My Dad-advice?

Bonnie12 · New User Joined: 13 May 2008 Posts: 3

My Dad was diagnosed with prostate cancer in June last year (Age 54). First had a PSA of 6, then it went up to 10 in a few months. (Also has type 2 diabetes). Had the operation (key-hole) last year in August (using the robot), as it was "localized". Dr was happy he got it all & also said that it was an agressive tumour. (Gleason score of 7)

Three months after his operation (Nov 07) he went back to have the routine check on his PSA and it was still fairly high at 0.8 (even after having his prostate removed). The Dr wasnt too happy about this as it should be alot lower or undectable. THe Dr said that it may need "more time" to come down as it was agressive. So he made another appointment for Dad to go see him towards the end of December 07.

Dad has his test again at the end of Dec 07 and his PSA had come down from 0.8 to 0.1, so everyone was very pleased/relieved & happy! The Dr said to have another test again in March.

Dad went back in March & his PSA had risen to 0.2 now. The Dr then decided that he needs to be given Radiation. As I assume now its spread outside the prostate. He saw the radiologist and he now has started today his 33 sittings of radiation. The radiologist told him that there is a 50 to 60% chance that this will work. He is having it in 6 spots.

We were all pretty shocked and upset at these odds, we thought it would have been abit higher???

Anyway, I'm just wondering if anyone has had any similar experiences. I just really want him to get better, the last year has been terrible Sad

Sephie · Regular Joined: 24 Apr 2008 Posts: 12

Bonnie, I am sorry to hear about your dad's (and your) battle with PCa. Gleason 7 is actually considered a moderately aggressive score, with 8 to 10 being more aggressive. Also, the Gleason 7 is comprised of either a 3+4 or a 4+3...and there is a difference. My understanding is that a 3+4 acts more like a Gleason 6 while a 4+3 acts more like a Gleason 8, making it more aggressive. Your post did not say what the surgical pathology report stated ... whether there were clean surgical margins, seminal vesicle involvement, or extracapsular invasion (when the cancer breaks through the capsule surrounding the prostate). My husband had a robot-assisted RP in March of this year in New York. His Gleason was 7 (3+4) and his surgical margins and seminal vesicles were clean. There was a miniscule invasion into the prostate capsule but not through it - which is excellent news.

I am concerned that the radiologist gave a 50 - 60% chance of success with the radiation therapy. If you don't have a copy of the pathology report from the surgery, I suggest you get it. This will tell you exactly what was found and where, which will help you and your dad be prepared to ask alot of questions and make informed decisions. As I told my husband, he is in charge of the situation (not the doctors).

You and your dad will be in my prayers. Let us know how things are going.

Replicant · Moderator Joined: 01 Nov 2006 Posts: 220

I agree with Sephie's excellent post. More information about surgical margins, seminal vesicle invasion, and extracapsular extension would be helpful.

Yes, the overall odds of success in salvage radiation are 50-50 or thereabouts, BUT you can get a better idea of the odds of success by running the medical history through a tool known as a nomogram. I have the nomogram developed by Andrew Stephenson and if you can provide the requested information, I'll run them through. But it's CRUCIAL to remember that your dad is not a statistic. He either has a local recurrence in which case radiation provides a likely long term benefit (or even cure) or he doesn't, in which case it won't help. So on an individual level, it's either 100% or 0% as far as whether the cancer is localized.

It's nearly impossible to tell whether PSA is coming from the site of the prostate, or whether it's coming from distant locations in the body. Scans can rule IN distant disease, but they cannot rule it OUT. Biopsies of the prostate bed are not of much use in trying to decide on salvage radiation.

You have to look at several variables--PSA before surgery, PSA before radiation, PSA doubling time, surgical margins, extracapsular extension, Gleason, whether or not PSA was persistently elevated after surgery, etc. Those inputs go into a nomogram, and out pops the percentage of men with the same characteristics who will have a durable response to salvage radiation. It does tend to hover around 50%, but can be higher than 60% for men with favorable characteristics or almost zero for men with very unfavorable characteristics.

The article in which the nomogram appeared was "Predicting the Outcome of Salvage Radiation Therapy for Recurrent Prostate Cancer After Radical Prostatectomy" by Andrew Stephenson, Peter Scardino, Michael Kattan, Thomas Pisansky, Kevin Slawin, and several others. Journal of Clinical Oncology, Vol. 25, Number 15, May 2007, p. 2035-2041. Your nearest library should be able to get this for you at low or no charge by interlibrary loan. Or, visit your nearest large hospital library where they might have it. Failing that, you can contact me via my blog and I will help you get a copy.

If you want to understand the odds, this is a great piece of research.

The salvage radiation nomogram has been published on the Memorial Sloan Kettering website ( http://www.nomograms.org ) but I think there may be programming mistakes in the online version as it does not produce the same results (using my history as an example) online as it does on paper.

