to beam or not to beam

mdyar · New User Joined: 16 Feb 2008 Posts: 2

this question is by proxy for my father who had a R.P. 24 months ago.

it appears he has a bio-chemical failure via an elevated psa.

a radiation oncologist solicited a saturday phonecall recently and said to "come on in and we'll zap it into oblivion".

wise or unwise??

some internet postings on salvage radio-therapy are bleak on their scientific efficacy e.g. 75 % chance of an elevated psa within 5 years of treatment, overall.

others a much more positive prognosis{depends on many variables}.

too much info. to correlate for an amatuer.

dad's original diagnosis was gleason 3+4[7] psa=10, dre = negative.

pathologist upgraded diag. to t3c[ s. vessicules involvement]
note: cancer grew independently at site
no nodes , no margins.

psa 6 weeks after R.P. = .03, 3 months thereafter = .03, .05, .05, .09, .083, .115 latest.
recent bone scan was negative.

Replicant · Moderator Joined: 01 Nov 2006 Posts: 220

whether tis nobler to suffer the slings and arrows of outrageous cancer, or to take up radiation and end them..

Sorry! Just following the theme! Smile

The overall odds are actually much better, especially in the short run (5 years). They drop down to something like 25-35% in the long run (look on the web for studies by Catalona and others by Andrew Stephenson, or check out my blog where I have summaries and links). However, for certain groups the odds are much better.

There are several important factors. If you have access to a medical library, I suggest getting a copy of "Predicting the Outcome of Salvage Radiation Therapy for Recurrent Prostate Cancer After Radical Prostatectomy" by Andrew Stephenson, Peter Scardino, Michael Kattan, and several other big guns in prostate cancer. It was published in Journal of Clinical Oncology, Vol. 25, Number 15, May 20, 2007, pp. 2035-2041.

I can help you obtain a copy if you cannot otherwise do so. Contact me on my blog if you wish.

Or, if you provide the following, I will run the numbers through the 4 year flow chart: current PSA, Gleason score from surgery, surgical margins (pos or neg), and at least a rough idea of his PSA doubling time (I can calculate this if you provide his post-surgery PSA scores).

And if you have additional information, I can run it through the predicted 6 year progression free probability nomogram. What's needed besides the above items: seminal vesicle invasion (yes or no), lymph node invasion (yes or no), persistently elevated PSA after surgery (yes or no), and whether or not hormone therapy (ADT) was done in conjunction with surgery.

I ran my own stats through this as I decided what to do. I have about a 58% chance of being progression free at 6 years. Those are pretty good odds, considering the ease of treatments (couldn't be any easier), and low rate of relatively mild and temporary side effects. This is not the radiation therapy of the past! So I underwent radiation, and it knocked my PSA into the basement.

Bottom line: many men can benefit from salvage radiation. I certainly did. Stephenson, the leading researcher in salvage radiation, says "Nearly half of all patients with recurrent prostatectomy have a long-term PSA response to SRT (salvage radiotherapy) when treatment is administered at the earliest sign of recurrence. The nomogram we developed predicts the outcome of SRT and should prove valuable for decision making for patients with a rising PSA level."

Sometimes with prostate cancer, there is no rush. But with salvage radiation, time is of the essence (assuming the patient is a candidate). Some men have a considerably better than 50-50 chance. For example, a man with a pre-radiation PSA of less than 2.0, positive margins, and a PSA doubling time of more than 10 months has a 69% chance of being free from PSA progression at 4 years.

Optimally, Stephenson says, you want to start before PSA hits 0.5, but if you start before it gets to 1.0 you're still in pretty good shape.

A very recent study, just released, is also optimistic about salvage radiation, showing that men who get radiation are about 60% less to die from prostate cancer: http://www.webmd.com/prostate-cancer/news/20080213/rapid-psa-rise-calls-for-radiation

Hope that helps--let me know if I can run the numbers for you.

When I was getting radiation, I often thought of a Shakespearean line:

"Out, damn'd spot! out, I say!—One; two: why, then
'tis time to do't." --Shakespeare, Macbeth (Act V, Scene 1)
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T3a, N0M0, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 <0.1, 12/07 <0.1, 4/08 <0.1
http://pcabefore50.blogspot.com

Replicant · Moderator Joined: 01 Nov 2006 Posts: 220

I see that I do have enough info for the flow chart.
* Pre-RT PSA less than 2.0 (assumed)
* Gleason 4-7
* negative margins (I assume this is what you mean by no margins--this is a critical piece of information. Negative margins means there was no cancer at the cut edge of the tissue removed).
* No node or vesicle invasion
* Doubling time less than 10 months ( it came out to .69 years, or 8.28 months, calculated on http://kevin.phys.unm.edu/psa/6formg.html )

Going through the flow chart, the odds of salvage radiation resulting in progression-free status 4 years out is 48%.

