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Medical Forum / Diseases and Disorders / Prostate Cancer / November 2007Rising PSA after RRP; what treatments has this group considered?
Hi everyone. I'd love to hear from anyone who has been faced with rising PSA after a radical prostatectomy, and what options they considered, or what treatment they're now on. Here's my story; Robotic RP in Nov 2005 Gleason 4+3, T2c, PSA was 5.7, age 49. "Undetectable" PSA readings until Nov 2006, then rising, now to 0.19 as of this week (doubling time of < 6 months). I've been sold on salvage radiation therapy, at Fred Hutchinson, here in Seattle, until recently. My only concern with this option was that they couldn't actually tell me where the cancer was located, so they proposed to radiate the fascia bed(?), since this is almost always where the cancer turns out to be. I'd been worried, however, that the radiation would affect erections since the nerves would obviously be within the target area for the radiation. A friend suggested I go to the Mayo Clinic in Rochester, where I saw a Dr Mynderse. He said that Mayo sees more PC men that any other center in the US. They have an MRI system (with rectal antenna) that appears to be more sensitive to detecting small masses of PC than others, but it's not too specific (it can show suspect areas that may not be cancerous). For a PSA of my level, Dr Mynderse said the chances of finding the cancer were probably less than 15%. I got the MRI, they saw something, and did a biopsy, but the tissue they biopsied was not cancerous. However, in the process of the consultation, they mentioned I might be a candidate for a Phase II trial of a combination of Androgen therapy and a CTLA-4 blockade drug (called MDX-010). I'll probably choose not to enrol in the study (the possible side effects listed were worrisome), but they did mention that in their treatments, patients respond very well to a 3 month dose of androgen therapy alone, and that could delay the growth of the cells significantly. So my quandry is; (i) do the radiation therapy, or (ii) elect to do hormone therapy in the hope that better treatment options will surface in a few years, or (iii) what else? By the way, my radiation oncologist said that with the IMRT radiation, I'd still only have a 40% chance of hitting 65. What's been your experience? Chris. On October 27, Chris wrote: > Hi everyone. I'd love to hear from anyone who has been faced with > rising PSA after a radical prostatectomy, and what options they > considered, or what treatment they're now on. I'm not a RP graduate, but I think that few will argue with the fact of a 30% RP failure rate. > Robotic RP in Nov 2005 Gleason 4+3, T2c, PSA was 5.7, age 49. > "Undetectable" PSA readings until Nov 2006, then rising, now to 0.19 > as of this week (doubling time of < 6 months). I'm unsure what is meant by "undetectable" PSA. Was it </= 0.05 ng/mL? That's the definition of UD PSA. And: When the PSA test results are <1.0, changes up or down are interesting but not important. Such changes are in and of themselves flyspecks. Over time, their trends do permit us to see what is happening. > I've been sold on salvage radiation therapy, at Fred Hutchinson, here > in Seattle, until recently. Yes, "sold" is right. > My only concern with this option was that they couldn't actually tell > me where the cancer was located, so they proposed to radiate the > fascia bed(?), since this is almost always where the cancer turns out > to be. Or it could be elsewhere and local treatment (tx) such as RT will not be curative. > I'd been worried, however, that the radiation would affect erections > since the nerves would obviously be within the target area for the > radiation. Hello? What is important, woodies or living? > A friend suggested I go to the Mayo Clinic in Rochester, where I saw > a Dr Mynderse. He said that Mayo sees more PC men that any other > center in the US. Good salesman. > They have an MRI system (with rectal antenna) that appears to be more > sensitive to detecting small masses of PC than others, but it's not > too specific (it can show suspect areas that may not be cancerous). > For a PSA of my level, Dr Mynderse said the chances of finding the > cancer were probably less than 15%. Well, at least he was honest. Move on. > I got the MRI, they saw something, and did a biopsy, but the tissue > they biopsied was not cancerous. However, in the process of the > consultation, they mentioned I might be a candidate for a Phase II > trial of a combination of Androgen therapy and a CTLA-4 blockade drug > (called MDX-010). I'll probably choose not to enrol in the study (the > possible side effects listed were worrisome) The side effects of doing nothing are horrible. > , but they did mention that in their treatments, patients respond > very well to a 3 month dose of androgen therapy alone, and that could > delay the growth