Just some random points from my latest appointment with my doctor
yesterday, FWIW, in case it triggers any useful dialog or ideas.

Refresher: PSA 8.8, Gleason 8, T3c @ age 61, RRP Oct ’04 w/ negative
margins but SVI. PSA still < 0.03 @ 18 months, but with pre-op PSAV >
2.0, SVI, and G8 I’m probably screwed; it will probably return. Our
major focus is on the selection and timing of my next tx (we can focus
on that now because my OTHER, more dangerous, cancer has been called
“probably cured”). Doc is uro, onc, surgeon, medical professor, and
large-study researcher who studies the literature rigorously, attends
many medical conferences, and is active in the robust Seattle medical
community. I believe he knows his stuff, and he consults with others
frequently and hooks me up with them when appropriate.

Now for some Q&A, paraphrased from my notes and my backup set of ears
(my very sharp, attentive, informed wife).

I.P.: I’ve begun modest adjuvant/salvage RT reading, and quickly find
two bottom lines drawn by studies and by formal polls of oncologists:
1. Whether we do RT preemptively (early adjuvant, w/no PSA) or upon PSA
return (thus SRT by definition) is a coin-toss in terms of results, and
2. That parity goes away if we let PSA slide past 1.0. i.e., if we’re
gonna do post-op RT, we’d best do it before 1.0.

Doc: Right, and right.

I.P.: And even the studies that show significant benefits of early
treatments usually mean biochemical advantage, not survival advantage,
right? I.e., any advantage is often just in the PSA number, not
something actually IMPORTANT or perceptive?

Doc: Correct. Doctors and pts choosing treatments and timing should
consider that distinction.

I.P.: What are the distinctions between adjuvant and salvage, when has
PSA failure occurred, and when does the PSA DT calculation begin after a
treatment?

Doc: The old PSA "failure" threshold of 0.2 is beginning to give way to
0.4 in many circles. After that point post-RP RT becomes "salvage", and
PSA DT calculation begins. The time-to-failure and the subsequent PSA DT
are two of the three best independently useful predictors, along with
verified Gleason number.

I.P.: Strum told one of our cancer forum guys that w/SVI, RT has only a
7% chance of helping, so why bother with the tx or risk the SEs? Do you
concur?

Doc: Strum is not invited to conferences and doesn’t get his literature
reviewed by peers because he can’t back his work up with data. I study
this particular literature exhaustively, and the real SRT benefit figure
for your case is 30%, even with SVI. So the benefit is clear and
significant, but the SEs often include serious or even severe diarrhea
and urinary problems for weeks to months plus some risk of long-term
bowel problems.

I.P.: Speaking of which, let’s get real; tats and even gold fiducial
implants and pelvic molds notwithstanding, how in heck can radiologists
zap an internal soft target within a millimeter 35 times without frying
the rectum and other goodies? Even if radiation WERE aimed within
microns, we’re talking MEAT here, not cast iron; radiation blooms
(similar scatter is the major technical challenge to Star Wars laser
weapons) and meat shifts.

Doc: This, plus the extra dosage, boosts post-RP RT's short and long
term SE threat. I worked with RT at S-K, and targeting is always a
challenge.

I.P.: Is Provenge [an immunotherapy candidate] becoming a prospect for
me if I can wait a while yet? And is immunotherapy in general a
promising technology? How about nanoparticles?

Doc: Both immunotherapy -- alone or with chemo -- and nanoparticles are
very promising technologies. I often discuss Provenge with the CEO of
Dendreon (the Provenge manufacturer), and the nanotechnology guru is on
our staff, so we follow both closely. But both are still a long ways
from USFDA approval. And chemo, while not nearly as traumatic as it was
years ago, is still of limited effectiveness, adding maybe 6 months to
survival in very advanced PC cases.

I.P.: Any emerging PC met predictors or detectors, such as CT/PET, for
screening pts considering RT?

Doc: CT/PET is still hampered in PC met detection by its slow sugar
uptake [as this forum has discussed], but there are many efforts to find
other enhancers which will light PC mets up like light bulbs.  It’s all
promising technology receiving a lot of attention. But because you had
negative surgical margins, any PSA recurrence is more likely to be
distant, reducing the likelihood that prostate fossa RT will resolve any
recurrence.

At that point I was about to suggest that given my PSA level and the SRT
effectiveness breakpoint of 1.0, we should reduce our face-to-face
meetings to every six months, plus quarterly PSA tests, plus ongoing
e-mail and phone calls as necessary (my doc is 220 miles away over a
very snowy mountain pass), and hold off on my intense SRT research until
my PSA dynamics say “it’s time”.

The doc beat me to it with exactly that recommendation, with one caveat:
“How do you feel about quarterly PSAs? Some men have a big problem with
them, but it is useful data.”

I.P.: I want to know what’s going on because it helps me feel more in
charge of this thing. Quarterly it is.

I.P.