Pathology report in - should we commend with HT?

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  • Pathfinder
    Pathfinder Member Posts: 55
    Big update and request for further advice/info

    There have been considerable developments since I last posted. I urged my family to go to Shanghai to see the surgeon who performed the original operation who was not convinced by the MRI result we obtained locally (being told of a 5cm tumour that had invaded the bladder). Of course, being distraught, it was a hard decision to make because we feared going to Shanghai would waste time - and of course the local hospital wanted to go straight to RT.

    But in my opinion the original surgeon should be the one to review the patient. In Shanghai they presented the MRI information and the doctors there said they could not see the tumour in question. They then performed a second MRI, and still couldn't see anything. They then did a bone scan and found no metastasis, and then finally a PSMA CT scan which sadly couldn't identify the cancer's location for RT.

    In my opinion the chances of the local hospital lying about the MRI result is high. That might sound absurd, but in China this sort of thing happens all too often and I have heard personal accounts from people who have received similarly profound diagnoses in an attempt to procure the patient for costly procedures. 

    Either way, I'm very grateful for your help and Old Salt suggesting the second opinion.

    At this stage the Shanghai doctors have suggested that we follow the guidelines and perform RT before the PSA reaches 0.5. There is some conflict of opinion as we have heard some suggesting it's better to wait for the PSA to rise and then perform new scans in an attempt to pinpoint the location of the cancer growth. But the Shanghai doctor thinks it's time to start with a full pelvic radiation therapy as he doesn't believe - based on the tests - that the cancer has left the region.

    We're only worried that full pelvic RT isn't as effective as pinpointing the location, but also we're up against the clock. We now have the option to stay in Shaghai to perform the RT, or to return back to the home city and do it there. OR, we can ignore the doctor's advice and wait for a PSA rise and attempt a new scan at a later date.

    Does anyone have any feedback regarding this? What are the pros and cons of peforming a full pelvic RT versus a pinpoint location?

    Thanks all once again!

  • VascodaGama
    VascodaGama Member Posts: 3,525 Member
    ... we're up against the clock. What for?

    Any added treatment will surely add risks and side effects to the ones already set in. The patient surfers and his quality of life become worse. Radiation, therefore, should aim proper targets to avoid collateral damage of benign tissues. Those targets should be identified and located firstly to serve as the field for the radiation. When targets are not identified then the field to be radiated is decided on guessing and involves a wider area of attack. The typical is the whole prostate bed, localized lymph nodes and pelvic bones.

    The outcome of a salvage radiation therapy (wider field or spot) is not restricted by the level of a PSA of 0.5 ng/ml, and it doesn't assure better results solo based on the level of a PSA. The success of the treatment is higher if the whole targets fall within the field to be radiated. Surely radiating the whole body one would be more assured of success but the consequences would be greater if not killing the patient. Radiation is not done as zipping out an area. Minimizing the field to avoid further damage is best so that reliable image exams get first priority. No one expects to hit the bull' eyes in the dark. Luck should be on our side.

    Please note that in PCa affairs rushing to a decision on a treatment doesn't provide any assurances of a good outcome.

    Wishes for luck in his journey

    VG  

     

  • Old Salt
    Old Salt Member Posts: 950 Member
    Difficult decision

    I agree that a decision is not at all straightforward. A relevant consideration is: what does the patient want? Vasco pointed out (see the post above) that irradiation of the whole prostate bed may have side effects and should be discussed with the patient.

    I tend to favor the advice of the Shanghai doctor(s) because their expertise seems to be good, if not excellent. Another argument in favor the Shanghai approach is that although it may seem nice to point irradiate 'hot spots', it's likely that there are other spots in the pelvic area that have 'micro' cancers that don't show up on the scans (as yet).

    Nevertheless, if possible, please discuss the two options some more with the Shanghai (or other) medical oncology specialists. See if my argument holds. Perhaps that will make it easier to arrive at the best decision.

    Best wishes; I am impressed with your care and concerns.

  • Pathfinder
    Pathfinder Member Posts: 55
    edited April 2018 #85

    ... we're up against the clock. What for?

    Any added treatment will surely add risks and side effects to the ones already set in. The patient surfers and his quality of life become worse. Radiation, therefore, should aim proper targets to avoid collateral damage of benign tissues. Those targets should be identified and located firstly to serve as the field for the radiation. When targets are not identified then the field to be radiated is decided on guessing and involves a wider area of attack. The typical is the whole prostate bed, localized lymph nodes and pelvic bones.

    The outcome of a salvage radiation therapy (wider field or spot) is not restricted by the level of a PSA of 0.5 ng/ml, and it doesn't assure better results solo based on the level of a PSA. The success of the treatment is higher if the whole targets fall within the field to be radiated. Surely radiating the whole body one would be more assured of success but the consequences would be greater if not killing the patient. Radiation is not done as zipping out an area. Minimizing the field to avoid further damage is best so that reliable image exams get first priority. No one expects to hit the bull' eyes in the dark. Luck should be on our side.