of the cells significantly. So my quandry is; (i) do > the radiation therapy, or (ii) elect to do hormone therapy in the > hope that better treatment options will surface in a few years, or > (iii) what else? "What else" would be to consult a source that is not selling anything. Frex, a geniune cancer specialist, a medical oncologist. See the objective and encyclopedic website of the Prostate Cancer Research Instistute (PCRI) at http://prostate-cancer.org/index.html and search on items of interest. > By the way, my radiation oncologist said that with the IMRT > radiation, I'd still only have a 40% chance of hitting 65. I reckon that that's because he knows that RT to the "bed" is speculative at best. Regards, Steve J "Empowerment: taking responsibility for and authority over one's own outcomes based on education and knowledge of the consequences and contingencies involved in one's own decisions. This focus provides the uplifting energy that can sustain in the face of crisis." --Donna Pogliano, co-author of _A Primer on Prostate Cancer_, subtitled "The Empowered Patient's Guide." > Hi everyone. I'd love to hear from anyone who has been faced with rising > PSA after a radical prostatectomy, and what options they considered, or what [quoted text clipped - 31 lines] > > What's been your experience? I haven't had a recurrence myself, but I've tried to keep up on the subject since it can certainly happen at any time. I'm not a physician, so you shouldn't take what I say too seriously, but let me review the basics. The point of radiation therapy for you at this point is that if the cancer is still localized, radiation to prostate bed may be able to kill the caner cells. If that is the case, you have a good chance of being cured. On the other hand, if it has already metastasized to distant sites, radiation to the prostate bed won't do any good. Unfortunately, there is no way to know for sure which is the case. You should make sure you get a good idea from experts you trust which of these possibilities is more likely in your case. I wouldn't worry too much about erections at this point. If you go on ADT, that will become moot. If the cancer can be stopped by radiation, even if you end up impotent, there are various ways to produce erections and continue your sex life. The more serious issue is deciding whether to take a chance on radiation at this point. If you decide against radiation, it may not be necessary to start ADT immediately. Oncologists disagree about the timing and type of such treatment, and you should get as many expert opinions as you can. You will have to make the final decision yourself. Good luck. > Chris. As I understand it, as technology stands today, your only chance of a complete cure is salvage radiation treatment (SRT) of the prostate bed. And then only if the cancer is confined to the prostate bed; and unfortunately there is no reliable way of knowing for sure whether it is or it isn't. And yes you may have side effects from SRT. On the other hand, your PSA is low, and at your age, if I were you, I sure wouldn't want to pass up a chance at a cure. As you'll see from my stats, SRT has worked for me,...so far! But they tell you not to celebrate for 2 years, and even then there are no guarantees. Get treated on the most up to date machine at a center with lots of experience in PCa. When I was treated the state of the art was the Trilogy IGRT, but that may have changed. Best wishes and good luck! Fred 4/99 PSA 1.58 10/01 PSA 1.68 9/02 PSA 2.7 10/03 PSA 3.8 11/03 needle biopsy. Positive for Gleasons 6 on left side. 12/03 Radical Prostatectomy performed at the Cleveland Clinic. Gleasons 3+4 = 7, clear surgical margins, extracapsular extension established. 3/17/04 PSA 0.003 4/27/04 PSA 0.003 7/22/04 PSA <0.1 (not 3rd generation test) 11/10/04 PSA <0.1 (not 3rd generation test) 5/10/05 PSA <0.1 (not 3rd generation test) 10/19/05 PSA 0.050 2/3/06 PSA 0.082 3/23/06 PSA 0.110 3/06-6/06 IMRT SRT 9/06 PSA 0.044 12/06 PSA 0.025 3/07 PSA 0.019 6/07 PSA 0.013 9/07 PSA 0.008 Hi, Chris, After RRP in 1995, I was faced with rising PSA and had RT in 2000. The rational was as yours. They couldn't find the cancer, chances are it's in the area of the pelvic floor, so "blast it" and hope for the best. It made my PSA go to undetectable level for another five years. Then, PSA started rising again. So, I figure that I got 5 additional years from the EBRT. That's not bad as far as I'm concerned. So, based on my experience, I'd say "go for it". And, there is some chance that the cancer will be eliminated. I was 52 when I had RRP. I'm almost 65 now. By your Doc's estimate, I'm getting close to the 16-year window that he said you'd have only a 40% chance of making. And, I figure I'll easily make it a few more years and get beyond that 16-year window. So, based on my experience, I'd not put too much stock in that time frame. I've been treated by a Doc at