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Medical Forum / Diseases and Disorders / Prostate Cancer / February 2006Why accept salvage RT w/o proof?
I am very surprised no one seems concerned about having salvage RT without first taking every USEFUL test to determine whether the rising PSA source is clearly confined to or clearly beyond the radiation field. Or am I missing a valid reason to fry our crotches even if tests can show a rib glowing with PC yet no "glow" in the fossa? After all, the doctor took a one-sided oath and has zero to lose and everything to gain (slightly better statistics and Superbowl tickets) if we accept salvage tx, so s/he is biased towards adjuvant tx. We, OTOH, should actually care whether adjuvant tx has a prayer of helping and an acceptable downside ... i.e., a non-zero therapeutic index. Even if one is desperate to wrest every possible waking moment away from this beast, at least tests may show which remaining tx option has the best chance of helping so we can start the best adjuvant tx first. I.P. >I am very surprised no one seems concerned about having salvage RT without >first taking every USEFUL test to determine whether the rising PSA source [quoted text clipped - 11 lines] > > I.P. IP, I agree with you, and did not have salvage RT because the statistics said that my PCa had probably left the area. Interestingly, only one urologist was really pushing for RT, and it was 3.5 years post RRP. His statement was, what do you have to lose? Even if there is only a 10% chance of being helped, RT is easy and low SE's. Well, that is not always the case, and three other urologists have told me that if I wanted radiation, go for it, but don't expect much. Even with "mild" SE's, there are still risks involved. The uro who was really pushing for radiation does not treat a large number of PCa patients. The other do treat a large number of PCa. Back to your point, as we discussed here a while back, finding the cancer metastases is not an easy thing to do. First off, a rib glowing is a bone scan result, and that scan does not do anything to look at soft tissue. Just a "glow" is not definitive for PCa. As my last bone scan said, a new foci of activity on the left 9th rib could most likely be from other causes. Prostascint test is very unreliable and can easily miss cancer. CTscan is good, but will not find small cancers. PET scans for prostate cancer are still being perfected, and may someday be a reliable tool for finding remote cancer. I don't know much about MRI, but my understanding is that it is not necessarily better than a CTscan. My post RRP PSA had gone to 18.2, and still no location can be determined for the cancer. And yes, you are absolutely correct that the Dr. has everything to gain and nothing to lose. While some clinics and hospitals are definitely looking at the cash flow motive, the other reason for offering RT is that many patients come to the Dr. expecting "treatment" and a "cure", so they are accommodating the desire of the patient. Many Dr.'s and patients feel that any effort, even with a low chance of helping, is better than doing nothing. The answer is not an easy one. Seems the more we know, the less we seem to be able to do with the knowledge. Dale P Denver, CO > I agree with you, and did not have salvage RT because the statistics said > that my PCa had probably left the area. I use statistics often, but not when there are alternative ways that address my own case specifically. Googling terms such as combined CT PET scan cancer leads me to think the combined CT/PET scan is a breakthrough that addresses most of your detection concerns (and inspired my "glow" comment). I'll dig much deeper when my PSA approaches 0.2, but if my doc told me to get RT tomorrow based in PSA I wouldn't do it without a combined CT/PET scan. My onc listed several met tests he'd run first, and he's big on proven protocols. > Interestingly, only one urologist > was really pushing for RT, and it was 3.5 years post RRP. His statement > was, what do you have to lose? Even if there is only a 10% chance of being > helped, RT is easy and low SE's. SE impact depends on the pt's priorities and prior symptoms profile. Some can be outright nasty. > finding the cancer metastases is not an easy thing to do. Nope. But IF we find one that could explain the PSA, that's a pretty dang good excuse to avoid a tx that will