Need Some Suggestions

My husband had a nerve-sparing RP 22 months ago.  The pathology was a Gleason 3+4, 20% both lobes, one foci extracapsular spot and close but clear margins.  He is fully functional at this time with no side effects of surgery.

He registered 0.00 at his first PSA..... up to 3 months ago, he was at <0.1.... This past December, it came back 0.1 (without the less than sign) - so I asked for the ultra-sensitive numbers - and it was 0.07......

Last month (February08), it again came back at 0.1 so we had blood drawn again with a different lab that does the ultrasensitive numbers and the 2nd February blood test came back 0.097 (almost a 0.1)..... We were escalated from the urologist to an oncologist.

 The oncologist looked at his records and suggested that he begin IMRT.  After a lengthy discussion, we decided to do another blood test at the beginning of April to see whether the 0.097 held or whether it rose again (which would be the 3rd rise) but would just be over 0.1 if it did.

 My questions are:  Is this too early to start radiation?  Does anyone have experience with side effects of IMRT?  We are so trying to decide whether to radiate now or wait until it reaches a 'readable' level, such as 0.2.  I know this is very low compared to what others are experiencing on this board but it is a critical decision.  My husband has pretty substantial anxiety (in general), has IBS - so afraid these treatments will make things so much worse.

 There is an array of studies that all seem to contradict each other - no 'path' for cure.  I believe you really get one shot and that's the surgery... what is cure rate for IMRT when it's this low.... Is there a difference in radiating now? or waiting till it reaches 0.2.  ANY information would really be appreciated.  The oncologist was concerned that one of these cells will escape - as they're pretty sure it's around the nerve area of the prostate bed.... of course, right next to the rectum and bladder!!!! 

a recent study defined recurrence after prostatectomy as a serum PSA of 0.2 ng/ml and rising or a single PSA of 0.5 ng/ml or greater.  However after an RP the PSA should be 0 so it does appear he has residual disease.  The key is to determine if it is a local recurrence or a systemic recurrence.  If local then RT is recommended.  When to start is perhaps less clear.  Salvage radiation therapy after RP is a treatment that is often used too infrequently and too late in the course of the disease especially in patients with + margins and aggressive features where the disease is most likely to become systemic.

 

On 3/6/2008 Oncrx wrote:

a recent study defined recurrence after prostatectomy as a serum PSA of 0.2 ng/ml and rising or a single PSA of 0.5 ng/ml or greater.  However after an RP the PSA should be 0 so it does appear he has residual disease.  The key is to determine if it is a local recurrence or a systemic recurrence.  If local then RT is recommended.  When to start is perhaps less clear.  Salvage radiation therapy after RP is a treatment that is often used too infrequently and too late in the course of the disease especially in patients with + margins and aggressive features where the disease is most likely to become systemic.

 

The oncologist did feel it was residual...and not systemic - since he did get to 0.00 after surgery.  He felt that cells were most likely left around the nerves (I guess that's typical).

Adjuvant therapy was not recommended as he had no positive margins and felt his odds were 70% that he would not recur.... this is very 0.09 is very low and it happened 22 months post surgery - so should be a good candidate for IMRT.  Just don't know if it's beneficial to begin treatment at this level or wait till it gets to 0.2 - where it's 'definite'.... right now - it "appears"....hate to create all of this damage - especially if it's so slow that it wouldnt' reach 0.2 for a while.

 

On 3/6/2008 Frant wrote:

My husband had a nerve-sparing RP 22 months ago.  The pathology was a Gleason 3+4, 20% both lobes, one foci extracapsular spot and close but clear margins.  He is fully functional at this time with no side effects of surgery.

He registered 0.00 at his first PSA..... up to 3 months ago, he was at <0.1.... This past December, it came back 0.1 (without the less than sign) - so I asked for the ultra-sensitive numbers - and it was 0.07......

Last month (February08), it again came back at 0.1 so we had blood drawn again with a different lab that does the ultrasensitive numbers and the 2nd February blood test came back 0.097 (almost a 0.1)..... We were escalated from the urologist to an oncologist.

 The oncologist looked at his records and suggested that he begin IMRT.  After a lengthy discussion, we decided to do another blood test at the beginning of April to see whether the 0.097 held or whether it rose again (which would be the 3rd rise) but would just be over 0.1 if it did.