If the margins were POSITIVE, on the other hand, the 4 year outlook is 57% chance of being progression free. The reason is that positive margins provide a logical explanation for a local recurrence (cancer left behind in the prostate bed).

A caution: I don't have the exact dates of the PSA tests. I ran the PSADT by putting in each score 3 months after the previous, starting with a random date.

The issues of margins caused me CONSIDERABLE angst in my own personal case, because the uro told me I had negative margins, and even wrote that on the cover sheet he sent to the radiation oncologist. But when the oncologist read the actual surgical report, he found that I had positive margins, which increased my odds of success.

Keep in mind that statistics are just statistics, and that all these studies are backward looking by necessity. The patients involved were sometimes undergoing radiation at lower doses than is delivered safely today, with equipment that is outmoded by today's standards--so these studies are most likely overly pessimistic.
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T3a, N0M0, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 <0.1, 12/07 <0.1, 4/08 <0.1
http://pcabefore50.blogspot.com

Replicant · Moderator Joined: 01 Nov 2006 Posts: 220

The six year tool yields more encouraging results. I made some assumptions--you can tell me later if they were correct, but those items where I made assumptions don't have a huge bearing on the result.

Prostatectomy PSA 10: 20 points
Gleason 7: 20 points
Seminal = no: 0 points
extracapsular extension = no: 0 points (assumed, but this factor only would add 2 points at the most if the answer was yes)
Margins: Negative: 20 points (would be zero for positive margins)
persistently elevated PSA = no: 0 points
Pre-rad PSA 0.5 (assumed): 15 points
PSADT 8 months: 65 points
ADT=no: 0 points
Radiation dose 70 Gy (assumed--this is what I had and is fairly standard): 10 points

Total points: 150
6 year progression free probability (PFP)= 60%

Now, bear in mind I made plenty of assumptions, and this nomogram is a ruler and paper affair--you might get a slightly different answer and that is why I would suggest getting the article. The sooner the person starts also affects the total points and the PFP. If, instead of starting at 0.5, he started at 1.0, there would be a net gain of 15 points and the PFP would drop to about 45%.

Being progression free 6 years later is not the same thing as being cured, but since most men who fail do so within the first two years, 6 years is a pretty good milestone, I think.

Hope that helps!
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T3a, N0M0, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 <0.1, 12/07 <0.1, 4/08 <0.1
http://pcabefore50.blogspot.com

mdyar · New User Joined: 16 Feb 2008 Posts: 2

thank's for the fast response.
his clinical staging was upgraded by pathologist to seminal positive.
note: cancer grew independently at vesicules , not spread to from tumor.
tumor volume was 70 % of gland.
margins = negative
current psa is .115 [jan. 7 th]
starts radiation feb. 25 th.

originaly ,my dad & i were suspicious of this solicitous phonecall as to what appeared to be to drum up business by the good doctor.

a lot of my family are R.N. 's [4] and have way too many stories that you don't want to hear.
but as you posted here , time is of the essence!

Replicant · Moderator Joined: 01 Nov 2006 Posts: 220

Having positive seminal vesicles adds about 12 points to the total score, putting the odds of progression free status at 50-60% as I read the nomogram. (I wish they'd computerize it as promised at nomograms.org, but it hasn't appeared yet).

A lot of cancer patients would jump through hoops for a 50% chance of a cure--and it sounds like your dad has made an informed decision to go for it. I wish him well. He has everything to gain, and not much to lose, from trying salvage radiation.

Today's radiation techniques are much more precise than just a few years ago. IMRT, which I had, is a big leap over 3D conformal, which was a huge leap over the crude blocks used before. And now there's IGRT which goes a step further in precision.

As you probably know, there is no sensation (except for boredom) during the treatment itself. If side effects appear, it probably won't be for a couple of weeks at least. In my case, I had some rectal irritation that really didn't get too annoying until the very end of treatment. My doctor prescribed Proctofoam, which worked wonderfully at relieving the symptoms, and in the year or so that has passed, the bowel symptoms have largely gone away on their own. Compared to surgery it was a piece of cake.

Good luck to your dad.
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T3a, N0M0, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 <0.1, 12/07 <0.1, 4/08 <0.1
http://pcabefore50.blogspot.com

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