IMRT for salvage after RP

will1946

Assuming a rising PSA first detected many years after a RP, would IMRT be used if no locatable tumor is found, or is one stuck with the old unfocused external beam treatment? This also assumes that the recurrence is local, and not a distant metastasis.

ProfWagstaff

Glad to see this string
I haven't been on the board for a few weeks. On December 14, I lost my membership in the zero club 18 months after RP. To say this was emotionally draining is putting it mildly. I just saw the radiation oncologist and had the CT scans and bone scan done on 12/31. I'm awaiting the results. In our first meeting, he was pretty sure I'd need radiation but mentioned that there was also a study for which I qualify. A computer randomly assigns you to one of three courses of treatment:
1) Radiation of prostate bed
2) Radiation of prostate bed and 4 months of hormone treatment
3) Radiation of prostate bed,pelvic lymph nodes and 4 months hormone treatment

His gut feelong in our first meeting was that I probably would not need hormone treatment yet he says he's okay if I opt to join the study and receive and of the above treatments.

Here's where I'm conflicted. Since my original diagnosis, I've railed about the lack of funding and research for PCa vs other cancers/diseases. Here's my chance to put my money where my mouth is yet I don't want to expose myself to any unnecessary risks. Anyone go through a short course of hormone therapy? If so, any recommendations?

mrspjd

Salvage Rad Therapy (SRT)
Assuming your bone scan and pelvic CTs are negative, then yes, IMRT may be used in salvage RT. When no tumor is dectected, the tx (treatment) would be to the prostate bed and usually includes local pelvic nodes. Tx to the local pelvic nodes is dependent on whether any, or how many pelvic nodes were removed during RP. There are different thoughts on the scope & breadth of RT tx to the pelvic nodes by well known respected radiation oncologists (whether for primary, adjuvant or salvage IMRT). The tx field and amount of Gy (radiation dosing) delivered may vary in treating the bed and the nodes (this is where the IMRT--Intensity Modulated--comes in), and unfocused, outdated, EBRT (external beam) has been replaced by newer IM/IGRT state-of-the-art medical equipment in most up-to-date tx centers. The subject of scope/breadth of node rad tx is an important topic to research as well as to have a critical discussion with your PCa oncologist AND your radiation oncologist prior to RT tx, as there is much debate in the medical profession about this issue. In addition, depending on your personal PCa stats, including your rising PSA post RP and your post RP pathology report, ADT in combination with SRT may also be a consideration, in order to help shrink (hopefully kill) PCa tumor cells, both in the prostate bed during IMRT, as well as those microscopic PCa cells that might be lurking undetected distally.

will1946

mrspjd said:

Salvage Rad Therapy (SRT)
Assuming your bone scan and pelvic CTs are negative, then yes, IMRT may be used in salvage RT. When no tumor is dectected, the tx (treatment) would be to the prostate bed and usually includes local pelvic nodes. Tx to the local pelvic nodes is dependent on whether any, or how many pelvic nodes were removed during RP. There are different thoughts on the scope & breadth of RT tx to the pelvic nodes by well known respected radiation oncologists (whether for primary, adjuvant or salvage IMRT). The tx field and amount of Gy (radiation dosing) delivered may vary in treating the bed and the nodes (this is where the IMRT--Intensity Modulated--comes in), and unfocused, outdated, EBRT (external beam) has been replaced by newer IM/IGRT state-of-the-art medical equipment in most up-to-date tx centers. The subject of scope/breadth of node rad tx is an important topic to research as well as to have a critical discussion with your PCa oncologist AND your radiation oncologist prior to RT tx, as there is much debate in the medical profession about this issue. In addition, depending on your personal PCa stats, including your rising PSA post RP and your post RP pathology report, ADT in combination with SRT may also be a consideration, in order to help shrink (hopefully kill) PCa tumor cells, both in the prostate bed during IMRT, as well as those microscopic PCa cells that might be lurking undetected distally.

