What are those "units?" It's important to know.

What reason has been given by the rad onc for recommending IMRT? There
must be some sort of indication. When was the RP?

MAP's  questions cannot be answered, even by us non-medics, without much
more clinical data.

Regards,

Steve J

I am not a doctor and my advice is probably worth less than I am
charging you for it.  But my thoughts on your dilemma are as follows.

First some assumptions:

1. I assume you have already been recently checked for
metastases via bone scan, prostatic acid phosphatase and any
other standard tests and gotten negative results.  With a PSA of
30 I would expect that the tests would have been done, and I
presume they came up negative or the doctor wouldn't have
performed the surgery.

Negative test results do not mean that you are metastasis free,
but positive results mean that you probably are metastatic and
further local treatment would be pointless.

If this first assumption is wrong, then you can skip the rest
of my thoughts.

2. PSA=30 is a high risk case.  It is more likely than not that some
cancer remains in the area around the prostate, although it is
possible that the doctor got it all, or that what remains will not
grow and spread.

3. Radiation is most effective when the cancer is small, weak
and localized.  If you are ever going to need radiation, it is better
to get it now than to wait.  The longer you wait, the more likely
it becomes that some cancer will have reached a spot that
the radiation does not reach.  The main reason for waiting
is not to postpone radiation, but to hope that you won't need
it at all - although there may also be some benefit to waiting if
healing from the surgery is not complete.

4. As you know, radiation is not without risk of negative side
effects, and in fact, radiation delivered immediately after
surgery and before healing has taken place may make
healing more difficult as well as adding whatever side
effects it would otherwise add.

If all of the above are true, then it seems to me that what your
doctor is doing is recommending a course of action that
places the greatest emphasis on saving your life.  He is
trying to maximize your odds of not dying of prostate cancer,
at the risk of some additional side effects - which may or
may not be serious - depending on the skill of the radiation
oncologist and the luck of the draw.

That seems like a reasonable and responsible thing for a
doctor to recommend, but may or may not be what you
wish to do.  If you choose not to follow the recommendation,
you should do so with full understanding of what you are
choosing.

What I think I would do in your situation is:

1. Try to find the best radiation oncologist you can find
and consult him or her for a second opinion.  Even though I
think your primary doctor is probably right, you and I are not
experts and since your life and health are at stake, I agree
with you that an hour's consultation with another expert
seems like a responsible thing to do.

A consultation will also give you a chance to evaluate the
rad onc.  Radiation specialists, like surgeons, can be good
or not so good.  The good ones get better results than the
not so good ones.

2. Tell the rad onc what your concerns are.  Ask him whether
he thinks radiation should be scheduled even if the PSA is
undetectable.  Ask him what he thinks the risks are in waiting
for the first sign of PSA before radiating.

3. In any blood tests you get, be sure to get tested for
testosterone and for indicators of metastasis along with
PSA tests.

If your testosterone is low, then your PSA test will not
be accurate.  It will mean that you're still seeing the effects
of the hormone therapy and can't yet tell how effective the
surgery was.

4. If, after your consultation with the rad onc, you decide
that radiation sounds like a good idea, go ahead and
schedule it.  It may take 30 days or more to line up the
people and equipment for treatment.

5. Arrange with the rad onc to have final blood testing
done shortly before the start of radiation, and come to
an agreement with him about what will be done based
on the results.

If there are indications of metastasis, then I would think
the radiation plan should be cancelled unless those
indications can be tracked down and shown to be caused
by something else.

If there is a solid rise in testosterone, but no detectable
PSA, then have a plan for what to do in that case.  It may
be you'll want to proceed anyway, or it may be that you won't.
It's better for you and the doctor to agree on which it will
be before it happens than to make last minute decisions
based on emotion.

I know all of this is very tough to deal with, but it sounds
like you're proceeding methodically and have a decent
chance at coming through with a good outcome.

Best of luck to you.

   Alan

That's a tough one, MAP.  My numbers were very close.  PSA 16, G7, RRP in
December 00.  When the post-biopsy results came in with SVI, my doc was
fairly certain I'd be doing radiation by June.  However, I had two PSAs come
back <0.1 and we decided to wait and see.  Instead, I ended up doing
radiation by July of the next year.

I absolutely didn't want to do radiation in 2001.  Now, I'll always wonder
if I had, whether I'd be cured.  Probably not.

Our surgeon said 2-3 months after surgery, to allow the surgery to
heal.

This is too bad it didn't go lower.  How long were you on the HT before
surgery?  What was your Testosterone then?

Your post-surgical PSA is probably affected by the hormone therapy so
may not tell you much.  However, even without HT it would probably be
low.  I don't think that is an indicator that you're home free.

What does your pathology report state?  The real report, not whatever
summary the doc gave you.  What was your post-surgical Gleason?  Extra
capsular extension?  Can you type it in here (the path report)?

Some studies indicate seminal vesicle involvement is worse than lymph
node involvement for recurrence.

