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  • Salvage radiation question?

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    Old 02-10-2020, 11:14 AM   #16
    Prostatefree
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    Re: Salvage radiation question?

    Quote:
    Originally Posted by Southsider170 View Post
    The purpose of the repeated PSA tests past surgery is to signal to the patient and doctor as to when followup therapy is going to be recommended and performed.

    If the patient has a less risky case and the doctor isn't going to recommend salvage radiation or something else until PSA reaches 0.1, there really is no point to an ultra sensitive test.
    A small study has shown better results from salvage radiation as early as 0.03 when adverse conciditions are present. ISZ had a positive margin which is an adverse condition. There is a good chance it is G6, but there is not 100% certainty. Hence, I suggested a second opinion on the pathology to confirm the G6. Genertic testing can also confirm or rule out higher risk G6.

    Also, these initial conversations around testing protocols post RP are generally with the urological surgeon. It's not their call. It is the radiation or medical oncologist's call. It irks me that a surgeon is prescribing testing for services provided by another medical specialist.
    __________________
    Born 1953; family w/PCa-grandfather, 3 brothers;
    7-12-04 PSA 1.9; 7-10-06 PSA 2.0; 8-30-07 PSA 3.2; 12-1-11 PSA 5.7; 5-16-12 PSA 4.76; 12-11-12 PSA 5.2; 3-7-16 PSA 7.2;
    3-14-16 TRUS biopsy, PCa 1%-60% across 8 of 12 samples, G3+3;
    5-4-16 DaVinci RP, Path-65g, lymph nodes, seminal vesicles, capsule, margin all neg, G3+4, T vol 35%, +pT2c, No Incontinence-6mos, Erections-14 months;
    12-8-19 PSA less than 0.02, zero club 3.5 yrs

     
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    Old 02-10-2020, 11:25 AM   #17
    DjinTonic
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    Re: Salvage radiation question?

    Quote:
    Originally Posted by Prostatefree View Post
    A small study has shown better results from salvage radiation as early as 0.03 when adverse conciditions are present. ISZ had a positive margin which is an adverse condition. There is a good chance it is G6, but there is not 100% certainty. Hence, I suggested a second opinion on the pathology to confirm the G6. Genertic testing can also confirm or rule out higher risk G6.

    Also, these initial conversations around testing protocols post RP are generally with the urological surgeon. It's not their call. It is the radiation or medical oncologist's call. It irks me that a surgeon is prescribing testing for services provided by another medical specialist.

    It's not quite that simple. I'll rely on my uro/surgeon to let me know if and when to go for an RO consult. Uros deal with PCa, before and after RT and SRT. While they don't administer RT they are well aware or current RO treatment protocols. In fact, I imagine my doc follows up on SRT for most if his referred patients. I'll rely on his input as well as that from any ROs I might have to consult.

    Djin
    __________________
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3-
    7-05-13 TURP for BPH (90→30 g) path neg. for PCa, then 6-mo. checks
    6-06-17 Nodule on R + PSA rise on finasteride: 3.6→4.3
    6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
    Nodule negative for PCa. Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, neg. frozen sections, Duke Regional Hosp.
    SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
    pT2c pN0 pMX, G9 (4+5) 5% of prostate (4.5x5x4 cm, 64 g)
    Dry; ED OK with sildenafil
    11-10-17 Decipher 0.37 Low Risk; 5-yr met risk 2.4%, 10-yr PCa mortality 3.3%
    LabCorp uPSA: 0.010 (3 mo.)0.015 (1 yr. 6 mo.)0.015 (2 yr. 4 mo.)

     
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    Old 02-10-2020, 11:48 AM   #18
    Prostatefree
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    Re: Salvage radiation question?

    Quote:
    Originally Posted by DjinTonic View Post
    It's not quite that simple. I'll rely on my uro/surgeon to let me know if and when to go for an RO consult. Uros deal with PCa, before and after RT and SRT. While they don't administer RT they are well aware or current RO treatment protocols. In fact, I imagine my doc follows up on SRT for most if his referred patients. I'll rely on his input as well as that from any ROs I might have to consult.

    Djin
    I understand, however, if my PSA breaches <0.02 I am consulting with an RO and we both can consult with the surgeon. I'd think a RO appreciates the professional courtesy to be included in the screening conversation for when his services are required.

    AS ISZ mentioned, you don't want to hear "I wish you had come in sooner." Most doctor's will never say it even if it is true.
    __________________
    Born 1953; family w/PCa-grandfather, 3 brothers;
    7-12-04 PSA 1.9; 7-10-06 PSA 2.0; 8-30-07 PSA 3.2; 12-1-11 PSA 5.7; 5-16-12 PSA 4.76; 12-11-12 PSA 5.2; 3-7-16 PSA 7.2;
    3-14-16 TRUS biopsy, PCa 1%-60% across 8 of 12 samples, G3+3;
    5-4-16 DaVinci RP, Path-65g, lymph nodes, seminal vesicles, capsule, margin all neg, G3+4, T vol 35%, +pT2c, No Incontinence-6mos, Erections-14 months;
    12-8-19 PSA less than 0.02, zero club 3.5 yrs

     
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    Old 02-10-2020, 11:51 AM   #19
    DjinTonic
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    Re: Salvage radiation question?

