Fortunately, Genomics is getting us closer.

    IMO, since he is < G(4+3), waiting a bit longer should not decrease his chances of achieving 100% Cure. However, his Jan 2020 uPSA was a "3rd Consecutive Rise" which is suggestive of pending BCR. I agree with Dj and would get another uPSA in March.

    If SRT is needed, I think OTS found his answer:

    "PSA < 0.1 had a 100% chance of being metastisis(sic) free at 10-years"

    Unless the RO's plan is to focally pinpoint radiate the site(s) of recurrence, I'm not sure that Proton Therapy would offer any advantage.

    Hoping that OTS' next uPSA is < 0.05

    MF
    __________________
    PSA: Oct '09 = 1.91, Oct '11 = 2.79, Dec '11 = 2.98 (PSA, Free =13%)
    Jan '12: Biopsy: 1/12 = G7 (3+4) & 5/12 = G6
    March '12: Robotic RP: Left: PM + EPE => MD excised additional adjacent tissues
    Pathology: Gleason (3+4) pT3a pNO pMX pRO c tertiary pattern 5 / Prostate Size = 32 grams / Tumor = Bilateral: 20% / PNI: present
    uPSA Range: 0.017 - 0.032 at 94 Months Post Op: Mean = 0.023 (n = 23)
    LabCorp: Ultrasensitive PSA: Roche ECLIA
    Continence = Very Good (≥ 99%) ED = present

     
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    Old 02-17-2020, 01:33 PM   #14
    Gary I
    Member
    (male)
     
    Join Date: Dec 2019
    Location: SoFL
    Posts: 56
    Gary I HB UserGary I HB User
    Re: 16-Months Post-RP Decisions to Make (Long & Detailed)

    Quote:
    Originally Posted by Michael F View Post
    .....I'm not sure that Proton Therapy would offer any advantage.

    Hoping that OTS next uPSA is < 0.05

    MF
    Amen to that....for his peace of mind and ours
    __________________
    3T MRI 5/16
    MRI fusion guided biopsy 6/16
    14 cores; four G 3+3, one G3+4,
    Second 3T MRI 1/17
    RALP 7/17, G3+4, Organ confined
    pT2 pNO pMn/a Grade Group 2
    PSA 0.32 to .54 over next 4 months
    DCFPyl PET & ercMRI @NCI - 11/17
    One inch tumor still in prostate bed
    To view links or images in signatures your post count must be 10 or greater. You currently have 0 posts.

    SRT, 2ADT, IMGT 70.2 Gy, complete 5/18
    PSA 0.066 1/20

     
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