not help and may harm (think bowel incontinence). And now for the combined CT/PET scan's strong suite: > First off, a rib glowing is a bone > scan result, and that scan does not do anything to look at soft tissue. [quoted text clipped - 22 lines] > to > be able to do with the knowledge. I KNOW what I'd NOT do with a PSA proven to be emanating from a rib: fry my fossa and rectum. OTOH, with no data to indicate a met, salvage RT looks a heluva lot better than adjuvant ADT. I.P. I suspect that at least 90% of men have at least a bone scan prior to salvage RT. The problem is that if they are approaching SRT at the level of PSA that is thought to be optimal, it is most unlikely that a bone scan or ProstaScint will show anything. Yes, if you get an otherwise unexplained hot spot, you forget about SRT, but there are far more false negatives than true positives. Please keep us up to date on the CT/PET scan. FWIW my uro had never mentioned it, nor did the rad-onc at M.D. Anderson in 4/04. Bill Denton RP 2/12/02 PSA .67 Memphis "Bill" <wrote > my uro had never mentioned [combined CT/PET scan], nor did the rad-onc at > M.D. Anderson in 4/04. Any onc who doesn't mention it now is an oncological cave man ... OR ... it's just not working as well as the FDA and the trials imply. It was new, non-FDA-approved technology in 4/04 (I think its approval was just a couple of months ago), but now SEEMS to be approaching mainstream status, at least comparable to lap or robotic RP. I may know more than I want to know about it by next winter. I.P. IP, I completely agree with you, but I think you are over optimistic about the CT-PET scan. PET detects the glucose uptake of the cells, and detects cancer by the abnormal activity of said cells. PCa is a slow cancer, so does not have that large of a difference in glucose activity. As new radio tracers come on line and are perfected, we may see more reliability in the PET scan for PCa. Many things you will see about the success of PET scanning on the internet are put out there by the manufacturers and clinics that are wanting to use the machine for cash flow. The higher Gleason scores that the PCa has, the more glucose activity and therefore the more likely to appear on a PET scan. While I would certainly be glad to be proven wrong, I do not think you will find any detection at a PSA of .20 with any current scan. You have said that the PSA is rising and you will be pursuing the CT-PET in the future. It looks like you will be our test model someday. Again, I completely agree with you as to seeking a more definitive answer before seeking treatment. I asked about a PET scan some years ago, and at that time it truly was not considered effective for PCa. There is no point for me to seek it now, as I am on ADT and the cancer activity is stifled for now. Later, Dale UP. "DP" <wrote > Many things you will see about the success of PET scanning on the internet > are put out there by the manufacturers and clinics that are wanting to use > the machine for cash flow. I've noticed that, which is one reason I've said little more about it than raising our consciousness of it. > The higher Gleason scores that the PCa has, the more glucose activity and > therefore the more likely to appear on a PET scan. FINALLY .... an "advantage" of a high G score? I.P. >I am very surprised no one seems concerned about having salvage RT without >first taking every USEFUL test to determine whether the rising PSA source >is clearly confined to or clearly beyond the radiation field. Or am I >missing a valid reason to fry our crotches even if tests can show a rib >glowing with PC yet no "glow" in the fossa? I cannot speak for myself in as much as I guess I just did what my doctor advised me. However, looking back on it, what would you suggest one do when his PSA is doubling every three months and nothing is popping up on any test? Wait until the cancer has left the bed and metastasizes somewhere else?  