Did you start radiation immediately or wait until PSA was 0.2 ng/ml

Posted by rlpostrp @rlpostrp, Aug 26 1:05pm

I am beginning to see that some gents out there started radiation therapy "immediately after" their RP, even before or with their first post-op PSA being < 0.1 ng/ml (a.k.a. "zero"). They started radiation therapy within the first three months post-op, many without any first post-op PSA. But...there seems to be another school of thought that physicians only start radiation if/when a post-op PSA value finally hits 0.2 ng/ml or higher.
It may be pathology dependent, but I am not so sure. So, please reply with "when" you started your post-op RP radiation therapy; what your original Gleason score was; and what features were reported in your surgical pathology report (EPE, Surgical Margins, Cribriform Glands, Seminal Vesicle invasion, etc.).
My cancer is a pT3b with slight invasion of my left seminal vesicle. Therefore, I had EPE of course, plus cribriform glands, and surgical margins. I read, and was told by my urologist, that 30-50% of the time or more, patients with a pT3b cancer "always see it come back", even though the seminal vesicles and the vas deferens were all removed with the prostate. Being in that unlucky 10-20% who had Surgical Margins, I am more than likely going to fall in that 30-50% that see the cancer return. But I would like to know "when" you started radiation therapy post-op: "immediately after surgery" or only after your PSA finally hit 0.2 ng/ml or higher? My thought is, that if my urologist knows that I am a pT3b and he left cancerous tissue behind in me ("Surgical Margins"), then why would he wait until my PSA eventually hits 0.2 ng/ml or higher? Why give the cancer time to grow/spread? Thanks guys

Interested in more discussions like this? Go to the Prostate Cancer Support Group.

lag | @lag | Sep 1 8:40am

In reply to @rlpostrp "My apologies for needing to ask, but I do not know what "MCRPC" is...please define/explain. Thank..." + (show)

It stands for metastatic castrate resistant prostate cancer.

jeff Marchi | @jeffmarc | Sep 1 10:52am

In reply to @rlpostrp "My apologies for needing to ask, but I do not know what "MCRPC" is...please define/explain. Thank..." + (show)

It means metastatic castrate resistant prostate cancer. When your PSA starts rising, even though you’re on ADT, you are considered castrate resistant. It usually requires you be on an ARSI drug (Zytiga or a lutamide) In order to get your PSA to come back down.

Some people become castrate resistant CRPC Without being metastatic yet. The ARSI Drugs can keep the PSA down and slow down the growth of metastasis. Unfortunately, it usually is a matter of time before metastasis start appearing, For me, it was a couple years after I became CRPC Before a metastasis appeared on my spine. I was on an ARSI But the metastasis still showed up.

thmssllvn | @thmssllvn | Sep 1 11:12am

I suspect the MAYO advice is also based on the moving target of risk stratification for each of the 'historical' Gleason scores. For contained (3T mpMRI & PSMA PET/CT) a G9 is likely to be metastasis free 70% at five years. Empirical/ or prophylactic irradiation of the pelvic lymph nodes [PLN] might be 50% 'effective'
One study I saw said the 'effectiveness' was for those > 40 PSA and only with regards to BCR not distal free metastasis, (DM), not overall survival, [OS], nor Prostate Cancer Specific Mortality [PCSM]Add to the mix Decipher & Arterra scores which may affect the weight of the Gleason category values for guidance. They can increase or decrease. Gleason guidance. Typical metastasis is in one lymph node [60%) and 2 nodes (22%). If PSA starts to climb a PSMA PETCT scan can quickly identify the single extra capsular lesion susceptible to spot radiation.

Eventually there will be an iPhone app that will include all of the variables and spit out a relevant number just in time for a universal therapeutic vaccine.

robertov | @robertov | Sep 1 2:28pm

Thank you!!! Now I understand better what he means.. I’ve been following Dr. Kwan since I was diagnosed. I felt more in my philosophy when my RO said it, but now I understand it all better. It was my feeling but if that is their general philosophy I’m good with it.

robertov | @robertov | Sep 2 9:45am

In reply to @heavyphil "Robert, “he only treats what he thinks is there.” If you take that statement completely out..." + (show)

Thanks Phil, I am struggling with this concept. My first RO insisted radiating the nodes was necessary. I don’t disagree. But mine, though aggressive (8), is very localized and small. Of course I’ve raised the question, but he seems to think he can cure me. I’ve had 9 months of orgovyx in the meantime. I admit it is the one area I’m uncertain of. I’m sure I’ll get to talk to the dosimeter and other members of the team about it. As usual, thanks!

bearcat998 | @bearcat998 | Sep 3 10:17pm

In reply to @jeffmarc "It means metastatic castrate resistant prostate cancer. When your PSA starts rising, even though you’re on..." + (show)

Jeff, do they radiate as spots appear?

jeff Marchi | @jeffmarc | Sep 4 10:29am

In reply to @bearcat998 "Jeff, do they radiate as spots appear?" + (show)

Some doctors swear by this. Dr. Mark Scholz One of the leaders of PCRI said at The meeting in March that he was doing exactly that and it was working very successfully. In fact, he preferred doing that to salvage radiation, Waiting for the metastasis to show up and then zapping them.

There’s a lot of controversy about this. In my case, I had salvage radiation 3 1/2 years after surgery and it kept me undetectable for another 2 1/2 years. If they had let metastasis grow, I would be in big trouble since I had BRCA2 Which prevents your body from correcting genetic errors. I would probably end up with many mets.

Another doctor in Houston, who was highly respected, feels that some people need to have adjunct radiation before the PSA starts rising if they have certain combinations of problems.

I know people that have had vacations from the cancer drugs and ended up with multiple metastasis that had to be zapped and in some cases too many and they required chemo.

lag | @lag | Sep 4 10:51am

In reply to @bearcat998 "Jeff, do they radiate as spots appear?" + (show)

For many years, my husband has had spot radiation at Mayo Rochester on his spinal metastases as they appear. He has worked with Dr Kwon since 2011 and also with several of the Mayo radiation oncologists over the years, and they all seem to agree on zapping them as they appear, which they call the whack-a- mole treatment protocol. 🙂

rlpostrp | @rlpostrp | Sep 4 11:26am

Do they serve you chips and salsa with that "Whack-a-mole"? Sorry...just a little humor to keep things "light" on this horrible experience we men all go through. You have to look for smiles sometimes when it is all frowns most of the time.