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nevergivenup 10-03-2012 03:20 PM

radiation and hormone therapy after RP
Hi new here been following board for 3 months now since husband was diagnosed with PC. He had RP in June, at his 3 mo. checkup PSA was .57. Dr wants to do RT and HT now. He had nerve sparing and things are coming along well plus no problems at all with incontinence. Our question is with RT what effect will that have on the nerves saved? What about incontinence since there has not been a problem there? And adding both together? They want to do 8 weeks of RT and 6 to 9 months of HT. Can anyone share their experinces and how things have progressed? Thanks

Tall Allen 10-04-2012 12:42 AM

Re: radiation and hormone therapy after RP
I'm sorry they didn't get it all the first time.

He will probably start the hormone treatments a couple of months before radiation (neoadjuvant) and continuing concurrently. The sexual side effects are unfortunately synergistic -- neoadjuvant hormone therapy + Salvage RT has lower rates of potency preservation than any of those therapies alone. He can ask his doctor if he can take daily Cialis or Viagra concurrent with radiation and continuing afterward as a protective measure. It seems to prevent radiation damage to the vasculature that feeds the penis. In terms of incontinence, the worse they are now, the worse they seem to get after SRT. However, if his continence is good now, it probably will not get worse. Generally, other urinary and rectal symptoms are irritative, temporary and manageable with Rapaflo (urinary) or Mesalamine (rectal) if bothersome.

A couple of weeks ago, the FDA approved a new imaging technique designed to find out exactly where the recurrences are. It is good at finding even small amounts of cancer -- much better than anything thus far approved. It's called C-11 Choline PET/CT and is only available for now at the Mayo Clinic in Rochester, MN. You might want to call Eugene Kwon's office to ask if your husband is a good candidate for it. If they can find and treat any metastases they find with SBRT radiation, it is quite a bit less toxic and possibly more curative than spraying the entire area blindly with radiation. For the met to show up, the PSA must be sufficiently high, so he can't be on hormone therapy before the PET scan.

I would also urge you to look into clinical trials of salvage radiation therapy -- there are many. Some use innovative imaging, some use chemo, some use new types of hormone therapies -- all for the purpose of improving the odds of recurrence-free survival. If you tell your oncologist you are interested, she can help you find the one most appropriate for your husband.

- Allen

nevergivenup 10-04-2012 04:45 PM

Re: radiation and hormone therapy after RP
thanks for the info Allen. I contacted Mayo to get some info Bill's PSA is too low right now for the C-11 scan and if he were accepted into the program the treatment would have to be done there because the machine is so new there isn't many that can read the results to give treatment.
We met with the RO 9/26 he scheduled bone scan and CT for the 9th, wants to start HT the 10th pending results, and RT possibly the following week. This is all so fast! Urologist says get it while PSA is this low and RO says that that is a high #. We are not sure what to think. Do we have time to wait and see what happens with PSA? BTW Bill is 53, PSA 6.3, 4+3,7 and had positive margins. He has also been on 1/4 viagra daily since cath removed.
Should we only consider RT and then wait and see if HT is needed? We have an appt. w/urologist in between injection and bone scan the 9th to discuss HT trying to come up with questions...any suggestions?

Tall Allen 10-04-2012 11:13 PM

Re: radiation and hormone therapy after RP
If his PSA is too low right now to show up on the C11-Choline PET scan it is [I]certainly[/I] too low to show up on the bone scan and CT, so imho, it is pointless. You may want to check with your insurance company to see how many and which imaging tests they will pay for.

Yes, he would have to have the test done at the Mayo clinic in MN -- that's the only place doing it right now. C-11 has a half-life of 20 minutes, so it must be done on site. However the test is non-invasive and would take at most a few hours. There are a few places doing a similar test using C-11 Acetate -- UCLA, and facilities in Kansas and Arizona, as I recall -- but they all would require some out-of-state travel for you.

Here's the dilemma: you can wait for his PSA to rise to the point where it would be detectable on the C-11 Choline PET (I think they are looking for something over 1.5 if I remember correctly). If they then find the mets and they are few in number, they can pick them off with SBRT and potentially cure him with very few or no side effects. [U]However[/U], there is a risk to this strategy. If the cancer were high grade (Gleason score 8-10), it may escape the pelvic region if he is not on HT, but with a 4+3 his odds are better. Salvage RT has the greatest chance of success when the PSA is less than .5. There is no easy answer. You have to carefully weigh the risks against the potential benefits, and decide what you both are willing to live with.