add lymphedema to the list of side effects
Thanks for your reply, mrspjd. The possible irradiation of the pelvic lymph nodes is something to consider. About a dozen, if I remember correctly, lymph nodes were removed in the RP, eight and a half years ago. About a year later I developed lymphedema in my feet. I didn't connect the two immediately, but eventually an MD in a little clinic in Guam asked if I had had any surgery recently, and the light came on. My surgeon/urologist was somewhat in denial that the swelling was caused by the surgery. That surprised me, as breast cancer survivors commonly have lymphedema of the arms when armpit lymph nodes are removed. My condition is more or less under control by wearing compression stockings all the time I am out of bed and dressed. I am concerned that radiation treatment of any type that irradiated the remaining pelvic lymph nodes, might further aggravate the lymphedema.
However, I'm glad to know that IMRT is a possibility, in the absence of a fixed target.

bdhilton

ProfWagstaff said:

Glad to see this string
I haven't been on the board for a few weeks. On December 14, I lost my membership in the zero club 18 months after RP. To say this was emotionally draining is putting it mildly. I just saw the radiation oncologist and had the CT scans and bone scan done on 12/31. I'm awaiting the results. In our first meeting, he was pretty sure I'd need radiation but mentioned that there was also a study for which I qualify. A computer randomly assigns you to one of three courses of treatment:
1) Radiation of prostate bed
2) Radiation of prostate bed and 4 months of hormone treatment
3) Radiation of prostate bed,pelvic lymph nodes and 4 months hormone treatment

His gut feelong in our first meeting was that I probably would not need hormone treatment yet he says he's okay if I opt to join the study and receive and of the above treatments.

Here's where I'm conflicted. Since my original diagnosis, I've railed about the lack of funding and research for PCa vs other cancers/diseases. Here's my chance to put my money where my mouth is yet I don't want to expose myself to any unnecessary risks. Anyone go through a short course of hormone therapy? If so, any recommendations?

sorry to hear :-( but Iknow
sorry to hear :-( but Iknow you will rise to the next challenge in dealing with this beast...The best to you and I will say a prayer for you tonight...

mrspjd

ProfWagstaff said:

Glad to see this string
I haven't been on the board for a few weeks. On December 14, I lost my membership in the zero club 18 months after RP. To say this was emotionally draining is putting it mildly. I just saw the radiation oncologist and had the CT scans and bone scan done on 12/31. I'm awaiting the results. In our first meeting, he was pretty sure I'd need radiation but mentioned that there was also a study for which I qualify. A computer randomly assigns you to one of three courses of treatment:
1) Radiation of prostate bed
2) Radiation of prostate bed and 4 months of hormone treatment
3) Radiation of prostate bed,pelvic lymph nodes and 4 months hormone treatment

His gut feelong in our first meeting was that I probably would not need hormone treatment yet he says he's okay if I opt to join the study and receive and of the above treatments.

Here's where I'm conflicted. Since my original diagnosis, I've railed about the lack of funding and research for PCa vs other cancers/diseases. Here's my chance to put my money where my mouth is yet I don't want to expose myself to any unnecessary risks. Anyone go through a short course of hormone therapy? If so, any recommendations?

ProfW
I'm truly sorry to read of your revised status and hope that you are OK, considering what you must be going through & feeling. Very good chance your CT and bone scan will come back negative. Seems like a few questions are in order prior to considering your question seeking recommendations about short course ADT (Androgen Deprivation Therapy), aka, hormones. Don't know if you've considered this, but here is what might be helpful to know/weigh in your decision process:
1) What is the history of your PSA rise in the 18 mos following RP? Pre RP PSA history?
2) What did your post RP path report indicate and was there much discrepancy between it and your pre RP biopsy path report? Gleason, positive margins, etc?
3) Did you have lymph nodes dissected at RP? How many? All negative? (Your post RP path report should indicate.)
4) In the clinical trial, what is (are) the specific proposed protocol re 4 mo course of ADT drugs (names, etc) assuming that info is available to you?
5) What is the scope of RT tx to the pelvic lymph nodes in the clincial trial? All pelvic nodes? local nodes?
6) Are the same hormone drugs being used in randomly assigned option #2 as in random option #3? Most likely they are, but it would be good to confirm that fact.

I realize (and apoligize if) the above info may be intrusive and you certainly are under no obligation to share any of it. You are faced with a tough decision and it is an understatement to write that this must be a difficult time for you and your family. IMHO, the add'l info might be helpful in soliciting any lay-advice on the forum, or at the very least, in using it to assist in your own decision process.

