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Still rising PSA after IMRT salvage radiation

nuclearduck
Posts: 9
Joined: Jul 2011

I had a RP in 2001 and was essentially PSA zero for nine years. Last October my annual physical showed a PSA of .52. Retests confirmed. Urologist detected a mass in my prostate bed. Biopsy confirmed cancerous. Had IMRT radiation treatment ending in April. Waited 3 months for cells to finish dying then took PSA in mid-July. PSA came back at 1.72. (shucks and other comments) Retested in mid-August. My PSA was then 2.52. (more deleted comments) I just finished getting a CAT scan and bone scan. They were essentially negative showing no 'hot spots' in bones or major organs. My oncologist suggests waiting until my PSA reaches 10 and then proceeding with Hormone Therapy. (he didn't specify exact type) So the question I have for the forum is 'Should I wait before beginning HT?' I plan on getting a second opinion but would value comments from the forum.
Tim

Old-timer's picture
Old-timer
Posts: 109
Joined: Apr 2011

In a nutshell, here's what has happned to me. In July 1991, at age 65, my PSA was 4.0 and a biopsy said I had prostate cancer. I underwent RP in September that year. Gleeson score 3+4 = 7). Surgery went OK and PSA dropped to 0 and stayed there 13 years. It then began a slow creep upwards. In 2005 it had reached 1.16. Radiation was recommended. After 36 sessions of that, the PSA continued to go up. After three more years, in June 2008, with PSA at 20.4, I went on hormone therapy. The PSA immediately dropped to <.01 (undetectable)and has remained there ever since. My uro says the cancer is in remission.

What would I do differently if I had it to do over? I am tempted to say skip the radiation. But the experts said it had a 67 percent chance of success. Taking it seemed to be worth a try, and I really don't regret having done so. By taking the treatment, I learned that I was in the 33 percent group!

Based on my understanding and my experience, I believe you can safely wait to begin hormone therapy until your PSA reaches at least 5.0 or 10.0. My uro wanted to begin hormone therapy when it reached 10.0, but I talked him into waiting until it reached 20.0. That turned out to be OK.

Hope this is helpful. Best of luck to you.

VascodaGama's picture
VascodaGama
Posts: 1531
Joined: Nov 2010

Tim

I am sorry to read about your high level of PSA. You may have a IMRT failure but you cannot say yet that you are in recurrence. The norms are for three consecutive rises of PSA to declare chemical failure. RT in few cases causes a bounce in guys without prostate (but with solid tumours).
Radiation induces inflammation at the areas targeted. Cells tend to “explode” and produce more PSA serum. The ones whose DNA is damaged (break of chromosomes) will lose its ability of duplication and dye. The process takes its own time starting during treatment and thereafter for a considerable length of period. Monthly tests have been OK to evaluate your present status, but it may be too short of a time in your case to define your real recurrence. Remember that doctors had a positive DRE indicative of solid tumor (Jane’s; http://csn.cancer.org/node/209285).

Negative bone scan contradicts distant metastasis and may indicate that the high PSA is a temporary “affair” (I really hope so). Nevertheless, the numbers are high and you could well be systemic. Hormonal treatment is regarded nowadays as a positive treatment in adjuvant protocols for IMRT. Studies have indicated successful rates of 30 to 35% for biochemical free survival rates in 10 years. The rates lose its value if HT is administered as a salvage treatment alone (given at a later date after a considerable rise of PSA).

Hormonal treatment (HT aka ADT) success also varies with the type of cancer cell and the diagnosis of the patient at the start of administration. You have not indicated your Gleason grade and sum but high risk grades of 4 and 5 are more prevalent for spread and for becoming refractory. Our friend survivor Old-timer has an intermediate risk of Gs 7 in 3+4 combi, therefore with many low risk pattern 3 cells.
I wonder what has been the Gleason grade attributed to you before RP in 2001 and at the last biopsy you done this year (2011). Jane commented to know that the data exists but at doctors’ hands (???).

Your doctor may be using this info in his recommendations for a threshold PSA of 10 to trigger ADT. But this is not the consensus of many famous oncologists of PCa. In systemic cases the soonest you start hormonal or chemo therapy “the longest such therapy will last”. This principle takes into account the status of the cancerous cells from previous treatments. These are survivors from a damaged DNA which may change its aggressiveness for proliferation or adaptation therefore leading to become hormone refractory prostate cancer (HRPC) Cells.

You can read details about this type and process in this site;
http://www.prostate-cancer.org/education/andind/Sartor_HormoneRefractory.html

I would recommend you to obtain a copy of Dr. Charles “Snuffy” Myers’ book; “Beating Prostate Cancer: Hormonal Therapy & Diet”, which informs on diagnosis and treatments for recurrence systemic cases.
It may help to get a second opinion from one of those famous oncologists. In this forum you can find many of my posts related to ADT, its principles and protocols, if you want any detail, please ask. I will reply

Hope you get a final positive diagnosis from IMRT.

The best to you.

Thinking of you.
VGama

Note; could you share details from your pathologist report of 2001 and on your diagnosis before IMRT in 2011? Are you experiencing any Side effect or Symptom?

nuclearduck
Posts: 9
Joined: Jul 2011

Vascodagama,
Thanks for the advice. Here are some other pertinent details. My gleason from the RP pathology report was 7, stage pT(5)3b Nx. In October 2011, my PSA registered at .52. My Urologist subsequently found a mass in my prostate bed when doing a follow up physical examination. They did a biopsy of the mass and confirmed it was cancerous. It was about 1 cm in diameter. I did not know you could get a Gleason score when you do not have a prostate so I did not ask for it. I just presumed the whole mass was cancerous. The IRMT was done using a calypso targeting system. The oncologist planted three beacons around the mass to provide 'aiming' points for the IRMT. Theoretically I had less side effects from the radiation that way. I am currently not experiencing any side effects or symptoms. I will take your advice and get Dr. Myers book. It sounds like it has the information I need at this point. Thanks again for your perspectives.
Tim

nuclearduck
Posts: 9
Joined: Jul 2011

Old-timer,
Thanks for sharing your experience. This is exactly the type of feedback I was hoping to see.
nuclearduck

mrspjd
Posts: 688
Joined: Apr 2010

Tim,

Sorry to learn of your continuing and frustrating situation. Sorry, again, that we cannot relate a personal experience as our PCa journey is different from yours and Jane’s. However, PJD’s primary tx did include 9 mos of ADT3. Just wanted to offer an opinion.

