Radiation & Recurrence Treatment (Inside & Outside Prostate)

You have a relatively mild case of prostate cancer. And in your situation radiation would probably be just as good as surgery. The difference is that surgery would tell you if it really was a 3+4 with 10%. It could be worse it could be better. You will never know with radiation.

The thing is, the percentages you are seeing are pretty accurate and we don’t frequently hear from people that have such low Gleason Score having reoccurrence.

Getting a decipher score could really cinch it. If you have a real low decipher, then your a chance of reoccurrence is definitely in the bottom percentages.

Some more information

People who have radiation as their primary treatment have been told by doctors that surgery isn’t really an option if there’s a reoccurrence. Other options are not really mentioned..

This study shows that both salvage focal therapy (HIFU and cryotherapy) and salvage surgery were equally effective at extending the life of a patient that started off with radiation.

Those that had focal therapy had fewer perioperative complications.
https://jamanetwork.com/journals/jamaoncology/article-abstract/2844900

Good analysis — except for the assumption that salvage surgery is the only option for recurrence.

The idea that “if you choose radiation first, you cannot have surgery later” has some truth to it (if you only want surgery for some reason), but it’s very old-school thinking and doesn’t consider modern treatment techniques.

If there is local recurrence after initial radiation, choice of treatment would depend on the nature of the recurrence; there are other options - focal therapy (e.g., cryo), brachytherapy, SBRT (because they’re all very targetable), and yes even re-radiation in some cases. I personally know two guys who had their prostate recurrence re-treated with SBRT, because the recurrence was a single spot.

So, I wouldn’t let the old-school “no options if recurrence” philosophy change my primary treatment decision.

Well, the work, aha homework, research...you've put in to date and the responses from the forum show treatment decisions are not binary, there are a multitude of treatment decisions.

Be wary of maxims, if then that....

Also, those maxims are often outdated, changes brought about by research make them less so. They are also population based...

Given the heterogeneity of PCa, your clinical data is what's important.

Radiation is one choice, surgery is another for de novo PCa. I chose surgery back in the day, March 2014, when choices were pretty much binary, surgery or brachytherapy, imaging was pretty much useless if PSA < 20.

There were no tests such as Decipher, Germline...to aid in decision making.

So, the biopsy results drove my de novo treatment decision.

I chose surgery, at the time the clinical data said it was contained to the prostate and taking that out was likely curative. There was risk of ED, Mine was nerve sparing but I told my surgeon that if the PCa was in the nerve bundles, take them out...,it was not...

The brachytherapy at the time was the other choice and the literature did not seem to indicate the same curative possibility and the side effects came later vice the surgery.

A great pathology report, T2CNoMx, ECE, SV and margins negative, 10% prostate involved. two lymph nodes negative and GS downgraded from 4+5 to 4+4. Heck, no incontinence, regained erectile function in less than a year!

18 months later, BCR...

You've addressed two treatment choices but there are others...,

Doublet therapy is one ADT+ARI for a defined period.

As to recurrence, you'll have choices there too if that is the case.

Prostate surgery is not out of the realm on the possibility.

There is this, do nothing...continue active monitoring.
https://ancan.us14.list-manage.com/track/click
You may be be able to do MDT and push back a need for systemic therapy.

You could do MDT + short term systemic therapy with an agent such as Orgovyx.

You could do the MDT + ADT and add an ARI.

You could do ARI monotherapy.

There is the PATCH trial and Estrogen.

There are ongoing trials bringing radioisotopes such as LU 177 forward into MHSPC

and...who knows what else at whatever point in the future you may face a subsequent treatment decision.

Were it I, focus on the decision at hand, ask yourself what clinical data do we need, how do we collect it, and when we have, what the choices.

I would keep in mind that generally the choices your medical team and you discuss are good choices. Is one the right one?

You'll never know since you can try one out, but cannot go back and choose differently.

Thinks like the dude effects, duration of the treatment, PFS and RPFS are factors to discuss and consider. I don't say OS because too hard to collect and much changes while that piece of the puzzle is being collected.

Asto the localized versus advanced, well, even today's sensitive imaging often does not detect micro-metastatic disease that may be 2mm or less and contain millions of PCa cells...

So, no side effects for me as a result of surgery, after 69 radiation treatments, STT, WPLN and SBRT, 155 Gya, no side effects...

After both systemic treatments, T recovered to 400+ in six months so again, side effects went away.

Heck, my hair grew back after chemotherapy though I was disappointed it did not come back in Rex, just the same old gray...

So, ending my long answer:

There is no definitive "right" choice!"
Either is a good choice.
Compare side effects
Look at PFS and RPFS, not just cure rates.
The future is not necessarily relevant to your choice today, you will have options, some we don't even know at this point.

Kevin

Hi,
Proton beam radiation can be used in areas where you are not allowed to use future radiation treatments due to maxed out dosages.

Dave 3+4

I had RARP 3/13 for 3/4 Gleason localized at base. I am 6 weeks out & still use 4 medium pads per day with no response in ED area. I can see incontinence improvement. There were 2 0.5 mm positive margins at bladder neck & base.
So, I now think I should have gone with radiation because a zone around the prostate is treated & I think percent people with ED or incontinence is lower with radiation initially, but may deteriorate with time. It is a difficult decision with a lot of research.

@clevelandguy
If you’ve already had radiation treatment, that gave you the maximum amount of radiation to the prostate, then you really can’t radiate it again with proton radiation. You can radiate other spots that weren’t radiated previously.

@jeffmarc hi i had 2 choices after having Turp procedure due lack of urine pressure . After biopsy, they found cancer 3+4, 4+3 =7 . my choice was to have prostate removed not Radiation . Test showed cancer was contained with in the prostate. After surgery was no Metastatic . Now been 2 years recurrence . 0.3 so now having Radiation for 5 weeks daily . hope that will kill all cells . be cancer free for at least 10 years . i’m 78 this coming birthday sept 26 cheers all good luck

I was diagnosed with a 3+4 so I had surgery and after surgery, they said it was a 4+3. 3 1/2 years later, it came back and I had radiation. Its been 16 years since I was first diagnosed and I am 78 as well.

I didn’t have a metastasis show up for 10 years. In my case, I have BRCA2 the genetic problem that causes it to keep coming back. I’ve had four reoccurrences, but the drugs work great. I’ve been on ADT for 8 years, When I became castrate resistant after 2 1/2 years on it, I went on Casodex and 1.25 years and then Zytiga. I was on it 2 1/2 years, but I was only undetectable for one month. Three years ago, I switched to Orgovyx and Darolutamide And I’ve been undetectable for the last 30 months. Darolutamide Is really great, Has no side effects for most people.

Are they gonna put you on ADT? I was on Lupron for six years and switched to Orgovyx. It’s a much better choice For most people since testosterone comes back quicker once you stop taking the drug And many people say it has fewer side effects.

They probably want to put you on at least six months of ADT during radiation. That can guarantee that you don’t have recurrence soon. Since you did have a one reoccurrence That can prevent you from having a second one.

Have you had a decipher test? It could show whether or not you’re likely to get a reoccurrence. Ask your doctor about getting one.

Wish you luck with your radiation hopefully it will take care of the problem.

@jeffmarc
That’s not true, you can radiate with Proton.

“ In many cases, if a patient has reached their lifetime dose limit from conventional X-ray radiation, proton therapy is the only safe option for further radiation treatment.” from Hutchinson cancer center.

“it is frequently used to treat recurrent tumors in areas that have previously received maximum doses of radiation, a scenario often referred to as re-irradiation.” from Georgetown University.

Dave 3+4