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Posted 3/29/2017 1:58 PM (GMT -5)
At our last doctor's visit, the doc was called out of the office, so we ended up seeing his PA. Just in general discussion, she told us that BCR doesn't require immediate treatment, even in high risk cases. She said it was common to wait until the PSA reached 10 before resuming treatment. She said that there was no proven benefit to resuming treatment earlier, but that there were QOL benefits from waiting. I was surprised. I can't seem to find anything that bears that out. My understanding is sooner is better, especially for high risk folks.

Since Randy is in the EMBARK study, this wouldn't apply to him. I was just surprised to hear that. Has anyone else been told the same?
Posted 3/29/2017 2:03 PM (GMT -5)
Please report the PA to the doctor for spreading misinformation.
Posted 3/29/2017 2:33 PM (GMT -5)
I have had failed RP and ART treatments. My first MO's treatment plan was to let my PSA go to between 10 and 20, then start ADT. His philosophy was to give me a reprieve from ADT because in his view there is no survival advantage to starting ADT early.

My current MO's plan is not much different. He is letting my PSA go to 5, doing the scans to see if the mets are local or distant, and then starting the ADT.

Perhaps the state of your husband's progrssession is different than mine.
Posted 3/29/2017 3:13 PM (GMT -5)
Tall Allen...that was my first thought. Haven't you posted something about earlier is better?

Mattamx...wow. Randy has systemic PCa. No distant metastasis has been found. Failed RP and IMRT with ADT. After about 4 months off ADT, his PSA began to rise rapidly with a PSADT of about 6 weeks. When his PSA reached 2.0, he joined the EMBARK clinical trial. He currently takes Lupron injections (3 months) and Xtandi (or maybe not....double blind). If his PSA is undetectable in June, they will suspend the medication and we will wait to see how long the remission lasts. If/when his PSA begins to rise, they will resume the meds. It sounds like your doc and our PA got their info from the same place.
Posted 3/29/2017 3:21 PM (GMT -5)
That was the TOAD study. It's not the last word, but the PA should not be presenting as fact things that are still very much an open question.

www.thelancet.com/journals/lanonc/article/PIIS1470-2045(16)00107-8/abstract
Posted 3/29/2017 3:32 PM (GMT -5)
If you are on intermittend ADT you can choose when to start with Lupron shots again, there is no specific PSA value everyone agrees on.

Since I want to extend my vacation als long as possible I use this study protocol as a guide. Unfortunately the full text is not available for free, so let me cite it here: "The condition for restarting treatment depended on the level of PSA at randomisation. For the patients whose PSA level dropped to <4 ng/ml, therapy was restarted if the PSA level rose to greater than 10 ng/ml for symptomatic individuals or to greater than 20 ng/ml for those without symptoms."

So if you choose to follow that study protocol you could start again with Lupron shots at a PSA value between 10 and 20.

George
Posted 3/29/2017 3:34 PM (GMT -5)
This is the general recommendation in Europe (Sweden):
"At a PSA doubling time of < 6 months, immediate hormonal therapy is recommended. When a slower rise recommended treatment is at PSA 5-10. At Gleason ≤ 6 and doubling time over 2 years, it is reasonable to postpone processing until the PSA value is even higher, particularly if the expected remaining life is not long."
Posted 3/29/2017 3:50 PM (GMT -5)

Gemlin said...
This is the general recommendation in Europe

Since I cited the protocol of the "Study of the South European Uroncological Group" I do not agree that this is the general recommendation in Europe. I think this is just a general recommendation in Sweden.

George
Posted 3/29/2017 6:51 PM (GMT -5)
Here's an interesting new article on salvage radiation.

https://www.ncbi.nlm.nih.gov/pubmed/28301348
Discord Among Radiation Oncologists and Urologists in the Postoperative Management of High-Risk Prostate Cancer.
Posted 3/29/2017 8:37 PM (GMT -5)
Hi RandyJoe,
Sorry to hear that your husband's PSA continues to rise. Looks like the ADT and the SRT knocked it way back but you may want to request a referral to a Medical Oncologist.
Posted 3/31/2017 1:39 PM (GMT -5)
Almost a 10,

I need to update the signature. We have been under the care of an MO, even while he was undergoing radiation. In September, Randy started clinical trials and has been receiving Lupron and either Xtandi, or a placebo. We don't know what the PSA level is at this point, since the clinical trial protocol doesn't allow us to have that information. I expect, that since he was hormone sensitive prior to beginning the trial, that the Lupron would have reduced his PSA. We should know more in June. If the PSA is undetectable in June, all medication will be suspended. Otherwise, medication will continue.
Posted 3/31/2017 4:00 PM (GMT -5)
RandyJoe, I will be following Randy's progress with great interest. I am in a similar position, recurrence with very short doubling time of around 6 weeks, with no distant mets. Not on a trial though, so no Xtandi (or not).

After consultation with my RO this week, I am now back on ADT and will have my next PSA test in June. I will see the results though and will stay on ADT until I have a well established low (hopefully zero). Will then come off meds until a new rise.

Wishing Randy great success on the trial. Do you know when you will find out if he was on Xtandi or the placebo?

Chas
Posted 3/31/2017 7:35 PM (GMT -5)
RandyJoe,
Thanks for updating. It was concerning to read your husband's issues and not knowing that he was under the care of a MO. Best to you both.
Posted 4/1/2017 1:19 PM (GMT -5)
RandyJoe, the PA was exactly right. Some of the studies trigger re-start IADT at 20ng/mL (SWOG 9346, and previously mentioned SEUG 9901), others trigger at 10ng/mL (PR7, Klotz et al). Primary goals are to minimize adverse effects and maximize QOL. Best wishes...

Post Edited (JackH) : 4/1/2017 12:42:58 PM (GMT-6)

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