ProfWagstaff

mrspjd said:

ProfW
I'm truly sorry to read of your revised status and hope that you are OK, considering what you must be going through & feeling. Very good chance your CT and bone scan will come back negative. Seems like a few questions are in order prior to considering your question seeking recommendations about short course ADT (Androgen Deprivation Therapy), aka, hormones. Don't know if you've considered this, but here is what might be helpful to know/weigh in your decision process:
1) What is the history of your PSA rise in the 18 mos following RP? Pre RP PSA history?
2) What did your post RP path report indicate and was there much discrepancy between it and your pre RP biopsy path report? Gleason, positive margins, etc?
3) Did you have lymph nodes dissected at RP? How many? All negative? (Your post RP path report should indicate.)
4) In the clinical trial, what is (are) the specific proposed protocol re 4 mo course of ADT drugs (names, etc) assuming that info is available to you?
5) What is the scope of RT tx to the pelvic lymph nodes in the clincial trial? All pelvic nodes? local nodes?
6) Are the same hormone drugs being used in randomly assigned option #2 as in random option #3? Most likely they are, but it would be good to confirm that fact.

I realize (and apoligize if) the above info may be intrusive and you certainly are under no obligation to share any of it. You are faced with a tough decision and it is an understatement to write that this must be a difficult time for you and your family. IMHO, the add'l info might be helpful in soliciting any lay-advice on the forum, or at the very least, in using it to assist in your own decision process.

Thanks mrspjd
You provided me with some things to consider. Thanks.
I'll try to address your questions by number so that I don't skip any.
1) At 3 and 6 months, PSA was less than 0.05. 9 months, 0.05. At 12 it was 0.06. I mentioned the rising number, but they were unconcerend as it was still undetectable (below 0.1) and the numbers we're talking about are so small that the test might not be sensitive enough to make that distinction. At 18 months, it was 0.15 or 0.17 depending on which of the 2 test you believe.
2 and 3) Post surgery path kept gleason at 7 (4+3) same as before. 8 lymph nodes examined, all negative. No positive margins. I was told by oncologist last week that there is an undisclosed thrid gleason number. If there is a noticeable number of cells, it is noted in the report. In my case, there were som gleason 5 cells found but they were not numerous enough to make either of the first 2 gleason score numbers.
4, 5 and 6 are questions I still have to ask the oncologist. I don't think I need to make a decision until we go over results in a few days.

ProfWagstaff

bdhilton said:

sorry to hear :-( but Iknow
sorry to hear :-( but Iknow you will rise to the next challenge in dealing with this beast...The best to you and I will say a prayer for you tonight...

Thanks, BD.
I'm hoping this is just a routine clean-up. I appreciate the support. It really helps knowing I have fellow survivors behind me.

ezra99

ProfWagstaff said:

Thanks, BD.
I'm hoping this is just a routine clean-up. I appreciate the support. It really helps knowing I have fellow survivors behind me.

my experience
I didn't really get kicked out of the Zero club since they slammed the door on me when I tried to get in it after surgery. I still hope that someday I get there but here's what I learned when I had to make my decision about IMRT following RP.

I was only given two choices - IMRT to prostate bed alone or IMRT to prostate bed with hormone treatment. I asked about doing a larger area to include pelvic lymph nodes but they said that was not an option. I was told that with hormone therapy it would start 2 months prior and continue 2 months after IMRT. Sounded like it was going to be 2 injections 3 months apart but didn't get into the actual adminstration of them. They explained that this may/can make the cancer cells "more suspectible" to the radiation.
I was given two statistics. This is what was presented based on my path report etc.
1.) IMRT alone - 35% chance of no re-occurence within 5 years
2.) IMRT with horomone - 47% chance of no re-occurence within 5 years

I was also explained the side effects and risk of horomones - specifically related my health related issues. I elected to have IMRT alone. I'm still waiting for my post-IMRT PSA which will be done in February. Hopefully I made the right choice and will get membership into the zero club.

I assume that you will be given some of this similiar information when you meet with a medical oncologist. I think the calculator on Sloan-Kettering website is the one they used because it gave me the same percentages as I was given by the oncologist.

