Treatment After Radical Prostatectomy Or Not?

Hi - We are evaluatint whether or not to undergo external beam radiation therapy after my husband had a radical prostatectomy, since the grade of the tumor went up from the pre-operation biopsi (Gleason score 6) to the biopsy of the actual prostate that was removed (Gleason score 4+3= 7). The cancer is a T2c. At 6 weeks after surgery he has a PSA of 0.2. There was a positive surgical margin though apparently no infiltration of seminal vesicles or lymph nodes.

We wonder what others out there with experience or expertise would recommend? Should we wait for the PSA to rise and then begin external beam radiation therapy? Or not wait for this given the stage of the cancer and 0.2 post-op PSA?  The treatment available in our area would use a radiation beam of 70Gy.  Can anyone advise us of likely side-effects?

My husband is 67 and is nearly 100% continent after the RP, but erectile function is still absent. It was good before the operation so we are hopeful for a return of erections one day, though are aware it may take a while.

Thank you very much for all sharing of thoughts or experience to help us with this decision!

Being in the same boat as your husband, m/l, age 61..rp/nns..clean margins & nodes..rp Jan 07..non-detect psa at 9 mo...to your question, having read 1000s of items of all classifications, most seem to indicate that the consensus is do nothing until there is an exponential increase in the velocity..velocity is the key word here, it seems...0.2 is almost non-detect. but is of concern because its so soon, relatively, after rp...I suppose the rule of thumb is that if same occurs so soon, probably the intial site, somehow, is the culprit....if it were a year or more, it would likely be a met....the exact time of likely start of additional treatment would best be determined by those whom know more than me...further, if the velocity starts to increase graphically, it'll likely be the time to move to further treatment...try not to worry about the sex & urine matters, you are really, at this point, trying to make a decision that can get another 15+ years of quality of life, cancer free or in remission....best wishes...

Have a further PSA test: a criteria is three higher peaks in PSA numbers.

 

On 11/21/2007 Prostate cancer spouse wrote:

Hi - We are evaluatint whether or not to undergo external beam radiation therapy after my husband had a radical prostatectomy, since the grade of the tumor went up from the pre-operation biopsi (Gleason score 6) to the biopsy of the actual prostate that was removed (Gleason score 4+3= 7). The cancer is a T2c. At 6 weeks after surgery he has a PSA of 0.2. There was a positive surgical margin though apparently no infiltration of seminal vesicles or lymph nodes.

We wonder what others out there with experience or expertise would recommend? Should we wait for the PSA to rise and then begin external beam radiation therapy? Or not wait for this given the stage of the cancer and 0.2 post-op PSA?  The treatment available in our area would use a radiation beam of 70Gy.  Can anyone advise us of likely side-effects?

My husband is 67 and is nearly 100% continent after the RP, but erectile function is still absent. It was good before the operation so we are hopeful for a return of erections one day, though are aware it may take a while.

Thank you very much for all sharing of thoughts or experience to help us with this decision!

I would concur with waiting for 2 to 3 more months and getting another PSA test to see if it is going up or not.  I was originally diagnosed with PCa in 2000.  I had an RRP in August 2000.  My PSA prior to surgery was 17.4 in May of 2000 and given one Lupron 3 month shot to get it down and allow me to go on vacation prior to the surgery.  It did come down to 1.4 and the surgery was performed on the 18th of August 2000.

My gleason score was 4+3 post surgery.  I maintained PSA's with low readings until April 2005 when it reached 0.311 showing chemical failure.  We monitored the PSA's until 2006 when the reading showed the following:

           03-23-06     0.553                 67 Months
05-02-06     0.534                 69 Months
07-06-06     0.621                 71 Months
08-03-06     0.735                  6 Years

In September 2006 I underwent EBRT radiation therapy, 37 treatments and very little side effects.  I have found that it is generally recommended that salvage radiation be performed prior to the PSA reaching 1.0.  Some recommend hormone therapy along with the EBRT but I did not take it in my case.  I completed radiation in November 2006 and my first PSA in January 2007 was 0.009 and my last one in August 2007 was 0.007.  I have a blog it you will at www.yananow.net and you can read my journey in full.  I also have my email site as I am a mentor.  You can look it up by diagnosis 2000 or PSA 17.4 or by name Dave Lynch.  I do hope that this gives you more insight.  Keep the faith and you and your husband will do just fine.  

 

 

 

 

 

 

Hi - and thank you very much to those who have responded - your advice has been very helpful. We now have one more somewhat complicating bit of info. that I will "throw out" in case there is anyone with any insight into that, too. At our consultation this week my husband had a routine blood test from the cancer hospital where he was operated, only 4 days after the previous blood test from our local hospital which gave a PSA = 0.2. We had wanted to know his post-op PSA in order to be able to make most use of the 6-week consultation, so if we opted for further treatment he could be put on the list soonest possible, since the PSA results from the consultation day wouldn't be available until after the consultation. The PSA was important to know since the biopsy results showed that a resection margin was missing at a site where the capsule showed a 4 Gleason score. This newest blood test showed a PSA = 0.4! I wonder if this should be interpretted as differences in the test precision/methods between the two different laboratories doing the analysis, or if PSA can in fact double in just 4 days? and if so, what this might suggest? We are leaning toward external beam radiation because of the biopsy showing that some cells might have been left behind, but we are also concerned about what signals might be expected in the case of metastasis?

