On June 1, Zoom wrote, in pertinent part:

(snip)

Here is what the authoritative Prostate Cancer Research Institute says:

"For patients suffering PSA progression following primary surgery,
viable treatment options include watchful waiting (no treatment),
salvage radiation to the prostatic fossa (with or without radiation to
the pelvic lymph nodes), or androgen deprivation therapy (ADT). Salvage
radiation treatment will benefit *only* those patients with *proven*
residual cancer in the prostatic fossa, whereas ADT can potentially
benefit those with residual cancer and/or metastatic disease. Serial PSA
measurements in the ensuing months following surgery can be used to help
determine the likelihood that a patient is more or less likely to
benefit from salvage radiation therapy." (emphasis added)

There is much more.

See
http://www.prostate-cancer.org/education/preclin/McDermed_Using_PSA_Intelligentl
y2.html
or
http://tinyurl.com/kdp7c

....and search the page for "salvage radiation."

BTW, "fossa" means "a cavity, or depression; as the location from which
the prostate was removed," per PCRI's glossary. I think the much-cited
"bed" is a misnomer.

As I understand it, it means no more than that the surgeon could not
*see* cancer outside the margins. Just that and no more.

The PCa could be systemic (which does not necessarily mean metastatic);
a local tx such as radiation would not be curative in such a case. This
is a consideration for the empowered patient and his medic. The latter
should not be a urologist, BTW. His job is done. The next step, IMO, is
to consult a medical oncologist. (S)he would likely recommend further
PSA tests (of the ultrasensitive kind) at monthly intervals to monitor
what is happening. If there is a serial rise over months, then it would
be necessary to decide what to do, based upon the then-existing clinical
record.

I recommend giving Walsh much more credence.

See above. The uro's job was finished when he removed his gloves post
surgery.

There are some but not all PCa specialists listed on the PCRI site. See:
http://www.prostate-cancer.org/resource/find-a-physician.html

Good luck.

Regards,

Steve J

"I believe it is a mistake for many urologists to be involved in the
endocrine therapy of prostate cancer.  Let me state why. Urologists are
surgeons and many times surgeons rush to a treatment without really
understanding what they are doing."
--Stephen B. Strum, MD
Oncologist

I had similar concerns with my positive margin as well as similar
numbers going in - age 60, PSA 4.9, Gleason 6 and T1c.  What swayed me
to not consider adjuvant radiation was "well focused 2mm tumor at the
margin" which I interpreted to mean growing up to the margin which is
a whole lot different in my lay opinion than slicing through the tumor
leaving some behind.  I too had no indication of prostatic extension
and had a T2c stage.  So far, four years later, my PSA is still <0.1,
and even if it starts to creep up I will put a lot of weight on its
doubling time before I jump into salvage radiation.  My surgeon missed
the 2mm thing completely and was totally surprised when he read the
report - I was there when he read it for the first time.  It's good
that your surgeon caught the margins on the left side and "dug a
little deeper."

Your decision to pursue radiation at this time is a tough one.  Even
Walsh says many positive margins never amount to anything.  Often when
there is a bit of cancer left behind, it can die off on its own
because it is now surrounded by a lot of scar tissue and starves from
diminished nutrients.  I certainly wouldn't commit to anything until
that first PSA comes back which won't be for another six weeks or
more, and in the meantime I would look for as much new information as
you can find on the benefits of adjuvant vs salvage radiation.  When I
had my surgery in 2003, I found a couple of studies that indicated
similar long-term results for both options (the same number had
progressed to advanced disease after 10 years) and since my lifelong
opinion is to avoid  medical procedures if at all possible, I opted
for no radiation.  My concern of course was to avoid the side effects
of the radiation and the possibility (likelyhood?) that I may never
need radiation at all.  A pathologist friend of mine suggested
adjuvant radiation and two uros who I consulted took a "wait and see"
approach.  I haven't pursued any more recent information so I don't
know if the thinking has changed but somehow I doubt there is any less
confusion now than there was four years ago.

Your only immediate concern right now is that first PSA so good luck
with that.
Dave Perry

On Jun 1, 3:01 pm, Zoom <One...@aTime.net> wrote...snip...