    Quote:
    Originally Posted by Prostatefree View Post
    I understand, however, if my PSA breaches <0.02 I am consulting with an RO and we both can consult with the surgeon. I'd think a RO appreciates the professional courtesy to be included in the screening for when his services are required.

    AS ISZ mentioned, you don't want to hear "I wish you had come in sooner."
    I totally agree. I may have rose-colored glasses on, because after my TURP and RP outcomes, my uro/surgeon looks to me like a demigod.

    Djjn

     
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    Old 02-10-2020, 12:59 PM   #20
    IceStationZebra
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    Re: Salvage radiation question?

    Quote:
    Originally Posted by DjinTonic View Post
    I totally agree. I may have rose-colored glasses on, because after my TURP and RP outcomes, my uro/surgeon looks to me like a demigod.

    Djjn
    Well what did we agree on? 😁

    I need a test I cannot get with my current batch of doctors. Based on how high that is, I might need a RO consultation.

    Who is the expert on this stuff? We cannot even agree here, I certainly don't want radiation if I can help it or for no reason. But I'm guessing my current doc wouldn't send me until I was .2 or higher. So I feel stuck.

    I'm so confused! 😫 I know it is coming so this isn't an exercise in mental masturbation. I have an appt with my primary care doc next Tuesday maybe if I explain it to him I can get him to order the upsa test after all.

    It shouldn't be his hard.

     
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    Old 02-10-2020, 01:14 PM   #21
    DjinTonic
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    Re: Salvage radiation question?

    If everything else fails, and you don't mind paying out of pocket, you can get the Quest or Labcorp PSA yourself.

    Djin

     
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    Old 02-10-2020, 01:17 PM   #22
    IceStationZebra
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    Re: Salvage radiation question?

    Quote:
    Originally Posted by DjinTonic View Post
    If everything else fails, and you don't mind paying out of pocket, you can get the Quest or Labcorp PSA yourself.

    Djin
    Yes that might be the last resort but I have insurance and should not be locked out like this.

    And what to do with the results if they are say .02 or .03? RO or not? I know my current doc would call that undetectable and say no.

     
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    Old 02-10-2020, 01:33 PM   #23
    DjinTonic
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    Re: Salvage radiation question?

    With regard to SRT:

    Salvage Radiotherapy for Prostate Cancer[2020, Overview]

    https://www.sciencedirect.com/science/article/abs/pii/S0936655520300030

    Quote:
    Highlights

    RT is the only curative treatment in case of biochemical recurrence after surgery.
    Early SRT at the first sign of PSA rise granted better disease control.
    High-dose radiotherapy is well tolerated in the salvage setting.
    The duration of optimal ADT treatment depends on the amount of risk factors.

    Abstract

    For patients experiencing biochemical recurrence in the absence of distant metastasis, salvage radiotherapy (SRT) with or without androgen deprivation therapy (ADT) is currently the only possible curative treatment option. Prostate-specific antigen (PSA) monitoring and the selected use of SRT has some advantages when compared with adjuvant radiotherapy. The most important one is avoidance of a potential overtreatment of patients who would never have disease progression, even in the presence of high-risk pathological features. The identification of a specific PSA cut-off seems to be incorrect. In patients with more adverse pathological features, early SRT administered at the very first sign of a PSA rise granted better disease control. Dose-intensified SRT is feasible and well tolerated with no significant difference in grade 2 or more acute and late toxicity. At least 66 Gy must be given in the salvage setting. ADT has a radio-sensitising effect on the radiotherapy by inhibiting the repair of DNA double-strand breaks. The use of ADT in the salvage setting results in a better oncological outcome. Hormonal therapy is associated with a decrease in quality of life and side-effects depending on the duration of hormone therapy. The oncological benefit of hormone therapy duration depends on their clinical and pathological characteristics. 68-Ga-prostate-specific membrane antigen positron emission tomography-computed tomography is the gold standard in staging prostate cancer patients with biochemical persistence or recurrence after radical prostatectomy. The implementation of 18F-labelled PSMA tracers can provide a further improvement.
    [Emphasis mine]

    This has basically been the picture I've gotten from studies: the "trigger PSA" for SRT should be adjusted according to risk factors, but the rush to treat can result in overtreatment. Imaging can help make the call as to adding or waiting on ADT.

     
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    Old 02-10-2020, 01:36 PM   #24
    IceStationZebra
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    Re: Salvage radiation question?

