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Posted 12/6/2013 11:09 AM (GMT -5)
Hello All :- RRP failed after 4 years of da-vince op in 2010, present PSA is 0.14,doubling time about 8 months.Path report-PT3A NO MO,Gleason 3+4=7, all negative but perinural invasion and extraprostatic ext identified focally involving neuro-vas bundle. Bone Scan, PET and MRI all negative. Please guide as to whether I should now go in for salvage radiation only or IMRT+Hormones[18 months or so] both simultanously, for better long term results?
Posted 12/6/2013 7:55 PM (GMT -5)
The medical guidance should come from a team of medical professionals, a second opinion surgeon/urologist, a radiation oncologist and a medical oncologist not all from the same practice so as to avoid any potential conflicts of interest with self referrals.

In theory the medical oncologist is the least biased with respect to surgery versus radiation, but listen to them all and then decide for yourself.

From your prior post it sounds like you are in India, and seeking treatment in US. You can't do better than the advice Tall Allen gave in that thread in link below

www.healingwell.com/community/default.aspx?f=35&m=2915316&g=2915713#m2915713

LupronJim
Posted 12/7/2013 1:07 PM (GMT -5)
The way I approached an identical decision was that I thought of this as a last chance, albeit a slim one, of a "cure." Consequently I choose hormones + radiation + radiation to pelvic lymph. If anything else had been available, I would have done that too. Finished treatment 18 months ago, and so far so good -- PSA undetectable. However, I am a Gleason 8 and post surgery doubling time was less than 3 mon and I figure I am only as good as my last PSA. Best wishes with your decision.

NewspaperLover
Posted 12/7/2013 2:39 PM (GMT -5)
If it were me I wouldn't do anything yet. RP hasn't failed with .14.
Bob
Posted 12/7/2013 5:34 PM (GMT -5)
On the question of whether to add ADT to your salvage radiation...

There was a recent randomized clinical trial (RTOG 9601) that looked at whether adding 2 years of Casodex (bicalutamide) to the salvage radiation was beneficial. It was.

Initial report of RTOG 9601, a phase III trial in prostate cancer: Effect of anti-androgen therapy (AAT) with bicalutamide during and after radiation therapy (RT) on freedom from progression and incidence of metastatic disease in patients following radical prostatectomy (RP) with pT2-3,N0 disease and elevated PSA levels.

However, the radiation dose in that study was only 65 Gy. It now seems that a radiation dose of at least 70 Gy is optimal, and a few Gy may make a big difference. It is less clear what the benefit may be in adding ADT to dose-escalated SRT. It seems to me that to some extent one can substitute increased dose for ADT.

There are two clinical trials of full ADT with/without pelvic radiation, one of which seeks to determine optimal duration of ADT. If you are able to travel, RTOG 0534 is at 460 locations in the US, Canada, Israel, and China. RADICALS is in 58 locations in the UK and Canada.
Prostate Radiation Therapy or Short-Term Androgen Deprivation Therapy and Pelvic Lymph Node Radiation Therapy With or Without Prostate Radiation Therapy in Treating Patients With a Rising Prostate Specific Antigen (PSA) After Surgery for Prostate Cancer
Radiation Therapy and Androgen Deprivation Therapy in Treating Patients Who Have Undergone Surgery for Prostate Cancer (RADICALS)
Posted 12/8/2013 12:57 AM (GMT -5)
I agree with Break 60, but the concern is real. I assume your prior psa was .07. did you use the same lab? Did you do any of the no no's. sex, DRE ,bicycle motor bike riding with 48 hours of the last test. this must be factored in. It might be prudent to prepare for further treatment with your pathology. I see the epe and stage. I am assuming a positive margin in the mix. What is your age. the ADT without radiation trial would be perfect for me if I had a BCR at my age. Lotsa factors involved. find as many dots as you can and connect them. I flat don't like the radiation, low odds, possible nasty S/E's. For a young man with high gleason who has not been shown systemic spread, yes…. You have a soft 7 3+4. For all you know it could be 95% 3 and 5% 4. Get as much information on the post op pathology as you can. Demand it. If the epe/margin is 3 chill. If 4 start working on a plan. Hopefully the .14 was an aberration and then you can totally relax. Again you do not have bcr by most experts in the field at this time . MSK, considers .4 a BCR, and they are one of the top Pca facilities in the nation. IMO If you are on the way to a BCR a monthly psa test will be definitive. This stuff usually does,t retreat with out treatment and it is a slow growing cancer.
Posted 12/8/2013 1:08 AM (GMT -5)
I wouldn't be thinking about any secondary treatment until BCR is confirmed. Wait until you have at least 3 consecutive rises above .10 before considering. That was the standard that was used locally when my surgery failed. Waiting till .20 is considered safe by most experts.

David
Posted 12/8/2013 1:05 PM (GMT -5)
Thank you all for the advise and the reference threads. I am now 60 years old.The negative parts of path report are,firstly "Gleason score 3+4=7 with tertiary pattern 5 [approximately 50% pattern 3, 45% pattern 4 and 5% pattern 5]", second "Extraprostatic Extension identified in three consecutive histologic sections of the right posterior-lateral prostate,measuring 5 mm in greatest dimension,and focally involving the neurovascular bundle" rest all positive.
As regarding the PSA tests, though I am following two different labs,one with WHO standard and the other Hybritech standard but both show a steady rise in PSA for the last about 18 months.At present the WHO reading is 0.14 and the Hybritech 0.16. So I think the relapse is for sure,that is why all this search for further treatment options. Once again thank you all and wish Good Luck!
Posted 12/8/2013 8:24 PM (GMT -5)
You seem on it and your prudence is is warranted with the psa and post op pathology. I would really grill any RO you talk to, and give some consideration to the adt only trial Tall Allen referred to. Do they know the pathology of the epe, margins? so as to hone in more on a treatment. If your psa stabilizes, let it happen till psa starts rising again. Pca is a strange duck and you never know with this stuff. At you age I would wait till double digets and then HT. You probably won't I know… good luck , hope psa stabilizes.
Posted 12/8/2013 9:46 PM (GMT -5)
I do not recommend waiting - there absolutely is an advantage to treating earlier, especially with your doubling rate. Dr. King found that the recurrence-free survival, as measured by PSA failure (bRFS), decreases by 2.6% for each incremental 0.1 ng/mL PSA at the time of SRT:

The timing of salvage radiotherapy after radical prostatectomy: a systematic review.

By the time you have found a doctor, traveled and begun the SRT, your PSA will most likely be over .2, so I think that quick action is desirable.

- Allen
Posted 12/9/2013 12:14 AM (GMT -5)
For my uro, there is no tertiary. He would call you a 9 (5+4). But, he would want to see .2 before adding a new salvage treatment.

However, you would have had adjuvant RT 5 months out based on the Gleason if he had been the original surgeon.

Problem now is - what makes the argument that Salvage RT will be useful 4 years out? I would ask for a reasoned argument (and possibly accept it). At 4 years out mine is in spine & ribs (based on scans), which would not make me a candidate for salvage RT.

Move carefully, but waiting does not seem prudent.
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