Group Health in Tacoma. I can't believe he's that much better than a Doc at Fred Hutch or at Mayo. But, as has been said in this newsgroup, the Doc who is treating you is much more important than the reputation of the hospital where he or she works! It's a tough spot you're in. Many of us in this group have been there. I wish you all the best. Feel free to contact me via email if you wish. Burney Lakewood >Hi everyone. I'd love to hear from anyone who has been faced with rising >PSA after a radical prostatectomy, and what options they considered, or what [quoted text clipped - 33 lines] > >Chris. RRP - 1995 - age 52 RT - 2000 ADT - 8/06 - 10/07 > I've been sold on salvage radiation therapy, at Fred Hutchinson, here in > Seattle, until recently. My only concern with this option was that they [quoted text clipped - 3 lines] > affect erections since the nerves would obviously be within the target > area for the radiation. SRT is the standard for treatment after biological failure following RRP. It seems to me that most of us registered failure at or about 18 months, so you're in the ballpark. There are some side effects from RT. The most notable ones are fatigue, diarrhea, and what feels like a urinary track infection. All of these can be warded off or minimized with lots of sleep, lots of water, and lots of walking. But, I have to admit, on May 12, 2002 I had my first unassisted 'stuffable' erection. I started EBRT in the same month and haven't had one since without assistance. But, it's not the end of the world. Dead penis is better than dead me; at least in my book. > biopsied was not cancerous. However, in the process of the consultation, > they mentioned I might be a candidate for a Phase II trial of a > combination of Androgen therapy and a CTLA-4 blockade drug (called > MDX-010). Phase II trials are those where they found something that seems to do something and now they want to see if it will do that something for a specific disease -- in this case, prostate cancer. Personally, unless I were done for, I don't think I would enter into any by a Phase III study. The prevailing thinking, right now, is that most or all of the remaining cancer is on your prostate bed. The ADT they would give you in the Phase II trial would probably suspend that cancer's growth. I assume while that is going on, the hope is MDX-010 would kill it. However, if it does not kill it, all the while you're in the study, you have the chance that the cancer cells will slough off into your blood stream (if it isn't already there) and take up residence away from the prostate bed. I'm not trying to talk you out of anything, just giving you some issues that you should bring up to your oncologyst before making a decision. It is also quite possible that the combination of ADT and MDX-010 can cure you. I don't know. > So my quandry is; (i) do the radiation therapy, or (ii) elect to do > hormone therapy in the hope that better treatment options will surface in > a few years, or (iii) what else? I would not skip SRT and go straight to ADT. You'd be passing up a chance of a cure for certain, if delayed, death. I think your real choices are the study or SRT. > By the way, my radiation oncologist said that with the IMRT radiation, I'd > still only have a 40% chance of hitting 65. My radiation onc told me I had a 50/50 chance of living ten years. That would take me to 2012 and make me 58. There once was the hope that cancer would be cured by 2015. I think the professionals are now hoping to make it a chronic disease by 2015. In either case, you were 49 two years ago and would be 65 in 2021? Ask him what your chances are of making it to 59. That's all you need worry about. BTW, statistics are statistics. They may help in evaluating decisions for treatment, but outside of that, what have you got? If you didn't have cancer, what were your chances of making it to 65? I've only had one male in my lineage to make it to 65. Don't worry about his stats.  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 PSAD 0.19 years EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 PSAD .056 years Lupron 07/03 (1 mo) 8/03 and every 4 months there after PSA .07 .05 .06 .09 .08 .132 .145 PSAD 1.4 years Casodex added daily 07/06 PSA <0.04, <0.05, <0.04, <0.04 10/11/07 Non Illegitimi Carborundum > Hi everyone. I'd love to hear from anyone who has been faced with rising > PSA after a radical prostatectomy, and what options they considered, or what [quoted text clipped - 33 lines] > > Chris. Chris.... I empathize with you as I was in a similiar situation to you a year and a half ago. For what it's worth attached is my history for comparison. I think in retrospect I did everything I should have. Radiation treatment was tolerable...little SE's for me. I too pondered ADT but I thought that the little bastards were in the prostate bed and I'd nukem to death and be done. Given my age etc I didn't see taking ADT was going to do anything. Now I am faced with what to do with a rapid doubling time... (PSA still low) and a Gleason 8 after RP & RT. Any case there are no easy answers as you know. You have to do your diligence and make a informed decision. Personally I am getting input from 3 different med onc's from Nat'l Cancer Centers and then going to make my decision ....probably a clinical trial.... in fact you my qualify for this as well.... http://clinicaltrials.gov/show/NCT00514917 CURRENT AGE = 51, Overall good health (need to lose weight). 