 My questions are:  Is this too early to start radiation?  Does anyone have experience with side effects of IMRT?  We are so trying to decide whether to radiate now or wait until it reaches a 'readable' level, such as 0.2.  I know this is very low compared to what others are experiencing on this board but it is a critical decision.  My husband has pretty substantial anxiety (in general), has IBS - so afraid these treatments will make things so much worse.

 There is an array of studies that all seem to contradict each other - no 'path' for cure.  I believe you really get one shot and that's the surgery... what is cure rate for IMRT when it's this low.... Is there a difference in radiating now? or waiting till it reaches 0.2.  ANY information would really be appreciated.  The oncologist was concerned that one of these cells will escape - as they're pretty sure it's around the nerve area of the prostate bed.... of course, right next to the rectum and bladder!!!! 

You did not say how old your husband is and that has a lot to do with the route you take.

For example if he is 75 or older forget about all this stuff about radiating and cutting and go straight to the bottom line, go the hormone therapy route and he'll die of something other than PC  with his rectum and bladder intact.

If he is 65 or younger you have some hard choices to make.

If he is between the two, 65-75 it's still a crap shoot on the hormone thing,  but at his age he still could die of something other than PC and with his bladder and rectum still intact.

Don 

 

Frant:

I understand the anxiety thing. Psa is a godsend for diagnosis and a devil for maintenance. A recurrence at his distance in time from surgery suggests that this could be a local condition and amenable to radiation. You are working with an oncologist, a good sign. His Gleason included a G4, he had close to the margin resection, significant tumor volume, and there was extracapsular extension. These are worrisome for recurrence, as he now appears to display. The radiation dose for salvage treatment is not usually as much as that used for primary treatment. Therefore, the side effects tend to be less. With his irritable bowel (IBS?) this may not be as difficult as he fears. No one can say for certain. The side effects of radiation tend to manifest months, or years, later in time with sexual issues and continence involved. If he is fully continent at this remove from surgery, this may be less of an issue. He may wait, a bit, to determine his doubling time, which will show what limits the disease will put on his schedule for this decision. Generally, the earlier in the recurrence salvage treatment is undertaken the better the results are. Certainly no later than 0.5, if at all possible. Your level of 0.2 is a good one. There is some evidence that men in his condition have disease that remains loco-regional for a time. How long? That is the magic question. In this situation men are lucky for such a clear marker as psa. All other cancer survivors would do anything for such a significant marker.

I agree with the previous poster that age is part of the calculation of risk versus benefit. If he is less than 65 he has a lot of living to do and a treatment that will perhaps delay the recurrence, even if it does not cure, could be a significant advantage.

These questions are ones that men often have to face. Recurrence is a shattering experience that too many men must deal with.  A visit to a radiologist, and meeting with his local Prostate Cancer Support Group will give much more information, and in the case of the group, might allay fears and provide a chance for some confidence.

Let us know how things go.

 

 

 

Please let us know how it goes! 

Just to clarify some info, my husband is 59 years old - in great health.  At the beginning of May, his blood level reached 0.2 - so has risin each nano test until this level.  There were no two blood tests that remained the same.  When he went in to be 'mapped' for IMRT, they found a right external iliac node that was enlarged.  Normal size is 1.5, this was 1.65.... so he had a biopsy last week - results yesterday were NEGATIVE!!! YAY..... The oncologist radiologist does believe it's local.... I'm glad that the one node that looked weird was biopsied to kind of cofirm this.

Some people think we should wait to radiate - but I guess the feeling is that during this whole prostate cancer issue - we never waited, even a week.  Once his psa rose - we immediately got the biopsy, within a month, he had a prostatectomy.  He is fully functional and feels great (except for the IBS) and in wonderful health at 6' and 178 lbs.  So now, that he has had escalating PSA in the nano numbers that finally his 0.2.... our question is:  If we wait until 0.5 or more, is it worth the risk of spreading and harder to handle - and will we have that "regret" feeling that "if only we had done it earlier.... ".  At least doing it early, we have the feeling that we did everything we could do and didn't wait.

Any thoughts about radiating at 0.2 would be appreciated - especially if you're in the field or have experience with IMRT side effects.