    Quote:
    Originally Posted by DjinTonic View Post
    With regard to SRT:

    Salvage Radiotherapy for Prostate Cancer[2020, Overview]

    https://www.sciencedirect.com/science/article/abs/pii/S0936655520300030



    [Emphasis mine]

    This has basically been the picture I've gotten from studies: the "trigger PSA" for SRT should be adjusted according to risk factors, but the rush to treat can result in overtreatment. Imaging can help make the call as to adding or waiting on ADT.
    Thank you as always. Very helpful information.

     
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    Old 02-10-2020, 03:22 PM   #25
    Prostatefree
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    Re: Salvage radiation question?

    Good odds your primary will intervene for you. He can probably also provide the PSA test your want or close. Let him make some money.

    Once it breaches detectable you can find a RO.

     
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    Old 02-10-2020, 09:04 PM   #26
    Southsider170
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    Re: Salvage radiation question?

    Quote:
    Originally Posted by Prostatefree View Post
    A small study has shown better results from salvage radiation as early as 0.03 when adverse conciditions are present. ISZ had a positive margin which is an adverse condition. There is a good chance it is G6, but there is not 100% certainty. Hence, I suggested a second opinion on the pathology to confirm the G6. Genertic testing can also confirm or rule out higher risk G6.

    Also, these initial conversations around testing protocols post RP are generally with the urological surgeon. It's not their call. It is the radiation or medical oncologist's call. It irks me that a surgeon is prescribing testing for services provided by another medical specialist.

    There is never a 100% certainty on anything in medicine, and further , any treatment has a downside which isn't necessarily known completely until the treatment is actually done.

    I was at the cardiologist this morning for another medical but non-urological problem of sorts. I was chatting with the man about aortic root dilation that I have. He said it was just something to keep an eye on, maybe get another echo in a few years. Didn't rush to proposing any treatment, even though I am as young as I ever will be and could definitely survive surgery better now than I could in a decade.


    The doctor didn't give me a 100% guarantee on this, I suppose that its "possible" that my cardiological situation could deteriorate in a hurry and I might bust an aneurysm and die quickly. Not that likely, however. After all, like prostate problems, its an asymptomatic condition.

    More and sooner treatment just isn't necessarily the best way to go, and that's why we go to professionals. And this cardiologist, just like the urologist, really doesn't make any money by recommending against immediate action. And that gives that opinion credibility with me as it goes against his financial interest.

     
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    Old 02-11-2020, 10:04 AM   #27
    Prostatefree
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    Re: Salvage radiation question?

    Quote:
    Originally Posted by Southsider170 View Post
    There is never a 100% certainty on anything in medicine, and further , any treatment has a downside which isn't necessarily known completely until the treatment is actually done.

    I was at the cardiologist this morning for another medical but non-urological problem of sorts. I was chatting with the man about aortic root dilation that I have. He said it was just something to keep an eye on, maybe get another echo in a few years. Didn't rush to proposing any treatment, even though I am as young as I ever will be and could definitely survive surgery better now than I could in a decade.


    The doctor didn't give me a 100% guarantee on this, I suppose that its "possible" that my cardiological situation could deteriorate in a hurry and I might bust an aneurysm and die quickly. Not that likely, however. After all, like prostate problems, its an asymptomatic condition.

    More and sooner treatment just isn't necessarily the best way to go, and that's why we go to professionals. And this cardiologist, just like the urologist, really doesn't make any money by recommending against immediate action. And that gives that opinion credibility with me as it goes against his financial interest.
    There is one hundred percent certainty on many things in medicine.

    The proceudre to repair the aortic root is safe and durable when performed by an experienced and qualified surgeon.

    What is certain is most of us hear what we want to hear first. What we don't want to hear takes a little longer.
    __________________
    Born 1953; family w/PCa-grandfather, 3 brothers;
    7-12-04 PSA 1.9; 7-10-06 PSA 2.0; 8-30-07 PSA 3.2; 12-1-11 PSA 5.7; 5-16-12 PSA 4.76; 12-11-12 PSA 5.2; 3-7-16 PSA 7.2;
    3-14-16 TRUS biopsy, PCa 1%-60% across 8 of 12 samples, G3+3;
    5-4-16 DaVinci RP, Path-65g, lymph nodes, seminal vesicles, capsule, margin all neg, G3+4, T vol 35%, +pT2c, No Incontinence-6mos, Erections-14 months;
    12-8-19 PSA less than 0.02, zero club 3.5 yrs

     
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    Old 02-11-2020, 10:13 AM   #28
    IceStationZebra
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    Re: Salvage radiation question?

    Quote:
    Originally Posted by Prostatefree View Post
    There is one hundred percent certainty on many things in medicine.

    The proceudre to repair the aortic root is safe and durable when performed by an experienced and qualified surgeon.

    What is certain is most of us hear what we want to hear first. What we don't want to hear takes a little longer.
    I would be happy with a little clarity and consistency. It is frustrating when you think you have a plan but the doctors will not participate. On one hand you trust their expertise but when it flies in the face of reason...well.

     
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