Posted 1/28/2015 12:23 PM (GMT -5)
I was very surprised with the off-handed nature that my surgeon stated that I "probably will need radiation treatment" following the RP surgery. This was mentioned as we were getting ready to leave, following removal of the catheter and was rather a shock.
Subsequently in doing some research (outside of this forum since I had not found it yet) I was surprised to find the "2013 ADJUVANT AND SALVAGE RADIOTHERAPY AFTER PROSTATECTOMY: ASTRO/AUA GUIDELINE" from the American Urological Association. Here is an excerpt the guideline; the document is available online.
GUIDELINE STATEMENTS
1. Patients who are being considered for management of localized prostate cancer with radical prostatectomy should be informed of the potential for adverse pathologic findings that portend a higher risk of cancer recurrence and that these findings may suggest a potential benefit of additional therapy after surgery. (Clinical Principle)
2. Patients with adverse pathologic findings including seminal vesicle invasion, positive surgical margins, and extraprostatic extension should be informed that adjuvant radiotherapy, [ART] compared to radical prostatectomy only, reduces the risk of biochemical (PSA) recurrence, local recurrence, and clinical progression of cancer. They should also be informed that the impact of adjuvant radiotherapy on subsequent metastases and overall survival is less clear; one of two randomized controlled trials that addressed these outcomes indicated a benefit but the other trial did not demonstrate a benefit. However, the other trial was not powered to test the benefit regarding metastases and overall survival. (Clinical Principle)
3. Physicians should offer adjuvant radiotherapy to patients with adverse pathologic findings at prostatectomy including seminal vesicle invasion, positive surgical margins, or extraprostatic extension because of demonstrated reductions in biochemical recurrence, local recurrence, and clinical progression. (Standard; Evidence Strength: Grade A)
4. Patients should be informed that the development of a PSA recurrence after surgery is associated with a higher risk of development of metastatic prostate cancer or death from the disease. Congruent with this clinical principle, physicians should regularly monitor PSA after radical prostatectomy to enable early administration of salvage therapies if appropriate. (Clinical Principle)
5. Clinicians should define biochemical recurrence as a detectable or rising PSA value after surgery that is ≥ 0.2 ng/ml with a second confirmatory level ≥ 0.2 ng/ml. (Recommendation; Evidence Strength: Grade C)
6. A restaging evaluation in the patient with a PSA recurrence may be considered.
7. Physicians should offer salvage radiotherapy to patients with PSA or local recurrence after radical prostatectomy in whom there is no evidence of distant metastatic disease. (Recommendation; Evidence Strength: Grade C)
8. Patients should be informed that the effectiveness of radiotherapy for PSA recurrence is greatest when given at lower levels of PSA. (Clinical Principle)
9. Patients should be informed of the possible short-term and long-term urinary, bowel, and sexual side effects of radiotherapy as well as of the potential benefits of controlling disease recurrence. (Clinical Principle)
This immediately struck me as a "bait and switch" issue, since it was never discussed prior to surgery, even though the risks were known to the surgeon.
The RO's that I talked to agreed that this would be the best course of action, generally within 1 year of the RP. One RO told me that "it is easier to explain the need for ART to you (since I have a positive margin) than a guy with a clean, fully contained capsular tumor surgery and no margins or other indications."
Both RO's indicated that this is normally not sufficient time for the ED to be resolved. One told me that this is not an issue since the radiation will not impact the spared nerves. The other RO elaborated slightly, mentioning casually, that while the nerves will not be damaged the capillary blood vessels supplying the nerves probably will be severely damaged or killed, and that recovery from the ED post ART is much more difficult. (I guess ED isn't a personal problem for the RO's, so the impact on their patient's QOL is less important.)
Then in rereading the AUA Guideline details I found the following statements:
Few studies focused on the QOL impact of urinary and GI symptoms and on overall QOL post-RT. No ART studies, two SRT studies, and one mixed study reported urinary and GI-related QOL information using a validated measure.
In addition, similar to the ART studies, post-RP patients who presented for salvage RT had very low rates of adequate erectile function (3.8% to 35.7%; most studies reported that <10% patients had full potency post-RP but pre-RT) and low scores on QOL measures of sexual function/bother. The only study that included pre-RP data reported that 74 of 110 patients (73%) were fully potent pre-RP, 9 (9%) were partially potent, and 18 (18%) were impotent. Post-RP/Pre-RT, 7 of 74 previously potent patients remained potent (9.5%); 14 of 74 previously potent patients became partially potent (19%); 53 of 74 previously potent patients became impotent (71.6%); in addition, all 9 patients who were partially potent pre-RP became impotent. Post-RT (minimum follow-up 60 months), of the 21 patients who were potent or partially potent post-RP, 9 (43%) became impotent, 10 (47.6%) became or remained partially potent, and 2 (9.4%) retained full potency; 1 of the 9 patients who lost partial potency post-RP regained partial potency during follow-up.
One last thought - in general the medical community is not terribly concerned about the potential for secondary cancers (bladder, rectal, etc.) through the extensive CT scans and X-rays that are part of the ART process because most PCa patients will not survive long enough for those to become significant (i.e., we won't be around >20 years).
Heart warming considerations from the medical community as a whole...