In most cases, your rising PSA would signal a “next step action plan” by your doctor. The “advice” your oncologist provided: “My oncologist suggests waiting until my PSA reaches 10 and then proceeding with Hormone Therapy” is akin to advising “let’s wait for the presence of metastasis to show up on your next imaging tests.” IMO, this is like saying the house is on fire, but we’ll wait until it burns down to put the fire out. If the doctor doesn’t consider the rise a recurrence and the SRT a failure, then what does he/she believe is causing the rise? Does he believe the rise is within the acceptable range of PSA bounce after RT? If so what is the “acceptable” range/standard that your doctor is using? Is the doctor providing any treatment options/suggestions to address the rising PSA now?

Scheduling a 2nd opinion consult with an independent & knowledgeable oncologist that specializes in PCa is wise. ADT can slow and shrink tumor growth. If you, along with your medical team, decide to begin a course of ADT/HT, I suggest you ask if an intermittent ADT protocol is right for you. You may find these threads with info on intermittent ADT helpful:
http://csn.cancer.org/node/220309
http://csn.cancer.org/node/215211

Please give my regards to Jane (http://csn.cancer.org/node/209285). All the best to you both.

janekirstine
Posts: 24
Joined: Nov 2010

Thank you all for your continued support. I have found no other place so supportive, or group of great people who care so much about helping those with PCa. Tim and I are both digging deep into research about hormone therapy, plus setting up second and third medical opinions. I have printed out many of the articles for reference. We truly appreciate all suggestions offered in this forum.

Wishing everyone the best possible! Jane

ncobjim
Posts: 35
Joined: Nov 2010

Had RP in 2006 with Gleason 3+4=7 PSA of 4.8
PSA of 0.05 stayed good for 4 years. In 2010 PSA went to 0.2 then to 0.4 in May 2011.
Was sent to radiation doctor. Started 6 month Hormone therapy right away with 38 IMRT treatments starting 3 weeks after first hormone shot.
IMRT ending Sept. 2010.
PSA in May 2011 was 0.01 with another due in Nov. 2011.
Both treatments together seem to have done quite well so far.
Have had no side effects to speak of so far.
Not on any meds or anything else at this time.

mrspjd
Posts: 688
Joined: Apr 2010

Jim,

Congrats and thx for sharing your impressive results. During your Salvage RT w/HT, do you know if your rad onc included tx to the local pelvic lymph nodes in the radiation field, in addition to the prostate bed? Also, any idea what the total Gy dosing was in the SRT?

Best wishes for continued success!

ncobjim
Posts: 35
Joined: Nov 2010

mrspjd,

Thank you. I have read a lot of your posts and still cannot believe you are not in some way a medical person. Very informative posts. I am pretty sure the tx was just to the prostate bed.
38 treatments with a total of 6840 cGy. Was more than happy with the results but know full well that nothing about this stuff is guaranteed. Thought my rad onc was great. Whatever she says i do it. In fact the whole radiation team was so nice to me that i was upset that i wasn't going back every day to see them. Some kind of experience.

mrspjd
Posts: 688
Joined: Apr 2010

Jim,

Thank you. Glad to know you found my posts informative.

PJD also felt a personal connection to his radiation treatment team. They’re a very caring, compassionate and professional group of men and women who often don't get the recognition they deserve.

Again, all the very best.

mrs pjd

nuclearduck
Posts: 9
Joined: Jul 2011

Ncobjim, thanks for sharing your experience. It really helps to get other perspectives.
Nuclearduck

SALESMANAL
Posts: 5
Joined: Jun 2011

I FOOLISHLY ALLOWED THE UROLOGIST TO GIVE ME A THREE MONTH INJECTION OF HORMONE THERAPY. I LOOKED UP THE SUBJECT AND CANCELED FUTURE INJECTIONS. MY FAMILY DOCTOR WARNED ME NOT TO GET THE HORMONE THERAPY, BUT I DID NOT LISTEN TO HIM AT FIRST. THE TREATMENT IS JUST BARBARIC AND DOES NOTHING TO CURE PROSTATE CANCER. YOU WILL BE IMPOTENT, TESTICLES SHRINK, BREASTS AND STOMACH GROW FAT, BONES AND JOINTS HURT, ETC, ETC. THE THEORY IS THAT IF YOU CUT OFF THE SUPPLY OF TESTOSTERONE, YOU WILL NOT BE "THROWING GASOLINE ON THE FIRE" BUT THAT IS NOT REALLY TRUE. THE FACT IS, WHEN YOU CUT OFF THE TESTOSTERONE, THE CANCER CELLS ADJUST TO CREATE THEIR OWN TESTOSTERONE DERIVATIVE AND THEY CAN THEN SPREAD THROUGHOUT THE BODY MORE EASILY. A BETTER PLAN WOULD BE TO START A STEADY EXERCISE PROGRAM TO GET OXYGEN TO THE PROSTATE AREA, TRY TO EAT AND DRINK MORE HEALTHY AND HELP YOUR IMMUNE SYSTEM TO FIGHT THE CANCER.

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