Here are a few final thoughts:

* Even if salvage radiation offers "only" a 50-60% chance of success, many cancer patients would jump at that chance of a cure.

* The alternative is 0% chance at a cure--going straight to androgen deprivation therapy (ADT) which provides palliation only, plus number of long-term side effects.

*Salvage radiation techniques such as IMRT, IGRT, and protons are much kinder and gentler on healthy tissues while being more effective (precise) against cancer, compared to radiation of just a decade ago. MOST patients find side effects of salvage radiation to be mild and temporary.

*If a patient decides to go for salvage radiation, time is of the essence. The lower the PSA before radiation, the better.

Best wishes.
_________________
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

H F · New User Joined: 25 Apr 2008 Posts: 8

<snip>
* The alternative is 0% chance at a cure--going straight to androgen deprivation therapy (ADT) which provides palliation only, plus number of long-term side effects.

Replicant - I do not recall reading that ADT provides palliation only. Can you refer me to any URL which discusses that?

Replicant · Moderator Joined: 01 Nov 2006 Posts: 220

In the setting where the man has systemic disease, ADT is palliative-only. I'm not saying it has no other value in combination with other treatments--for example, it seems to make radiation more effective.

But--in the advanced PCa setting, where the cancer is systemic (I'm not saying this is the case for this particular person), ADT is palliative-only.

There are two approaches--curative and palliative. I am aware that the definition of "cure" has and continues to be challenged, but I'm talking about the more generally accepted terminology--ADT is not curative, so it must be palliative.

As requested, here are some quotes and URLs.

"Although ADT may modestly prolong survival, it is palliative and not curative. "UpToDate for Patients" by Drs. Savarese, Dawson, Vogelzang, and Ross.
http://tinyurl.com/6ep6ab

"Considered to be the primary approach for treating men with symptomatic metastatic prostate cancer, ADT has been found to be palliative, not curative." Professor Martha K. Terris, MD. http://www.emedicine.com/med/TOPIC3197.HTM

"The mainstay of systemic treatment for prostate cancer remains ADT; it is the standard of care as initial therapy for metastatic prostate cancer, as it has confirmed palliative effects and possibly prolongs survival...however, ADT is not curative and carries with it short- and long-term sequelae, such as loss of libido, fatigue, muscle wasting, osteoporosis, and anaemia." From "Clinical trials in patients with biochemically relapsed prostate cancer" by Lin and Rini, The Cleveland Clinic .
http://tinyurl.com/477gzk

"But hormone therapy does not cure prostate cancer and is not a substitute for curative treatment. "
http://www.celtnet.org.uk/cancer/prostate-cancer-treatment.html

"The removal of androgens by castration (surgical or chemical) results in a regression of symptoms and measurable disease in 80 percent of patients. Unfortunately, there are androgen-resistant clones in most tumors, which makes this form of therapy palliative." http://www.healthline.com/galecontent/prostate-cancer

"ADT is commonly used as palliative therapy for patients with advanced prostate cancer." CancerConsultants.com http://tinyurl.com/4rn585

"...hormone therapy does not cure prostate cancer." American Cancer Society, http://tinyurl.com/5sx7wx

"Hormonal therapy cannot cure prostate cancer. Instead, it slows the cancer's growth and reduces the size of the tumor(s)."
http://www.prostateinfo.com/patients/treatment/hormone.asp

"But while hormonal manipulation causes prostate cancer to shrink in 85 to 90 percent of advanced prostate cancer patients, it does not cure the disease." http://www.urologyhealth.org/adult/index.cfm?cat=09&topic=90

"For cancer outside of the prostate, palliation with hormonal therapy, radiation therapy, or chemotherapy" http://www.merck.com/mmpe/sec17/ch241/ch241e.html

"Regrettably, at this time, no form of hormone-refractory prostate cancer is curable. All the available forms of therapy are palliative, which means that they can be used only to slow the progression of the disease and to relieve symptoms." http://www.phoenix5.org/Infolink/refractory/overview.html

And there are many others. I found these with a few quick Googles.
_________________
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

It may help to understand the medical definition of "palliate"

To palliate is "to reduce the violence of a disease; to ease without curing" (MedLine dictionary); "to treat partially and incompletely"(MedTerms.com); "To reduce the severity of; to relieve slightly." (Stedman's Medical Dictionary).

To get back to my main point--if someone is a good candidate for salvage therapy, the standard alternative is to go on ADT at some point. That would not be curative--it would be an effort to delay the cancer and reduce the symptoms.