Thanks again for all thoughts and sharing of experience . it really helps!

 

On 11/25/2007 Prostate cancer spouse wrote:

Hi - and thank you very much to those who have responded - your advice has been very helpful. We now have one more somewhat complicating bit of info. that I will "throw out" in case there is anyone with any insight into that, too. At our consultation this week my husband had a routine blood test from the cancer hospital where he was operated, only 4 days after the previous blood test from our local hospital which gave a PSA = 0.2. We had wanted to know his post-op PSA in order to be able to make most use of the 6-week consultation, so if we opted for further treatment he could be put on the list soonest possible, since the PSA results from the consultation day wouldn't be available until after the consultation. The PSA was important to know since the biopsy results showed that a resection margin was missing at a site where the capsule showed a 4 Gleason score. This newest blood test showed a PSA = 0.4! I wonder if this should be interpretted as differences in the test precision/methods between the two different laboratories doing the analysis, or if PSA can in fact double in just 4 days? and if so, what this might suggest? We are leaning toward external beam radiation because of the biopsy showing that some cells might have been left behind, but we are also concerned about what signals might be expected in the case of metastasis?

Thanks again for all thoughts and sharing of experience . it really helps!

I would not be overly concerned about that difference.  Different labs and different assay methods could easily account for this slight variation.  In the future if I were you, I would stay with one lab for all PSA tests.  It has even been shown that taking the same blood specimen to the same lab and getting two different results, so there are variations within the same labs.  If you can get a lab that does sensitive testing i.e. Immulite Third Generation, they can go out to 0.003 readings and you can keep a close account of your readings.  The trend is important in that if you were to get three readings going up getting tested about every three months, then you and your doctor will have a better idea of possible recurrence.  I am just going on my experience as a patient and a lot of reading about this disease.  Monitor everything and document things along the way.  Best of everything to you and yours.

 

Dave

 

 

Thank you for taking the time to respond, your answer was very helpful, a confirmation of what I believe - and prefer to believe - is probably the case. :)  We will stay with one lab in the future! 

I would be very concerned with PSA of 0.4 following RP. 0.4 is NOT insignificant and any enlightened physician considers anything above 0.01 following RP to indicate a failure to cure. Order Stephen Strum's book titled Prostate Cancer An Enlightened Patient's Guide. Read it thoroughly. Also immediately seek a true expert in prostate cancer to help you. Don't sit around and wait for the PSA to continue to rise. Your husband's situation is serious and you really need to take action. You need to have a battery of tests run to determine where the residual cancer is located. You can't let this situation get out of hand and 0.4 is out of hand. I can tell you that recent studies show that salvage RT is much more effective at below 0.5 PSA. Your hubby is right at that level. If you want a couple of names of experts then reply to me either publicly or privately. It might be helpful to know what part of the country you are in so I can direct you to a geographically friendly expert.

Hi, and thank you for your response, which is what I believe to be the case - that the situation needs attention immediately and if we could only find out where the PSA was coming from we would be in a much better situation to decide futher treatment. There was a positive surgical margin in the area of a 4 Gleason score, so it is likely that some may be coming from there, hopefully contained to the prostate bed?? but is there any way to find out? - and anything to do if it is not coming from the operation site??  We live in Norway, and the Norwegian Cancer Hospital is one of the best in the world, and a "sister Hospital" to the Andersen Cancer Hospital in Houston, Texas . However, there is national health care in Norway, so the soonest likely start of treatment is right after Christmas, so we would be willing to consider a trip preferably in Europe to another cancer center if someone there could help us - any suggestions? If not in Europe, we have family in Schenectady (near Albany), NY, and in Boulder Colorado we could stay with if there were any good centers for prostate cancer near those locations?  Thanks again for taking the time to answer.  Sincerely, Amy

I'd want to determine if: a) the cancer is in the bone, or b) the cancer is in the lymph system before pursuing radiation. I'd suggest a 18F-Fluoride PET/CT scan to rule out spread to the bones. Assuming that is negative, I'd suggest a Combidex exam to rule out spread to the lymph system. Both of these tests can be obtained through Dr. Jelle Barentsz in Nijmegen, Netherlands. Dr. Barentsz contact information is Jelle Barentsz, M.D., Voorzitter Management Team Wetenschap, Afdeling Radiologie, UMC St. Radboud, Postbus 9101, 6500 HB Nijmegen, The Netherlands, j.barentsz@rad.umcn.nl, http://myprofile.cos.com/j.barentsz.  Dr. Barentsz is a great doctor and I'd suggest that you ask him for additional recommendations for prostate cancer experts in Europe. Additionally, I'd suggest that you contact Dr. Helmut Bonkhoff in Germany. His contact info is Institut für Pathologie, Bonn-Duisdorf, Heilsbachstraße 15, 53123 Bonn Germany, Phone: 49 228 98 65 50, Fax: 49 228 98 65 555. Dr. Bonkhoff is an expert at prostate pathology and you'll want to have the tissue from the RP reviewed by him. If the tests are negative then I'd pursue radiation therapy but only using the Tomotherapy system (http://www.tomotherapy.com ). Tomotherapy is the state of the art in radiation therapy. You'll find locations of Tomotherapy's systems in Europe at its web site. If you pursue anything at MD Anderson, the person in Houston who I'd contact is Dr. Chris Logothetis who is an expert in prostate cancer. I hope this information is helpful and my best wishes to you.