<quote> Invasion of the seminal vesicle tissue, has generally been
found to significantly worsen the prognosis more than extra-capsular
extension alone,19,22,27,29  with a 5 year progression-free rate as low
as 5% in men who have seminal vesicle invasion without lymph node
metastases at the time of surgery.
http://www.uscap.org/newindex.htm?92nd/companion10h2.htm

<quote>Invasion of the seminal vesicle tissue, has generally been found
to significantly worsen the prognosis more than extra-capsular
extension alone,19,22,27,29  with a 5 year progression-free rate as low
as 5% in men who have seminal vesicle invasion without lymph node
metastases at the time of surgery.
http://www.uscap.org/newindex.htm?92nd/companion10h2.htm

<quote>(v) Lymph node & seminal vesicle involvement
Although clearly in the minority, some men with microscopic N(+)
disease have undetectable PSA levels at 5-10 years. Progression in N(+)
disease appears to be related to the volume of tumour in the lymph
nodes. As well, not all men with seminal vesicle involvement have poor
outcomes (464).

<quote>Despite the observation that seminal vesicle and lymph node
involvement are associated with poor results post-prostatectomy, in the
Catalona series, at seven years the disease-free survival rates were
26% for men with seminal vesicle involvement and 9% for men with N(+)
disease (337). There also appears to be a difference if seminal vesicle
involvement is a direct extension from the primary tumour, in which
case it behaves more like an extracapsular extension rather than a
separate metastatic focus which implies systemic involvement.
http://www.endotext.org/male/male10/ch01s09.html

As far as too soon, the studies are clear that salvage radiation has
the best chance of success when done while PSAs are below .1.   Second
best is below .2.  The cure-curve drops off pretty rapidly after that.
As far as how hormone therapy relates to those facts, I don't know.
Since hopefully your HT will make your PSA undetectable.

If the radiation is 50 Gy, then it is defiinitely not too high.  It
could be too low.  Normal radiation, I would guess, is 75-85 Gy, and I
think in England they do 65 Gy.  I would get another consult with
another rad onc, too, because once you get radiation that's it.  You
can't say, oh, that wasn't enough, and then go back with another dose.
I think that "cleanup" radiation can use less Gy, but your pretreatment
PSA is not promising.

To copy Alan, my opinion is worth what you're paying for it, but my
husband (age 49) is getting IGRT (Tomotherapy) three months after an RP
that had extraprostatic extension, lymph node involvement, and no
seminal vesicle involvement.

Hope it helps.  If we had more information we could provide more.

best wishes, laurel

MAP.

Your oncologist is taking the very agressive route. With your post
surgery pathology it is usually what doctors recommend. Studies have
shown that IMRT given after RP within three months is highly effective
- even for high grade disease.

Your post PSA will be a major factor. If it is <0.1 you have some time
to think about things. If it is above 0.1 then the IMRT decision may be
a bit easier to make.

It would be best to get a 2nd opionion from another qualified
oncologist. You need all the information possible to make the best
choice.

Never quit and do what you have to do to defeat the disease.

Dave P

I was going to point out the same thing that Laurel did - that SVI is
generally associated w/ a high risk of systemic disease that will not
be affected by SRT. Indeed, the med-onc I saw at Vanderbilt last month
said that he NEVER recommended SRT for men w/ SVI. That may be a little
extreme but you might inquire what experience the docs you are talking
to have w/ SVI cases. In the long run it may be helpful to have a
couple of post-RP PSAs for a baseline.

Laurel, I think we went over this before. It stands to reason that the
earlier the better but the no. I have most often heard is SRT before .6
- I have never heard that it falls off after .2.

Has IMRT become the standard for SRT? The rad-onc I saw at M.D.
Anderson in 2004 said regular 3D was sufficient for salvage as opposed
to primary Tx.

Bill Denton
RP 2/12/02
PSA .96
Memphis

As most know on this list, I do not think that you can get too aggressive.
After the IMRT, I would chase it with chemo. Some will disagree, so check
with your oncologist.

My reasoning is simple. When people talk about cancer, usually they think in
terms of a solid mass tumor - cut it out and you are home-free. I think that
you will find that cancer spreads through micro-fibers too small to be seen
on any test developed as of yet, that float around in your vascular
highways, streets and avenues until they find a home to latch onto. Hence,
distant metastasis. Once the cancer has escaped its local or home base, it
is present in your body somewhere and the only method of measuring is the
PSA draw with an eye toward upward movement and the term velocity.

Another thought that I have is that the cancer started in the first place by
a inherited defective gene. Until the gene is modified, it will always
produce mutated cells that could be cancerous, ie, cells that grow
abnormally. So whatever treatment is available to stun, delay, stop cancer
growth, it is a matter of time before the mutated gene starts the process
over. Now most of us will be long gone through normal aging before the
happens in some cases. it all depends on how aggressive the cancer is that
is being created. So delaying tactics are good. They lengthen the time that
we have on this Earth.

Take care Friend and as our fellow poster writes:  Non Illegitimi
Carborundum