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G9 - Positive Margins

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Posted 7/9/2016 4:22 PM (GMT -5)
2 years ago I was diagnosed with PC - 3 cores G6 small volume. Did AS for 1 year until next biopsy showed higher grade G8 present. December 2015 had RP surgery at Johns Hopkins - confirmed G9 with positive margins but no seminal or lymph node invasion.

I am 6 1/2 months post surgery. RO is pushing hard for me to do radiation but I am delaying as my continence continues to improve (1 pad a day). Surgeon at JH has recommended Adjuvant Radiation but also said I could delay until there is evidence of biochemical recurrence - any psa > 0.1. My first two psa's have been 0.019 and 0.030. Hopkins surgeon has said Early Salvage works as well as Adjuvant - although there is some controversy about this.

Has anyone had similar numbers and elected NOT to proceed with radiation therapy? I am glad I have delayed until now but concerned about how much time I should give. Maybe I would be part of the fortunate group that does not have recurrence -but I know my case is higher risk. Any comments would be appreciated.

Thanks, SD
Posted 7/9/2016 5:09 PM (GMT -5)
SPDRI
Sorry, but Welcome to this forum! I had my RP at JH as well but had faster BCR and worse path than you. You definitely will need RT and ADT and I suggest you don't delay any longer after you're continent because there is a benefit to adjutant RT. And definitely do your lymph nodes along with prostate bed as G9 is aggressive. Delaying saves you nothing and doing it ASAP has benefits.
Bob
Posted 7/9/2016 5:55 PM (GMT -5)
I waited until my PSA hit 0.2 which has been the gold standard to start SRT. There have several published papers that showed very little disadvantage to waiting until PSA hit 0.2. But I was GS7 (3+4) which isn't the same animal as GS9.

I can tell you that 39 treatments of SRT (IGRT/IMRT) was a non-event. No side effects what so ever, and I didn't change diet or anything while undergoing the radiotherapy. I was 99% continent prior to SRT and I might have dropped down to 98% after SRT (stress incontinence.)

That is a hard call, if I was you I think I would wait until another PSA test and see what it is and if it is increasing faster, just because of you incontinence.
Posted 7/9/2016 6:54 PM (GMT -5)
Welcome to HW, sorry you need to be here.

The old standard, was to start planning for SRT at .1 and pull the trigger no later than .2. Newer studies suggest earlier SRT is better.

At G9, most would be inclined to throw everything at it. You should get another PSA test soon. I know you only have two data points, but if a third comes in over .03, I'd be listening to your RO.

Andrew
Posted 7/9/2016 7:19 PM (GMT -5)
I agree that early salvage may be as good as adjuvant radiation. But Johns Hopkins actually suggested that early salvage begin at a PSA of 0.01 ng/ml. I took issue with that, and think that 0.03 ng/ml is still safe and will avoid unnecessary radiation:

Johns Hopkins: ultrasensitive PSA after surgery predicts biochemical relapse

With your GS 9 and positive margins, you have a risky case, but also every reason to believe that early treatment can beat it. By 6 months, the tissues have healed, and it is not at all clear that waiting longer will make any difference in your urinary function recovery.

I think you should be talking to a radiation oncologist about this rather than your surgeon.

- Allen
Posted 7/10/2016 6:22 AM (GMT -5)
Tall Allen, when you say it's not clear that urinary function will improve after 6 months - is not the common thinking that continence can improve up one full year out? Also, I did not mention in post that I am participating in a Metformin trial. Metformin is associated with slowing doubling time of psa as it interferes with glucose production. When you say "early treatment" - what time frame do you have in mind? If I proceed with radiation, it looks like it would be about 8 months post surgery - a little later than normal adjuvant but still reasonable. Keep in mind there are also the potential side effects of radiation which include WORSENING urinary function as well as sexual function. I think I am leaning towards radiation - just hate the thought of exposing myself to something that is not clear I need. Steve
Posted 7/10/2016 7:06 AM (GMT -5)
Since I had a positive node along with my 4+3, I was automatically channeled to ADT and SRT (@ MD Anderson.) I was 99% continent after surgery and I can detect no change after radiation.
Posted 7/10/2016 8:25 AM (GMT -5)
SPDRI,

"Urinary incontinence after radical prostatectomy: incidence by definition, risk factors and temporal trend in a large series with a long-term follow-up."

http://www.ncbi.nlm.nih.gov/pubmed/16686718

CONCLUSIONS:

"Continence improves progressively until 2 years from RRP but some patients can become incontinent later. The criterion of pad use discriminates well between men with a limited reduction in their QoL (no or one pad used) and those with a markedly affected QoL (> or =2 pads/day). It could be clinically valid to consider users of 1 pad/day as continent. Age, bilateral neurovascular bundle resection and anastomotic stricture are significant risk factors for incontinence. There was a marked trend for the incidence of incontinence and anastomotic stricture to decrease with time."
Posted 7/10/2016 10:34 AM (GMT -5)
With G-9, I would hit it as hard as possible with everything that's available to you and do it as soon as possible......
Posted 7/10/2016 1:58 PM (GMT -5)
SPDRI-

What I meant is that whether you have the salvage radiation now or have it later, the effect on urinary function is likely to be the same. I am not saying it will have no effect. And I am not saying that your continence won't continue to improve. What I am saying is that the healing of the anastomosis has already occurred and radiation won't damage that further at this point. Radiation adds the possibility of irritative complications (e.g., urinary retention, frequency and urgency) on top of the surgery-related incontinence. But those side effects will or will not occur based on your individual reaction to the radiation, and I've seen nothing to make me believe that those complications, if they occur, will be any less severe if you continue to wait.

Sexual function may worsen too, but whether you have radiation now or wait is not likely to make a difference. Radiation impairs erectile function due to a very different mechanism (the accumulation of fibrotic tissue in blood vessels) compared to radiation (damage to nerves). So waiting buys you nothing.

What I mean by "early salvage" is salvage radiation before the PSA hits 0.2 or there is clinical evidence of progression. "Adjuvant" radiation is usually done within the first 6 months following prostatectomy.You can see it more clearly in the chart in the following article.

When should the patient and doctor consider salvage radiation therapy?

The 3 major randomized clinical trials that proved that there is a benefit to adjuvant radiation over "wait and see," did not specifically address "early salvage." Doctors hope that early salvage will provide the same benefit as adjuvant radiation, but that it will eliminate unnecessary treatment (over-treatment).

- Allen
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