IMRT was more nusiance then a problem. Thought that 8 weeks would never get over. About 5 weeks into it I did have some excessive fatigue and some frequency, urgency and dribbling. Got better within in a couple weeks after finishing treatment.

Hoping for the best for you.

ProfWagstaff

ezra99 said:

my experience
I didn't really get kicked out of the Zero club since they slammed the door on me when I tried to get in it after surgery. I still hope that someday I get there but here's what I learned when I had to make my decision about IMRT following RP.

I was only given two choices - IMRT to prostate bed alone or IMRT to prostate bed with hormone treatment. I asked about doing a larger area to include pelvic lymph nodes but they said that was not an option. I was told that with hormone therapy it would start 2 months prior and continue 2 months after IMRT. Sounded like it was going to be 2 injections 3 months apart but didn't get into the actual adminstration of them. They explained that this may/can make the cancer cells "more suspectible" to the radiation.
I was given two statistics. This is what was presented based on my path report etc.
1.) IMRT alone - 35% chance of no re-occurence within 5 years
2.) IMRT with horomone - 47% chance of no re-occurence within 5 years

I was also explained the side effects and risk of horomones - specifically related my health related issues. I elected to have IMRT alone. I'm still waiting for my post-IMRT PSA which will be done in February. Hopefully I made the right choice and will get membership into the zero club.

I assume that you will be given some of this similiar information when you meet with a medical oncologist. I think the calculator on Sloan-Kettering website is the one they used because it gave me the same percentages as I was given by the oncologist.

IMRT was more nusiance then a problem. Thought that 8 weeks would never get over. About 5 weeks into it I did have some excessive fatigue and some frequency, urgency and dribbling. Got better within in a couple weeks after finishing treatment.

Hoping for the best for you.

Thanks, Ezra
You gave me some great info as did mrspjd earlier. Now I've got some intelligent questions to ask at my next appointment.

My best to you all.
Prof Quincy Adams Wagstaff

ob66

ProfWagstaff said:

Glad to see this string
I haven't been on the board for a few weeks. On December 14, I lost my membership in the zero club 18 months after RP. To say this was emotionally draining is putting it mildly. I just saw the radiation oncologist and had the CT scans and bone scan done on 12/31. I'm awaiting the results. In our first meeting, he was pretty sure I'd need radiation but mentioned that there was also a study for which I qualify. A computer randomly assigns you to one of three courses of treatment:
1) Radiation of prostate bed
2) Radiation of prostate bed and 4 months of hormone treatment
3) Radiation of prostate bed,pelvic lymph nodes and 4 months hormone treatment

His gut feelong in our first meeting was that I probably would not need hormone treatment yet he says he's okay if I opt to join the study and receive and of the above treatments.

Here's where I'm conflicted. Since my original diagnosis, I've railed about the lack of funding and research for PCa vs other cancers/diseases. Here's my chance to put my money where my mouth is yet I don't want to expose myself to any unnecessary risks. Anyone go through a short course of hormone therapy? If so, any recommendations?

ProfWagstaff
I am not sure my situation will help you, but here goes. daVinci surgery June 6, 2009. PSAs 0.05 first two times, then third PSA was ultrasensitive and still 0.05. Fourth on in April 2010 (ultrasensitive) was 0.07. Pre surgery Gleason 7, post surgery Gleason 8. DaVinci was done for I have Factor V clotting issues, and emboli were a concern. So after the 0.07 my urologist wanted to be most aggressive. I went on Casodex (to eliminate/control flairs) for two weeks, then Lupron. Have been on Lupron since April with my third shot in December (four month shots)---side effects hot flashes (none other). In July I started 37 IMRT treatments to the prostate bed. The theory was that the CA cells were most likely there, and get on them sooner rather than later. As I have chronicled in previous posts I have also gone on the Med/Asian diet of no red meat, no dairy, and as little sugar as possible. Twenty months out, I feel great, have lost the weight I gained in the summer, and would recommend the route I went. As with all of us, worry lingers. Hope this helps, and if any questions, I would willingly answer. Bob

mrspjd

ProfWagstaff said:

Thanks, Ezra
You gave me some great info as did mrspjd earlier. Now I've got some intelligent questions to ask at my next appointment.