When I was offered salvage radiation I was so happy that I was a candidate--because otherwise it would have been ADT at age 44 and goodbye to the second and last chance at a cure. On another board, a patient who had turned down salvage asked me--"Why are you doing this? Don't you know the odds are only 50/50?" My response--I would have done this even if my odds were much lower, because salvage was my only hope. It turns out the questioner was 30 years my senior.
_________________
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

H F · New User Joined: 25 Apr 2008 Posts: 8

Replicant - thanks for this helpful post. 14 months ago, I had RP. Gleason=9 (5+4), nerve invasion, lymph node invasion (4), T3a. My doctors proposed participation in a Clinical Trial. I am in a deferred treatment group which, when PSA = 0.4, will receive a combination of ADT (Eligard) and Chemo (Taxotere) simultaneously. I struggle to understand both of these drugs and whether or not I should participate when that time comes. My PSA has been <0.007 since the RP. Your discussion helps.

Bonnie12 · New User Joined: 13 May 2008 Posts: 3

Thank you for all your responses.

We got told last night that Dad's gleason score of 7 is a 4 + 3. He told us that what has happended is that a few cancer cells have spread outside the prostate. So I can only assume that its better news then it spreading to any lymph nodes etc. He is into Day 11 of his radiation, so we are keeping our fingers crossed!!!

Sephie · Regular Joined: 24 Apr 2008 Posts: 12

Sounds like the surgeon wasn't able to get clean surgical margins and/or your dad had a small extracapsular extension. There are so many variables with this disease but from the little I've learned in my husband's experience, radiation treatment sounds like the right course of action in your dad's case.

Take it from someone who's been through all the emotional ups and downs - your dad will be fine. Please come back and let us know how things are going.

Bonnie12 · New User Joined: 13 May 2008 Posts: 3

Thanks Sephie.

I'm not really sure about the clean surgical margins and/or a small extracapsular extension. I dont really understand all that. To be honest, we havent been told all these details, well not that Dad has said. He probably doesnt quite get it either? But anyway, Im hoping that after he has finished he treatment that he will be able to get on with his life.
Did your husband have radiotherapy aswell?

Replicant · Moderator Joined: 01 Nov 2006 Posts: 220

Hi again. Glad to hear your dad is doing okay on the radiation treatments. The treatments themselves are about the easiest medical procedures in the world.

Hopefully he won't be bothered much by side effects. If he is bothered by them, they can be managed and will almost certainly fade away after treatment.

If the cancer didn't get far--if it's still near where the prostate was--radiation can finish it off. If your dad's PSA falls after radiation, that's a good sign. And if it falls to less than 0.1 within 9 months or so after radiation, that would be a VERY good sign.

It's not uncommon to have positive surgical margins, especially with "keyhole" or minimally invasive surgery. It just means that there was cancerous tissue all the way to the cut edge of what the doctor removed. If that was the case with your dad, then it's actually a good thing, because it provides a local explanation for the PSA (rather than distant disease). Having positive margins actually increases your odds of successful salvage radiation, according to Dr. Andrew Stephenson and others.

If you want to find out about surgical margins, extracapsular extension, etc., just get a copy of your dad's medical record.

Keep the faith! There's plenty of reasons to believe radiation will mop up the remaining cancer. It seems to have worked with me (fingers crossed)!

FYI, it takes time after radiation treatments end for the cancer cells to die off. So your dad will probably have to wait several weeks after the last treatment before having his PSA checked. Even then, some PSA might remain in the blood. It can take up to several months before PSA hits the lowest point (called the nadir) after treatments end.

Best wishes.
_________________
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

Sephie · Regular Joined: 24 Apr 2008 Posts: 12

Bonnie, no my husband did not have radiation therapy following his RALP (robot-assisted laprascopic prostatectomy ... say that after a couple of martinis!). I spoke with the urologist about this possibility as my husband did have extraprostatetic extension (this means that the cancer moved from the prostate gland into the capsule surrounding the gland but did not break through the capsule which is called extracapsular extension). Since my husband's surgical margins and seminal vesicles were clean post surgery and his PSA dropped to zero 8 weeks after surgery, additional treatment is not warranted.

I know that this is all very new - and extremely frightening - for everyone. The first month after we heard the words "you have prostate cancer" was a very tough time for me - my husband was absolutely fine and confident that the surgery would take care of the problem. I had mood swings ranging from confidence to absolute misery. The more I researched - and this board was an amazing source of information and comfort - the more I learned that this is a disease that can be dealt with effectively. Since February (when we found out about the PCa), we have been amazed at the number of men in our lives who have been treated for PCa. The world became a much smaller place for us.

Keep the faith and don't let the words "prostate cancer" do to you what it did to me. There are far worse diseases and afflictions.

	Cancer Forums Forum Index -> Prostate Cancer Forum	All times are GMT - 5 Hours
Page 1 of 1

A website for discussions about any type of cancer, including lung cancer, breast cancer, mesothelioma, prostate cancer, laryngeal cancer, leukemia, lymphoma, multiple myeloma and others