SignaturePSA 16 10/17/2000 @ 46 Biopsy 11/01/2000 G7 (3+4), T2c RRP 12/15/2000 G7 (3+4), T3cN0M0 Neg margins PSA .1 .1 .1 .27 .37 .75 EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 Lupron 07/03 (1 mo) 8/03 (4 mo), 12/03, 4/04, 09/04, 01/05, 5/05, 10/05 PSA .07 .05 .06 .05 .08 Non Illegitimi Carborundum I am not accepting it without doing due diligence but as Steve says I don't want to want until things have spread beyond the prostate bed....then I'd really have issues. I am only 8 weeks since surgery so if I get other opinions to wait to see I may but not too long. Only 3 months ago I had endo rectal MRI, Bone Scans and CAT which was unremarkable. I am expecting a call from another Dr from Hopkins (2nd opinion) tonight so I'll see what he thinks. "Steve Kramer" asks > I cannot speak for myself in as much as I guess I just did what my doctor > advised me. However, looking back on it, what would you suggest one do > when his PSA is doubling every three months and nothing is popping up on > any test? Wait until the cancer has left the bed and metastasizes > somewhere else? Although it's still at ultrasensitive levels (.023 now), mine did double at each of my last two quarterly tests. *IF* this were to continue at exactly this doubling rate, my alarm bells would go off in 9 months at 0.2 and I'd be making my next life-affecting decision in 12 months @ 0.4: Act now based on PSA or wait until we see symptoms or clinical proof of reoccurrence. Walsh and others have suggested -- almost even advised -- waiting until one of those latter points, especially regarding adjuvant ADT. But as I approach the PSA threshold for salvage RT -- 0.4 is fast becoming the accepted standard -- I'm going to do these things: 1. Pump multiple docs on the options available -- technology, availability, reliability, sequence, at least -- to determine where my PSA source is. 2. Go nuts on Google to bone up on current technology ... including following leads until they prove real or fantasy so I can consider all the promising diagnostic tools without asking the docs to chase windmills. I'll save the windmills until they're all I have left or I find one with good promises and minimal downside. 3. Starting points for my Google research include various combinations from these groups of key words: A. "salvage radiation" prostate Amling Mayo (Dr. Amling works at Mayo and does a lot of salvage RT research) B. combined CT PET scan cancer (I might add FDA to see whether I imagined its approval; I've already added Seattle to confirm that it is available there.) C. adjuvant radiation HT ADT prostate D. PDA velocity DT adjuvant prostate 4. Buy this report: http://www.jco.org/cgi/content/abstract/23/32/8204 . I already have some bowel hassles, not even counting my colon cancer aftermath. I'll want to do a LOT more research into the statistics of RT SEs to help determine whether I want to act based on PSA or wait until we see further proof of reoccurrence. The odds that SRT will help even a mild case of PC reoccurrence start out at 0.25 and go downhill from there; my Gleason 8 score is a major factor in driving that number down. I hope to learn how far it lowers my odds that SRT will help; PSA DT is probably THE major negative predictor of SRT success. There's always an appreciable chance that a PSA met can be defined, localized, and even treated locally (surgery or radiation), and the new combined CT/PET scan has offered specific promise towards that end, if I recall correctly. We got some readin' to do, and it sounds like you're ahead of me in line. I.P. > "Steve Kramer" asks >> I cannot speak for myself in as much as I guess I just did what my doctor [quoted text clipped - 11 lines] > waiting until one of those latter points, especially regarding adjuvant > ADT. Based on your and my and others' view of ultrasensitive testing, then, you are on the same page. I acted when it doubled all the way to 0.37. 0.40 was just around the corner and there was no doubt I was going to keep going. Your choice isn't all that simple at that point. You can, as you say, act on the PSA or wait for a symptom. Except the symptom is going to be a metastacis on your pelvis, or a rib (i.e., long, painful death), or in your liver or brain (i.e., shorter death). So, your forced field analysis is relatively simple: RT + SE </= cure or WW = death The ADT argument, IMHO, isn't applicable when a cure is still possible. And, of course, that is how *I* can make the decision so easily. With your colon cancer scare, RT just makes me uncomfortable from the git-go. Your formula might be: RT + (RT)SE + (CCa)SE </= cure if CCa = cure SignaturePSA 16 10/17/2000 @ 46 Biopsy 11/01/2000 G7 (3+4), T2c RRP 12/15/2000 G7 (3+4), T3cN0M0 Neg margins PSA .1 .1 .1 .27 .37 .75 EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 Lupron 07/03 (1 mo) 8/03 (4 