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  • Post-RP predictions customized for each of us

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    Old 02-18-2020, 01:29 PM   #1
    OldTiredSailor
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    Post-RP predictions customized for each of us

    As I read comments about aRT -vs- eSRT -vs- SRT and the addition of ADT to any of those protocols I see that many of our members do not appreciate how much post-RP prognostics is changing to incorporate risk factors uniquely and highly customized for each of us.

    The more I read current research papers about our post-RP prognosis the more I understand that Prostate Cancer is very much an individualized disease. Current researchers are constantly finding better ways to specify an INDIVIDUAL’s specific pathology and genomics characteristics.

    That same research identifies every more specific categorization factors, which can more precisely estimate an individual’s path forward post-RP.

    I have carefully studied 17 papers published in the last 12-years, which incorporate some or a lot of customization when predicting BCR, MFS, PCaSM, and OS. I’d like to demonstrate how just a couple of them give very different results when specific individual pathology or timing choices are varied.

    PSADT = PSA Doubling Time in months
    DM = Distant Metastasis
    MFS = Metastasis Free Survival
    CR= Clinical Recurrence (imaging finds mets)
    OS = Overall Survival
    PCaSM = PCa Specific Mortality (died due to metastatic prostate disease)

    Den 2015
    If a post-RP man has a Decipher score ≤ 0.4 aRT (beginning at PSA <0.2) shows NO reduction in 10-year DM compared to SRT (beginning at PSA <0.5).

    If the Decipher score is >0.4 aRT gives 6% risk of DM in 10-years compared to 29% for SRT.

    However, IF Decipher score is >0.4 and RT begins at PSA <0.1 there is 0% risk of DM.

    A LOW risk Decipher subject can afford to wait to begin SRT but an intermediate Risk man will guarantee no DM with very early aRT.

    Fossati 2017
    all men had RT with PSA < 0.5 but many started much earlier
    Very Low Risk men (nadir <0.1, ≤G7, ≤pT3a) NO relationship between level of PSA at start of SRT and MFS at 8-years (98%). This was 41% of all his subjects.

    The same for Very High Risk (nadir>0.1 and >G7) – only 62% were metastasis free at 8-years and represented 7% of the study. Timing of RT made no difference.

    The rest of the subjects showed a significant correlation between PSA level at start of RT and MFS at 8-years.

    Dalela 2017
    My probability of 10-year CR is 8% with a Decipher score of 0.47, <1% with a score of 0.3, and 14% with a score of 0.65. This assumes No aRT but SRT if needed.

    D’Amico 2010
    All high risk (pT3 or G7 with BCR) subjects
    Men with PSADT<10-months were 3.4 times more likely to die from any cause after having chosen SRT rather than aRT (RT within 6-months of RP at a PSA<0.2).

    If the PSADT was > 10-months the timing of RT (as long as it began <0.5) made no difference to OS

    Abdollah 2015
    all men were high risk (pT3a or worse) with a 10-year follow-up
    Men with 0 or 1 adverse pathology features received no benefit from aRT vs SRT when looking at PCaSM or OS. Men with two or more adverse features had an 8% CSM rate at 10-years with aRT compared to 18% with SRT, ONLY if they were less than 70-years old. For ME, being 72 with only one risk factor - aRT seems to be of no benefit, as long as I commit to SRT at PSA < 0.5!

    Trock 2008
    Looking at PCaSM at 10-years:
    PSADT<6 G7 SM+ 10% with SRT and 59% with NO SRT
    PSADT>6 G7 SM+ 12% with SRT and 17% with NO SRT
    This study finds that PSA kinetics is hugely important!

    Given all this research I would be hard pressed to make a blanket statement that aRT -vs- SRT has any single answer or quantification. It appears that a proper decision requires knowledge of PSA nadir, PSA kinetics, Age, genomics and pathology.

    In fact in my particular case I can cite the following bits of detail:

    Dotan 2005
    Nomogram to predict Positive bone scan (metastasis) with rising PSA
    I have less than 1% chance of metastasis

    Memorial Sloan Kettering Post-RP Survival Nomogram (Eggener 2016)
    ME – PcaSpecific Survival = 98% at 15-years & BCR occurrence=36%

    Spratt 2017
    Decipher < 0.6 / madir PSA <0.1 / LNI-
    10-year risk of Metastasis <10%

    Marascio 2019
    Decipher<0.60, Low Risk Group, more than 2-years to BCR
    I have 3% chance of metastasis with NO RT compared to 0.5% with ART
    When adjusted for CAPRA-S ≤ 5 HR for NO ART -vs- ART statistically insignificant

    Those men with Decipher > 0.6 who chose RT+ADT had less than a 12% risk of PSA increase following RT but NOT choosing that option had more than a 25% chance of further increase in PSA after RT.

    Preisser 2019

    GradeGroup= 2 pT3x 4.3% chance of Metastatic PCa
    Risk of False Negative=0.6% (99% certain that risk is that or less)

    Those customized predictions are far below the older numbers derived from a more general set of post-RP men with diverse pathology, genomics, age…etc.
    __________________
    DOB: July 1947
    RALP 8/23/18 pT3a, G7 (3+4), 20% involvement, SM+ (Focal 2mm G6), EPE(Focal G6)+, PNI+, LNI-, SVI-, LVI-
    7g Tumor 20x size in MRI & biopsy report & in BOTH lobes not just L as biopsy reported
    Decipher RP = 0.47, which is .01 above a LOW risk

    Post-RP PSA
    10/3/18 0.021 01/4/19 0.018 04/03/19 0.022 06/26/19 0.028 10/1/19 0.035 1/1/20 0.050

    Last edited by OldTiredSailor; 02-19-2020 at 06:26 AM. Reason: Added more variables to Marisco

     
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    Old 02-18-2020, 02:10 PM   #2
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    Re: Post-RP predictions customized for each of us

    Quote:
    Originally Posted by OldTiredSailor View Post
    As I read comments about aRT -vs- eSRT -vs- SRT and the addition of ADT to any of those protocols I see that many of our members do not appreciate how much post-RP prognostics is changing to incorporate risk factors uniquely and highly customized for each of us.

    The more I read current research papers about our post-RP prognosis the more I understand that Prostate Cancer is very much an individualized disease. Current researchers are constantly finding better ways to specify an INDIVIDUAL’s specific pathology and genomics characteristics....

    I really appreciate your detailed look at how Decipher and other data can individualize case assessment and aid decision making. Your own example is also very helpful in illustrating how this all works in a real setting. I have been at this a long time, 20 years now, but that means I do not have first-hand knowledge of our modern assessment tools, like Decipher, or the first person experience of using of that data as you do. I have heard presentations about them, but it helps to see how a real patient is dealing with this information.

    Thanks for contributing, and I hope you will keep it up!

    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 02-18-2020, 04:41 PM   #3
    DjinTonic
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    Re: Post-RP predictions customized for each of us

    OTS, have you come to any conclusions/decisions for your own path forward based on your research?

    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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