6/03 - PSA 2.0, 6/04 - PSA 2.5, 8/05 - PSA 4.2, 11/05 - PSA 5.89 BIOPSY 8/16/05, T2A, 3+5 = 8 RP 12/13/05 PATHOLOGY GLEASON 3+5=8 TERTIARY 4, SEMINAL & LYMPH - NEG EXTRACAPSULAR EXTENSION TO MARGIN POSITIVE MARGIN - RIGHT APEX PSA POST RP 1/26/06 = 0.5, 2/1/06 = 0.55 PSA on 3/27/06 = 0.95 START SRT ON 3/27/06 FINISHED SRT 5/19/06 06-20-06 - PSA 0.24 07-08-06 - PSA 0.15 09-14-06 - PSA 0.10 12-19-06 - PSA 0.08 02-07-07 - PSA 0.09 08-17-07 - PSA 0.31 10/02/07 - PSA 0.48 Good luck in your fight!! > > Hi everyone. I'd love to hear from anyone who has been faced with rising > > PSA after a radical prostatectomy, and what options they considered, or what [quoted text clipped - 80 lines] > > - Show quoted text - Ignore the comment on the Clinical Trail.... you want something that is curative. SRT in my non medical opinion the way to go. In case you haven't been there NCCN.org has decision trees that may be informative. Chris, I'm not a doctor and my opinion is decidedly non-expert. But for whatever that's worth, I endorse what everyone else has said. Salvage radiation is worth trying. It's a roll of the dice. It might not work. But at your age it seems to me that you should take the chance. Here's a link an abstract of an article studying the success rates for SRT: http://tinyurl.com/3dgv37. The bottom line was: "CONCLUSION: Nearly half of patients with recurrent prostate cancer after radical prostatectomy have a long-term PSA response to SRT when treatment is administered at the earliest sign of recurrence." For more information, see the above URL, and click some of the "Related Links". Best of luck. Alan Here's another interesting link offering statistics for success for salvage radiation: http://www.medscape.com/viewarticle/471933 If I read the article correctly (I'm not sure that I did), four years after radiation, 45% of patients were still free of "biochemical recurrence", which means their PSAs were still low. However, much depended on Gleason score, PSA, PSA doubling time, and how quickly the SRT was administered after recurrence. Men in favorable categories did substantially better than the average while others, of course, did substantially worse. Alan Alan, Curtis, Steve, et al; thanks so much for your information. I've decided to go with the radiation approach. By the way, the article you refer to (which I also got in full text from my urologist) has a great decision tree showing the survival rates for various PSA scores, gleason scores, etc. They make the point repeatedly that doubling time is significant (they differentiate between those with a doubling rate of 10 months or less), and they recommend treatment starts before the PSA reaches 0.5ng/ml. This was a multi-site study with 1540 patients (so it carried some weight for me)... Thank you again! Chris. > Chris, > [quoted text clipped - 20 lines] > > Alan > Alan, Curtis, Steve, et al; thanks so much for your information. I've > decided to go with the radiation approach. By the way, the article you [quoted text clipped - 7 lines] > This was a multi-site study with 1540 patients (so it carried some weight > for me)... I'm not endorsing the results of that one study, but that would be nice, wouldn't it? Based on 0.50, you might not be doing SRT until this time next year. There is also a study that shows that aggressive treatment has long-term, positive effects. I cannot cite it, but I remember my numbers would give me an averge of 9.3 with conservative treatment and 15+ with aggressive. So far, it seems like those averages are being born out. I decided on SRT at 0.37 (though it was 0.75 by the time the particles were sent through me. 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 PSAD 0.19 years EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 PSAD .056 years Lupron 07/03 (1 mo) 8/03 and every 4 months there after PSA .07 .05 .06 .09 .08 .132 .145 PSAD 1.4 years Casodex added daily 07/06 PSA <0.04, <0.05, <0.04, <0.04 10/11/07 Non Illegitimi Carborundum ?Based on 0.50, you might not be doing SRT until this time next > year. Yeah, but if you are convinced that your Pca has recurred, the only reasonable rationale for waiting is the hope that some better treatment will come along in the interim. I would (and did) choose to radiate now rather than radiate later, given this scenario. Fred |
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