mo), 12/03, 4/04, 09/04, 01/05, 5/05, 10/05 PSA .07 .05 .06 .05 .08 Non Illegitimi Carborundum Repeated in this thread just to cover the bases: Wow. Bill and Ron and Steve and Dave have given me a lot to digest and consider re SRT and CT/PET. Thanks. You guys are already ahead of my SRT and CT/PET reading, so ... Ah'll be baaak! The only bolus that came right back up was the paragraph on >> (hazard ratio [HR], 2.6; 95% CI, 1.7-4.1; P<.001) ... What do those terms mean? The only one I understand is the 95% CI. I.P. I was afraid of this: I hoped this would be clear to me if I came back to it later, but it didn't help. Could you translate, please? I.P. > So, your forced field analysis is relatively simple: > [quoted text clipped - 7 lines] > > RT + (RT)SE + (CCa)SE </= cure if CCa = cure > I was afraid of this: I hoped this would be clear to me if I came back to > it later, but it didn't help. Could you translate, please? I was hoping to produce a clever formula that an engineer would understand. I guess I should stay in my own milieu. Remembering that this was a forced field analysis, I was trying to give you one formula on each side; RT or WW. >> RT + SE </= cure or WW = death Radiation (RT) plus (+) the side effects (SE) that come with it offers (=) a cure or something less (<) than a cure. Watchful waiting (WW) after a failed RRP and increasing PSA is (=) a death warrant. Of course, this is just a tad simplistic. I didn't put as much effort into it as did Pathagorus. Other factors have to be within reasonable ranges. However, it is fairly consistent with, say, 61-year-old men with a Gleason of 8 and failed RRP. And, of course, it does not take into account watchful waiting until one's PSA grows to a certain level and then getting RT. >> RT + (RT)SE + (CCa)SE </= cure if CCa = cure In your case, we have to take into account your previous cancer and treatment. So, radiation treatment (RT) that you have already had, compounded by the radiation treatment (RT) side effects (SE) than you can expect with new RT, plus (+) the colon cancer (CCa) side effects (SE) you have already have will also result in (=) a cure or something less than (<) a cure, but only if your colon cancer (CCa) is (=) cured. I am sympathetic to your decision. None of us enter RT knowing that we will come out without cancer. We know that there is a good chance that we will experience mild to significant side effects immediately and well down the line, if one is cured. But, there is always that chance of a cure... and it is only a chance. You, however, had/have colon cancer. Your chances of an overall cancer cure are less. Your chances of a PCa cure is less than most of us because of your 8 Gleason. You have already had the region radiated and further radiation is accumulative. Therefore, you can expect your immediate side effects will be worse. And, your down-the-road side effects may be worse if you are cured. I just watched a short show about Doolittle. I imagine he had similar thoughts. A whole lot of preparation, risking his life and the life of all those guys in the B-25s, knowing that there was almost no chance of curing the problem and no chance of surviving the operation unscathed. SignaturePSA 16 10/17/2000 @ 46 Biopsy 11/01/2000 G7 (3+4), T2c RRP 12/15/2000 G7 (3+4), T3cN0M0 Neg margins PSA .1 .1 .1 .27 .37 .75 EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 Lupron 07/03 (1 mo) 8/03 (4 mo), 12/03, 4/04, 09/04, 01/05, 5/05, 10/05 PSA .07 .05 .06 .05 .08 Non Illegitimi Carborundum >> I was afraid of this: I hoped this would be clear to me if I came back to >> it later, but it didn't help. Could you translate, please? [quoted text clipped - 43 lines] > those guys in the B-25s, knowing that there was almost no chance of curing > the problem and no chance of surviving the operation unscathed. That helps. I have never seen/heard this forced field analysis, so it was confusing. BTW I haven't had any RT yet, so among the least of my worries is over-radiation. (Don't worry about it; I can't keep everybody's tx status clear, either.) And for those trying to apply others' cases/treatments to their cases, I should clarify that I try very hard not to let my OTHER, unrelated, cancer color my PC discussions unless I clearly say it's a factor. Otherwise my comments would mean even less that they do now. I.P. |
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