The whole point of neoadjuvant hormone therapy is to start it [I]before[/I] the radiation. It makes the cancer more sensitive to the killing effects of the radiation. There is some evidence to support this, but it's not a certainty. Continuing HT afterwards is even more problematic -- if the actual cancer killing is accomplished by the radiation, what is the point of continuing the HT afterwards? Yet there is some evidence it may help, and many cancer centers continue the HT for up to 2 years afterwards. No one really knows for sure. There is a lot of uncertainty in this area. If you decide to forego the C-11 PET scan, you may want to enter a clinical trial that uses other means aside from traditional HT (e.g., Taxotere or Abiraterone) to sensitize the cancer.

- Allen

I wish I could give you more certainty on these issues, but I don't think anyone can.

- Allen

Baptista 10-05-2012 05:10 AM

Re: radiation and hormone therapy after RP

I am sorry to read about RP failure. The info you shared is evident of recurrence and you are now facing the need to decide on a salvage treatment. It may help to read about the experiences of others. Type this in a search engine: You Are Not Alone Now.

My case was similar to that of your husband’s, however my experience was 12 years ago when techniques and tests were different than the ones at present.
Back in 2000 (50 y/o) three weeks after surgery the first PSA was high at 0.18 and recurrence was declared at the 6-month mark with a PSA of 0.42. I was positive for extra capsular extensions too.
All scans were negative and doctors (MSKCC, JH, Japan) diagnosed me with Micrometastases. This is a condition where cancer forms colonies of tiny tumours difficult of being detected by traditional scans (CT, MRI, Bone scan). I looked for other means to locate the cancer (so that I would have it as a target where to direct radiation) but earlier (2001) Prostascint and PET scans were considered “impractical” because of the many false positive results. It seems that the cause was due to poor contrast agents and techniques used at that time. Now I also know that the resolution of the equipments do not catch small tumours with sizes of lesser than 1.5 to 2.0 mm.

Because of the low Gleason of my case (2+3), doctors recommended me Watchful Waiting (similar to the Active Surveillance of those times), and so I waited until 2006 before committing to salvage radiotherapy, even with negative image studies. I did SRT with a starting PSA of 3.8 ng/ml and that took me to a nadir of 0.05 at 13-months post RT.
Recurrence became apparent again in 2010 which lead me to start hormonal treatment. You can read about my events after that in this link;

Newer contrast agents and testing techniques with crisscrossing information (PET + MRI or CT) or (MRI + MRSI) seem to give better results in image studies but they all require a certain tumour “size”. As commented by Allen there is a lot of uncertainty once one recurs from a major treatment. No one can say that by choosing a different approach the results would be better.

Doctors also do not know what exactly may be the outcomes from their suggestions and everything resumes to guessing. Their recommendations are based on past experiences from similar cases but no two cases are equal in prostate cancer affairs.

I would recommend you to consider Quality of Life and that you do researches on the side effects. They tend to superimpose the ones already in place. There are always things that one would not like to lose or trade.

You should also get second opinions from specialist in all fields. A radiation oncologist and/or medical oncologist may be proper for consultations on following treatments. Your husband got enough time to go through before commiting to any protocol. Do things coordinately and timely.

Wishing you find a decision suitable to both of you and the best of lucks.

Baptista ;)

harpman 10-07-2012 10:07 AM

Re: radiation and hormone therapy after RP
I also had a failed RP and I chose Proton Therapy for salvage in Dec 2009. My PSA was approximately 0.5 and I have had a good outcome with Proton, PSA 0.01 so far with no side effects. There is a Proton Center at Indiana University and nine others operating around the US with nine more under construction.

harpman 10-07-2012 10:25 AM

Re: radiation and hormone therapy after RP
I also had a failed RP and I chose Proton Therapy for salvage in Dec 2009. My PSA was approximately 0.5 and I have had a good outcome with Proton, PSA 0.01 so far with no side effects. There is a Proton Center at Indiana University and nine others operating around the US with nine more under construction.

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