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Early SRT When approaching Biochemical Failure?

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Posted 7/1/2015 11:58 AM (GMT -5)
I am an outlier.

I had an RP in March 2008, at age 70 with post-op pathology staged at pT2aN0MX and a Gleason of 4+5=9!
What makes me an outlier --at that GS--is that the tumor was very small and organ contained with negative
margins, SV, LN, etc. All very good news on top of the GS9 very bad news.

My first post-op PSA in June of 2008 was <0.01 on an ultra sensitive assay. That remained that way for three years of quarterly tests (my wife is a physician and walks into my office for a blood draw on the first of each quarter, like clockwork.)

After the third year (post-op) my PSA wavered between .03 and .02, went to .04 a year ago (6 years post-op). Now, at 7 years post-op it has gone to .074 on a Roche ultra sensitive assay and has stayed there for the first six months of this year.

Here is the dilemma: BCF is not recognized in general until a PSA of 0.2, with two or three consecutive rises after that. Some institutions don't declare BCF until 0.4. But when one sees a very slow but obvious rise much earlier, with a GS9 history one can logically conclude it's only a matter of time until 0.2. Could be a year, could be two.

Since salvage radiation has its own potential misery and risks to deal with, the conventional wisdom seems to be to wait until 0.2 at the earliest (but definitely before 0.5).

So the question is-- has anyone read anything that suggests that SRT at a much lower PSA, like 0.1, has sufficient proven benefits to justify accepting earlier and added side effects of SRT?

My wife is "the boss of me" on this and her plan is to wait until the September 1 PSA check, and if there is a further rise, to schedule a consult at Roswell Park, an hour away. We had a local consult with a well-respected general oncologist last week (not a specific "prostate" oncologist) who agreed with my wife.


Thanks for any input.

Steve
Posted 7/1/2015 12:13 PM (GMT -5)
I am sure you will get many responses to this. The latest research suggests that if the PSA is steadily rising, then pretty much everyone who hits .05 will ultimately go on to hit .2 and a recurrence will be officially declared, and then must be treated in most cases. The phrase "steadily rising" in that sentence is important. People whose PSA fluctuates without a clear trend in the range less than .1 do not necessarily go on to have a recurrence.

Given this recent research, some people have started getting SRT as early as .03 if there have been three consecutive increases. Particularly if there is something else adverse in the picture like a high gleason score.

In my case, being a G7 (3+4) I tracked PSA as it slowly went from <.01 up to .11 over four years after surgery. But my docs at a major cancer center agreed that we should move to SRT at .1 rather than wait for the official threshhold to be reached.

If your PSA stays steady in the .07 range you might catch a break and not need SRT. But if I were you, and I got a couple of consecutive increases at this level, I'd probably move on to SRT.

Post Edited (proscapt) : 7/1/2015 11:18:19 AM (GMT-6)

Posted 7/1/2015 12:25 PM (GMT -5)
It might be worth watching the video by Dr Kwon referenced in this thread:www.healingwell.com/community/default.aspx?f=35&m=3439598

/www.youtube.com/watch?v=NkqizmvqJPo

My understanding is that he might recommend advanced imaging in your situation to detect and treat mets as early as possible before a significant PSA rise. Anyway, worth a look.
Posted 7/1/2015 12:43 PM (GMT -5)
Steve,

This is a tough decision. On the one hand, you don't want to incur the sometimes nasty SEs that occur with salvage treatment. On the other hand, GS9s can spread very quickly. The definition of BCR at a PSA of 0.2 is quite arbitrary and had to do with the limited sensitivity of PSA tests back then. Three major randomized clinical trials have demonstrated at least some advantage to earlier treatment.

You may want to read the following article that discusses your situation:

Low detectable PSA after prostatectomy – watch or treat?

You seem to fall into their category of "low, detectable, unstable PSA" which has a high chance of progressing.

There is a genomic classifier test called Decipher that can tell you what your odds are for developing full blown detectable metastases within the next 5 years. It's an expensive test, so check that your insurance covers it first - most do.

- Allen
Posted 7/1/2015 1:06 PM (GMT -5)
Hi All,
Thank you all so very much for the quick and very helpful replies. I kind of agree that if it looks like a duck, quacks like a duck and walks like a duck...chances are it's a duck. And thus with BCR

Steve
Posted 7/1/2015 2:33 PM (GMT -5)
Super max"

The Dr. Kwon video was fascinating and eye opening. Super thanks for the link. Those who have not seen it, should.

Allen:

I had seen that paper on another site. Sort of suggests that the handwriting will be on the wall a lot earlier than "0.2" I am taking it to heart. I gather the "Decipher" test requires prostate pathology samples. I suspect after 7 years my slides have gone the way of Hillary Clinton and Lois Lerner's email files. Will ask my wife.
Posted 11/8/2015 10:22 AM (GMT -5)
Well, decision time. My PSA went to 0.1 in August and then 0.12 this November. Time to uncross the fingers, dump the rabbit's foot and face the obvious: a recurrence.

While it is tempting to wait until the "official" .2, it will get there anyway so why risk waiting? I had my RP in April 2008, no detectible PSA for three years, then some bouncing around between 0.03 and 0.06 for a couple of years, then a slow but steady increase this year to a current 0.12.

I have an MRI scheduled for Tuesday and a sit down with the radiation oncologist the next day. My wife drew blood on me last week for a full panel. At 77 I have the profile of a healthy person decades younger. But my Gleason 4+5=9 trumps all that.

From emails and phone discussions between my MD wife and the oncologist, it will be radiation with a short hormone therapy course.

This morning I started an exercise regimen. We have a very nice gym in our house that I have managed not to notice for years. Hate the very thought of lacing up "sneakers." But I am told it is important and when you get a little scared you start to listen.

A new journey for one who hates travel of any kind.
Posted 11/8/2015 12:13 PM (GMT -5)
Steven
You have your answer. I waited until two successive .2's because I was following Johns Hopkins guidance which I think is outdated. Psa doubling time is more important and Gleason 9 is a giant red flag. You're lucky to have had so many years without an increase. My decision was easy due to fast doubling time.
As far as SRT, I wish that I had both the prostate bed and pelvic lymph nodes done in the first place even though ten nodes dissected were benign at pathology post RP. Now I'm undergoing a round of IMRT to pelvic nodes after two suspicious iliac nodes were discovered by MRI.
So I suggest you ask that question!
Bob
Posted 11/8/2015 12:37 PM (GMT -5)
Thank you, Bob

I will print your post and bring it with me. At the time of my surgery I had such clean pathology that even with a G9 additional therapy was not suggested or recommended. That of course was nearly 8 years ago and things change, as you suggest with the dated ".2" marker for recurrence.

All of us have to deal with what we've got and what's available, and so will I.

Thanks again,

Steve
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