Don't burn a bridge.

Newly diagnosed, doing my homework and adsorbing every word on this forum.
When my doc called to give me the dx and I mentioned BT, he immediately responded: "don't burn a bridge, you can't have surgery in the event of recurrence after BT".
One week later, speaking with a surgeon in Pittsburgh, he dismisses BT out of hand.
So we take a drive to the Cleveland Clinic to visit a surgeon and a Radonc. We found both to be equally impressive and a credit to their renowned institution. So it has become abundantly clear: I have no friggin idea what I should do!
I have researched many of the published studies comparing RP with BT and see the trend in favor of seeds (curatively and SEs). I'm stuck on the 'burn a bridge' dilemma.
The Radonc at CC said I should make my treatment decision based upon what is most likely to cure me the first time. One of the links on this board led me to a similar sentiment. I just find that thought process lacking. I want one more bullet in my gun in case my PSA starts rising after Brachy Therapy five years from now.
So my specific questions is: what are the salvage options in the case of BT not curing my PCa?
[I know you guys hear this all the time, but Thanks so much for your advice!!!]

Sorry, for some reason my signature line doesn't show:
PCa Dx Sept. 2016, age 58. Biopsy right side, 3+3, two of eight cores, one core = 2MM, less than 5%. Biopsy left side, 3+4, five of eleven cores, one core = 8MM, 60%. PNI seen on both sides. No lymph perm seen.
PSA- 11/12 = 3.52, 6/16 = 6.43, 7/16 =8.08 8/16 = 5.2 (15%free).

steveinErie said...
Sorry, for some reason my signature line doesn't show:
PCa Dx Sept. 2016, age 58. Biopsy right side, 3+3, two of eight cores, one core = 2MM, less than 5%. Biopsy left side, 3+4, five of eleven cores, one core = 8MM, 60%. PNI seen on both sides. No lymph perm seen.
PSA- 11/12 = 3.52, 6/16 = 6.43, 7/16 =8.08 8/16 = 5.2 (15%free).

Hey Steve,
In case you missed it, you have to click the "include signature" box at the bottom every time you post, just above "submit".

Unfortunately, a part of human nature that must be dealt with when trying to decide what to do, is the fact that if a person makes his living doing a certain procedure, there is a natural tendency to consider that procedure as the gold standard. There is also a natural human tendency to consider competing procedures to not be as good. Or as the old saying goes: "if a man has a hammer, everything looks like a nail.". You will probably have to deal with this and do your own research and figure it out for you. Or, you can just take the word of which ever practitioner seems the most trustworthy to you.

It is a very tough decision. One of the advantages of surgery is that you do have a second possible curative bullet -- SRT -- in case the first one fails. Every time I mention this, I get a horde of angry responders, but it is a VERY valid argument.

These responders will accurately point out that if the backup radiation works, then that would have worked the first time and you would not have gone through surgery. That is all true. My point has been that you did not know it at the time. It would be great if we knew that treatment X would be the one working. If we KNEW, then a backup tx. would be a totally moot point, never needed. But that isn't the case.

So, having a backup bullet is perfectly valid.

I hope I haven't reopened that can of worms!

But, to be fair, if you go with radiation and it fails, while it is true that surgery as a backup gets to be very difficult/problematical, it has been mentioned to me that there are other curative backup possibilities. Others more knowledgeable than I can be more specific.

I think this is that very difficult personal tx. choice. Only YOU can look at all the aspects, such as SE, your age, and, in effect, which poison you choose! It is never a simple choice and it is NEVER cut and dried.

Mel

If you look at the results of the ProtecT trial, surgery and radiation were equally effective treating prostate cancer. However, radiation had significantly lower side effects.

Surgery after radiation is possible but it is difficult to find a specialist who will do that. Otherwise you can treat a recurrence with brachytherapy, HIFU, Cryo, NanoKnife or maybe CyberKnife. So there are bullets left.

Also the combination of surgery and radiation will also combine the side effects of these treatments!

I also want to cite Dr. Scholz:
"One old pitch deserves mention: “Salvage radiation is feasible after surgery but salvage surgery after radiation is not.” Basically the implicit message is that surgery and radiation are indistinguishable, therefore, one should prioritize the backup plan. This outdated argument actually had merit fifteen years ago when radiation cure rates were lower than surgery. These days, however, men should know that cure rates are as good as or perhaps better with radiation. The best results come from “getting the job right the first time” rather than planning for failure."

George

Post Edited (George_) : 10/25/2016 10:39:13 AM (GMT-6)

Are there 'results based' studies showing the effectiveness of salvage therapies in the event of recurrence after BT? I see cryo is mentioned in some articles but can't find scholarly publications. Cyberknife (or any SBRT) HIFU are mentioned sometimes as well, but, does literature exist to show, even limited, results.
I truly appreciate the "get it done right the first time' sentiment. It's just that my decision making algorithm is hungry for the answer to the "what ifs".

We would all love to get it done right the first time.
If it were that simple, HW would go out of business!

From everything I've read, one tx (surgery vs. radiation) is not better than the other in terms of cure rates.

You have to factor all kinds of other considerations into your decision.

As I recall, the cure rate for SRT is about 30%. The reality is that the PC is either in the prostate bed area or it's not. If it is, then I guess the cure rate approaches 100%. But, you don't know. But that 30% was the figure I had in 2011, when I did SRT. (Mine failed). These days, with better imaging, etc., I wonder if cure rates are higher. Does anyone have that information?