My best to you all.
Prof Quincy Adams Wagstaff

a few more Q's to add to the list
Prof Q.A.W. -- (Groucho Marx was a comedic hoot!)
Is the IMRT tx course (i.e. length of time, # of tx sessions) the same/different for random options 2 & 3? or between random options 1 & 3? What about possible differences in the size/scope of the rad field and Gy (rad dosing delivered) between each of the 3 random options--the same or do they vary? While one might make assumptions about the clinical trial, assumptions can be dangerous, so best to ask many questions and confirm facts. If you elect not to participate in the clinical study, what is the course of IMRT tx being proposed, does it include ADT as an option, and how might it be the same or different from the randomly assigned txs in the clinical trial?
Best,
mrs pjd

Kongo

ProfWagstaff said:

Glad to see this string
I haven't been on the board for a few weeks. On December 14, I lost my membership in the zero club 18 months after RP. To say this was emotionally draining is putting it mildly. I just saw the radiation oncologist and had the CT scans and bone scan done on 12/31. I'm awaiting the results. In our first meeting, he was pretty sure I'd need radiation but mentioned that there was also a study for which I qualify. A computer randomly assigns you to one of three courses of treatment:
1) Radiation of prostate bed
2) Radiation of prostate bed and 4 months of hormone treatment
3) Radiation of prostate bed,pelvic lymph nodes and 4 months hormone treatment

His gut feelong in our first meeting was that I probably would not need hormone treatment yet he says he's okay if I opt to join the study and receive and of the above treatments.

Here's where I'm conflicted. Since my original diagnosis, I've railed about the lack of funding and research for PCa vs other cancers/diseases. Here's my chance to put my money where my mouth is yet I don't want to expose myself to any unnecessary risks. Anyone go through a short course of hormone therapy? If so, any recommendations?

Studies and trials
Professor,

Sorry that you're still dealing with these issues. One thing I would suggest that you do before agreeing to participate in a study or trial is to ask to see the protocol document which they are required to have and will detail the purpose, expected findings, methodology, statistical foundation, and basic science behind the trial. I would read it carefully and insist your doctor explain thoroughly any questions you might have.

I am in a trial myself and personally believe the are absolutely necessary in advancing the fight against this disease but I would want to know EXACTLY what I am signing up for.

Best of luck to you.

ProfWagstaff

Kongo said:

Studies and trials
Professor,

Sorry that you're still dealing with these issues. One thing I would suggest that you do before agreeing to participate in a study or trial is to ask to see the protocol document which they are required to have and will detail the purpose, expected findings, methodology, statistical foundation, and basic science behind the trial. I would read it carefully and insist your doctor explain thoroughly any questions you might have.

I am in a trial myself and personally believe the are absolutely necessary in advancing the fight against this disease but I would want to know EXACTLY what I am signing up for.

Best of luck to you.

Thanks to all who have responded
I sincerely appreciate the questions, histories and suggestions you've all provided. I originally joined the Network because I wanted to help other men wjo are just going through this. I never dreamed that I'd need to be on the receiving end. My best to all of you. ....and thanks.

mattmans5

ProfWagstaff said:

Glad to see this string
I haven't been on the board for a few weeks. On December 14, I lost my membership in the zero club 18 months after RP. To say this was emotionally draining is putting it mildly. I just saw the radiation oncologist and had the CT scans and bone scan done on 12/31. I'm awaiting the results. In our first meeting, he was pretty sure I'd need radiation but mentioned that there was also a study for which I qualify. A computer randomly assigns you to one of three courses of treatment:
1) Radiation of prostate bed
2) Radiation of prostate bed and 4 months of hormone treatment
3) Radiation of prostate bed,pelvic lymph nodes and 4 months hormone treatment

His gut feelong in our first meeting was that I probably would not need hormone treatment yet he says he's okay if I opt to join the study and receive and of the above treatments.

Here's where I'm conflicted. Since my original diagnosis, I've railed about the lack of funding and research for PCa vs other cancers/diseases. Here's my chance to put my money where my mouth is yet I don't want to expose myself to any unnecessary risks. Anyone go through a short course of hormone therapy? If so, any recommendations?

I am really sorry to have

I am really sorry to have read your post , I had an rp jan42011 so am a new member ,

I will be keeping positive thoughts for you , and all on this post that has been a blessing for me , good luck