Hi Zoom...The prostate is physically attached to the body by tissue,
this is what the surgeon cuts through to remove the prostate.  If he
cuts through cancerous tissue, leaving some cancerous tissue behind
when the prostate is removed, then there is a positive margin.  The
remainder of the prostate that is not anatomically attached, is simply
exposed to the inside of the body.  When PCa grows out of the prostate
and exists on this exposed surface, terms such as extraprostatic
extension or capsular penetration are used to describe it.
Extraprostatic extension will continue to spread up the exterior side
of the prostate until it reaches a point where the prostate is
attached to the body, then it can continue to spread beyond the
prostate.

As to your question on SRT, rad oncs will not radiate until you heal
from the surgery.  Ther are too many healing factors, etc, in that
area now and it is thought that they can interfere with the radiation
process.  This will give you time to study your post-RP PSA trend.
Distinguishing between local and systemic recurrence is not always
straight-forward.  Again, measuring your PSA and determining the
velocity or doubling time, is thought by some, to be an indicator of
local vs. systemic recurrence.  Also take a look at Partin II
calculators...Best wishes and good health, ron

http://www.prostate-cancer.org/tools/software/partin2.html

PARTIN II CALCULATIONS

The Partin II algorithm estimates a probability as to whether rising
PSA after radical prostatectomy is the result of local recurrence or
distant metastases. The results of this paper are based on only 51
patients. The table used in this calculation appears in Alan Partin,
M.D., et al; Evaluation of Serum Prostate Specific Antigen Velocity
(PSAV) After Radical Prostatectomy to Distinguish Local Recurrence
from Distant Metastases;Urology, May 1994, Volume 43, Number 5. The
results published were:

RESULTS. A linear mixed effects regression analysis was used to model
these data. Using these models, the time to a serum PSA level of 0.5
ng/mL, the PSA level one year following surgery, pathologic stage,
Gleason sum, and the rate of change of PSA (PSA velocity or PSAV) were
tested as predictors of local versus distant metastases. A combination
of PSAV, pathologic stage, and Gleason grade best distinguished local
from distant metastases.

A program to perform the Partin II calculation can be found in PC
Tools II.

Check this thread from this forum:
http://groups.google.com/group/alt.support.cancer.prostate/browse_thread/thread/
3f1d8a711a85cb37/45d3f184b887ba12?lnk=st&q=&rnum=1&hl=en#45d3f184b887ba12

If that link doesn't work. the thread was titled "The early adjuvant HT
dilemma loooooong" and began on 29 Dec 04. It begins with:
THE EARLY, ADJUVANT HT DILEMMA

Early screening often leads to RP or RT followed by UD (undetectable) PSA
and no symptoms. We then expect a QOL graph consisting of years of high,
asymptomatic QOL, followed by biochemical (PSA) failure, then clinical
(symptomatic) failure, then a falling QOL curve from great to OK to bad to
intolerable to blessed relief. The objective of adjuvant therapy -- HT, for
this discussion -- is to prolong life by delaying recurrence/refraction. HT'
s drawbacks are that its SEs lower the QOL curve right out of the gate, it
may prolong heartbeat by only months if at all, and it may even exacerbate
refraction. So . . . which is more important, higher QOL before recurrence
or maximum delay of recurrence? That's my present dilemma, and it probably
concerns a few hundred thousand others, too.

OBJECTIVES FOR THIS TOME

To obtain advice on this dilemma and feedback on this package (something
like this goes to my medical team soon), and to provide data, philosophy,
and a strawman for others facing similar decisions. My sources include the
leading PC books and web sites such as Walsh, PCRI (Strum, Scholz, et.al,),
Marks, Blasko, Lange, leading universities and hospitals, NCI, NEJM, JAMA,
Lancet, ACS, the VA, Harrison's Internal Medicine, etc. I've researched
medical web sites for many years and always wear hip boots. The good news .
. . and the bad news: there's a lot of detail here.

and on and on it goes.

Beyond that thread, you might Google the forum archives with key words
such as ht hormone adt therapy (caps don't matter) beginning in late
'04. It's been discussed endlessly. (Ask us if you don't know how to
Google the archives.) You'll see that a huge factor - probably the major
factor before one's cancer returns -- is your own personal criteria in
life.

I.P.

Thanks much, Steve, Dave, Claude, Ron, I.P, & Bill. This really helps
my perspective in going in to talk with my uro on Monday to assess
where I'm at. I feel VERY strongly that I just want to heal up for a
while & try to regain continence & hopefully potency & see where my
PSA is for the rest of 2007. I REALLY appreciate your input. I wish
you all the lowest possible PSAs in our journeys.

Z