One other item: in my particular case, I was having major problems with BPH. Flomax had worked great for 10 years, but was starting to fail. I was having streaks of great difficulty urinating. Twice, I had my coat on ready to go to the ER (catheter time?) but fortunately things relented. So, for me, a fabulous SE of the surgery was that it eliminated my BPH symptoms.

Mel

Post Edited (compiler) : 10/25/2016 11:32:11 AM (GMT-6)

First don't ask a surgeon about procedures he is not qualified to do. If you want to learn about radiation therapy go see a radiation oncologist. Better yet see several that specialize in different treatments. You should look at seeds, HDR brachytherapy and SBRT.

I was too far advanced for surgery and used radiation effectively. Total cancer control and no side effects nearly six years later

As to salvage treatment it is rarely neede after radiation because radiation covers a larger area than the surgeon can excise. If there is a recurrence after radiation it is because there were already micro mets somewhere else.

Surgery is not the gold standard. That might have been true 15-20 years ago but not now. It is no better at cancer control than many different forms of radiotherapy. And for intermediate and high risk radiotherapy is better at cancer control. Radiotherapy also results in less significant side effects.

There is simply no substitute for seeking out the different expert practitioners to get the true information. Don't ask a surgeon about radiotherapy and don't ask a rad onc about surgery. You have seen two surgeons and you know what a third surgeon will suggest. Now see specifically radiation oncologists that specialize in SBRT, HDR brachytherapy and seed brachytherapy. You are unlikely to fin a rad onc that does all three.

steveinErie-

Yes, there are studies that show the efficacy of salvage therapy after primary radiation. I have dozens in my files. Here are a few articles that discuss this, and include links to peer-reviewed studies in professional journals:

Most of the recurrences after primary radiation failure are salvageable

Salvage SBRT for local recurrence after primary radiation therapy (RT)

Salvage Low Dose Rate Brachytherapy (LDRBT) after primary LDRBT failure

Outcomes of salvage prostate cryotherapy stratified by pre-treatment PSA: update from the COLD registry

Salvage Radical Prostatectomy for Radiation-recurrent Prostate Cancer: A Multi-institutional Collaboration

The best salvage options include focal ablation, focal brachytherapy, and whole-gland SBRT. Salvage surgery is certainly an option as well, but there are only a handful of surgeons who have the experience to do it well. Until about the last 5-10 years, failure after RT was considered to be unsalvageable because the radiation had already treated the prostate plus an area outside of it, so failures were assumed to be due to distant metastases rather than local failure. New imaging technology revealed that up to half of the failures after IMRT were local-only and still could be salvaged.

I agree with your doctor who advised you to make your decision based on the primary therapy. Here's why. Your kind of prostate cancer, which is "favorable intermediate risk," has 95+% chance of being cured by primary therapy. Take a look at these, for example:

/pcnrv.blogspot.com/2016/09/5-year-sbrt-trial-high-cancer-control.html
/pcnrv.blogspot.com/2016/08/high-dose-rate-brachytherapy-hdrbt.html

(only about 20% of the few failures were local-only failures in those therapies)

As Michael said, you have plenty of time to make this decision. Here are some questions you may want to ask yourself:

• Do I need to see a pathology report to tell me how contained it was?
• If I choose radiation, can I live with the fact that PSA goes down over a number of years, with bounces along the way, and never becomes undetectable?
• If the pathology is adverse and PSA does not become undetectable, am I prepared to undergo adjuvant radiation with all the potential side effects that entails? (Your doctor has hopefully run a nomogram showing the probability of this happening)
• If the radiation doesn't work, am I prepared to have a biopsy and possible focal brachy re-treatment?
• Which bothers me more - the potential for incontinence and ED after surgery or the potential for retention and irritative effects after radiation? (given the probabilities of those side effects)
• Do I understand the other possible side effects of surgery? (e.g., infection, hernia, climacturia, penile shrinkage, stress incontinence, etc.) Am I prepared to take on penile rehab?
• Do I understand the other possible side effects of radiation? (e.g., fatigue, proctitis, hemorrhoids, frequency, urgency, burning while peeing, ED).
• Am I prepared to undergo radiation therapy and its side effects?
• Am I prepared to undergo surgery and its recovery?

As usual, the guys have hit all the important points about results for us favorable intermediate risk guys. All of the radiation and surgical treatments have the same cure rates. The other thing to consider is that with the cure rates of treatments like SBRT (IIRC 97% at 5 years, 93% or 95% at 9 year) do you really need a backup plan?

As I said, the 5% chance of recurrence is not all local - in Katz's study (9 years), only 1% was local only, the remaining 4% was distant - so there was no treatment that could have been curative with any salvage therapy.

There is a long term study of SBRT - 9 years (see link in my signature). There will be a 10-year update out soon (no significant changes). That is as long as the longest IMRT study, but the SBRT study also has a much bigger sample size.

The chances of secondary cancers due to RT are very small, and are actually probably smaller with SBRT due to its superior accuracy. Here's our best estimate:

Radiotherapy-induced second primary cancer (RTSPC) risk is low and may differ by radiation technique.


In order to understand all these things, you should be talking to experts in each therapy. You can't reasonably expect a surgeon to know much about brachytherapy, or a brachytherapist to know much about SBRT, etc. Each is an advocate in his own therapy (or he shouldn't be doing it!). I'm sure they will express an opinion on other therapies if pressed, or sometimes without being pressed. The burden falls to the patient to get the answers from the specialists.

Is it wise to extrapolate similar/favorable results for the long term based upon 9 years for SBRT?