Initial consult with the R.O.

At my last visit, my uro and I decided he would refer me to his go-to R.O. at the Duke Cancer Clinic (Rachel Blitzblau, MD, PhD) as his philosophy is that it’s never to early to meet with the R.O. I had my consult with her this afternoon. She had reviewed my case and IMO was as knowledgeable as I had hoped about SRT for PCa. She was very generous with her time and easy to converse with.

Here is my PSA history:

DATE Labcorp uPSA
11-28-17 0.010 (3 months)
02-26-18 0.009
05-30-18 0.007 (nadir)
08-27-18 0.018
09-26-18 0.013 (retest)
11-26-18 0.012
02-25-19 0.015
05-22-19 0.015
08-28-19 0.016 (2 yr.)
12-18-19 0.015
06-30-20 0.013
12-30-20 0.037
03-31-21 0.020
07-13-21 0.018 (4 yr.)
01-25-22 0.023
07-25-22 0.038 (5 yr)
10-24-22 0.036
02-02-23 0.049
05-04-23 0.054
08-03-23 0.065 (6 yr.)
11-14-23 0.068
02-20-24 0.079
05-21-24 0.094
08-14-24 0.111 (7 yr.)
08-21-24 0.125 (retest)
10-07-24 0.118
10-15-24 0.12 (Done at Duke Labs as a check)

We reviewed my PCa history, and she said that I was quite an unusual case, given that high-Gleason PCa doesn’t often behave as mine is, which, she emphasized, is actually in line with other cancers with a low-risk Decipher score. She said that in her opinion I would be hard-pressed to find an R.O. who would advise SRT now. My PSA trend shows none of the characteristics we often talk about in the Forum: high numbers, a fast doubling rate, a rise relative soon after surgery rather than years down the pike, etc. (When I said that it's not clear to me exactly how low a PSA you can pick to start figuring a doubling rate, she agreed.)

She agreed with continuing monthly uPSA with my uro (i.e., Labcorp uPSA), but wanted to confirm with a Duke lab PSA every 6 months, because there are cases—very rare—of the Labcorp test not measuring all the bound forms of PSA—so we’d double check with Duke’s test (I had blood drawn at the end of my visit today). I just got my Duke result back, which is at the end of the above list. I was staring at the results on the Duke portal when my phone range—it was the R.O. with the good news that my Duke PSA matched the last Labcorp result, so we are reasonably sure we’re dealing with good data.

We spoke about my BPH history serving me well in that all indications are that my PCa was diagnosed very early since I saw the uro often and had numerous biopsies. She mentioned that tumor burden is an important indicator of what lies ahead and that mine (6%) was very low, as was my pre-op PSA (8.6 correcting for finasteride), 16 negative lymph nodes, and my “clean slate” path report, and, finally, the good Decipher results.

She agreed that the trigger point for SRT in cases like mine, are a gray area and she’s OK with perhaps waiting for a PSA of, say, 2.5 to do a PSMA/PET test and SRT perhaps even waiting until 0.5 for treatment. The problem with zapping the fossa only early on “blindly” (with no imaging) is that you might find a positive pelvic node later on, and have missed the opportunity for a wider irradiation field at the start that would have treated the nodes. She said that of course if I insisted I wanted SRT now, she wouldn't object. She is not at all enthusiastic about the value of PSMA/PET imaging at very low PSA levels.

We discussed briefly Dr. A. D'Amico's work with high-risk PCa patients, and the value of <0.25 and 0.1 PSA levels for initiating SRT for very high risk patients.

Of course everything is subject to change. As mentioned, I’ll be monitoring my uPSA montly with Labcorp and we’ll do a 6-month checks with Duke’s PSA test.

Before today's consult, my hope was that I could put off SRT because of my path status, Decipher score, and PSA results, but I was afraid I might have been looking through rose-colored glasses.

(We only briefly touched on my RT questions, which I had prepared in case the decision was to start RT soon. But basically, IMRT for salvage can by hypofractionated and SBRT can be done if the field is fossa-only or spot zaps to nodes, but not for pelvic radiation to capture the nodes, too. I saw a SpaceOar miniposter and mentioned it and the complications that can occur. She agreed and said their interventional R.O. was top-notch and they now lean toward another brand of gel that doesn’t set as quickly as SpaceOad, so that minor adjustments can be made immediately after injection.)

I'll remain vigilant, as always!
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The R.O. just posted her visit summary, which includes:

"...
He and I reviewed that his 2017 pathology really had no adverse features aside from his Gleason Score. He has researched the data available for adjuvant and salvage post prostatectomy radiation therapy. He is aware that adjuvant radiotherapy would clearly not have been indicated in his case and did discuss that with Dr. Kim at the time. I discussed that retrospective data suggests that initiating salvage radiation before PSA reaches 0.5 does tend to lead to better overall outcomes than waiting until PSA reach a higher value, though many factors would go into this decision, including his preferences and QOL considerations.
..."

Djin

Mucho thanks, island time!! It would be terrific if my PSA actually did plateau, but I can accept a slow, more-or-less linear--if fluctuating--increase. Perhaps this can drag out long enough for improvements in the sensitivity of PSMA scans and even better radionuclides.

But even if I don't plateau, I learned today of some disadvantages of starting SRT too soon/without known if there are lesions and their sites. For example, If you need to re-irradiate the prostate fossa because the field wasn't wide enough, there is increased risk of more severe bowel and bladder symptoms.

I'm 76 now and who knows what medical conditions I'll be up against down the pike: the relative pros and cons of SRT and of ADT can certainly change.

Post Edited (DjinTonic) : 10/15/2024 9:32:07 PM (GMT-4)

Djin, when you mentioned that you went to the appointment with a list of questions, it raised my eyebrows. Only because I never imagined you with questions, I always felt you know everything there is to know about PCs.

I'm curious, regarding your comments on SpaceOar and alternative gels. I thought they only used that stuff in the setting of primary treatment, and not after the prostate has been removed. I guess I was misinformed?

Glad things are going so well for you. With all the people you have helped here (and elsewhere) you deserve things to go well.