    Please note that in PCa affairs rushing to a decision on a treatment doesn't provide any assurances of a good outcome.

    Wishes for luck in his journey

    VG  

     

    Thank you for your response!

    edited and reposted to include responses to others.

  • Pathfinder
    Pathfinder Member Posts: 55
    Thank you for your responses!

    Thank you for your responses!

    To clarify, we have definitely been able to breathe easier and slow down since the second opinion and further tests. The only quandary is data relating to when it is appropriate to perform RT and whether or not one should wait a period of time to allow the cancer to become identifiable by the machine. 

    Of course I completely agree with you: being able to see the location and target it specifically is ideal. The problem is, post PSMA CT result, and failure to locate in this instance, the doctor has already suggested doing full pelvic RT.

    The official guidelines suggest RT should be performed under 0.5 ng/ml, but we have spoken to someone personally whose PSA is at 4.6 and the imaging studies still couldn't reveal anything.

    In another instance (in this case an online account) imaging studies couldn't identify a location for RT when BCR in the patient and his PSA reached 10. Suddenly the cancer metastasised thereafter.

    It's a confusing thing. On one hand you wish to be as accurate as possible, but to do so you need to allow a disease to grow to dangerous levels. We understand both why people here have suggested allowing the PSA to rise and then doing further imaging tests, but also why the doctor - who believes post testing that the cancer has not left the pelvic area - thinks RT of the entire pelvic area is necessary.

    I only worry particularly about the efficacy of full pelvic RT and the potential side effects. On that note I should probably ask, side effects aside, is there any difference in efficacy when pinpointing a select location or doing a full pelvic coverage? Or would the outcome be approximately the same?

    Old Salt: Yes, the Shanghai people are certainly more reliable than the ones available locally. They do at the very least, tell you the truth. And I appreciate your reply here, and we will endeavour to explain this to the patient. He does have very little understanding of the issue and we tend to do all the decision making, but he certainly will understand the possible side effects if explained. 

    Hopefully he will have some idea about what he wants to do, we're just all working hard to figure out the best thing to do.

    Once again, thank you all for your continued input. It's been invaluable to have an English speaking resource to turn to for advice.

  • VascodaGama
    VascodaGama Member Posts: 3,525 Member
    Wishing to be as accurate as possible to avoid colateral damages

    Pathfinder,

    A PSMA-PET exam will show where probable cancer is hidden. Such doesn't imply that the radiologist will avoid radiating the traditional areas of a salvage therapy in a RP failure case. I believe that the radiologist will always radiate the prostate fossa. He may not include the local lymph nodes (to avoid lymphedema) and pelvic bones (to avoid bone marrow depression), if the exam is negative in those areas, but cancer at far places could exist and be detected in the exam. Those areas should also be radiated at the same time of SRT. Radiation should not be planned/projected to be repeated (applied twice) to the same area for the risks of fistulas.

    Moreover, spot radiation does not incorporate a single one point as a target. The whole cone shaped tissues in the path of the ray will be irradiated. These represent a big volumetric quantity of benign tissues that receive unneeded radiation. Surely the radiologist will define the isodose area more accurately with the results of the PET scan and his plan (direction of rays path) will avoid critical directions that could affect other organs, etc.

    The experience of the physicians involved and the facilities will weigh in the outcomes.

    https://www.mayoclinic.org/tests-procedures/external-beam-radiation-for-prostate-cancer/about/pac-20384743

    http://www.upmc.com/patients-visitors/education/cancer-radiation/Pages/bone-marrow-depression.aspx

     

    Best,

    VG

  • Pathfinder
    Pathfinder Member Posts: 55
    Hello all, I just wanted to

    Hello all, I just wanted to update the thread on our progress and decisions and also run a question by you. 

    After full testing in Shanghai including MRI, Advanced MRI, Bone Scan and PSMA PET CT, it was concluded that the cancer is contained within the pelvic region. They couldn't find any evidence of metastases, but unfortunately, the PSMA PET CT also could not locate the precise region of the cancer.

    The doctor suggested that rather than wait for the PSA to rise further (now at 0.251) and do additional scans, that we instead perform RT on the whole pelvic region. We are now in Shanghai preparing to start the procedure. 

    The question I wanted to ask is the following:

    The course in Shanghai is IGRT at 70g, 35 times. Includes the prostate, fossa and lymphatic drainage area. The NCCN guidelines recommends combining RT with 6 months of ADT for 'high risk' patients. However, our doctor suggested just doing the RT first and then maybe ADT later. I just want to know your opinions about RT and ADT combination and timings, and is it safe to do ADT sometime after the RT course has finished?

    Thank you for your continued input!

  • VascodaGama
    VascodaGama Member Posts: 3,525 Member
    edited May 2018 #89
    Contained within the pelvic region ....

    I agree that you can advance with a salvage therapy since far metastases have not been detected in the exams you describe above. The proposed protocol is typical (70Gy in 35 sections). Adding ADT is an option that, according to clinical trials, did show 35% of improvement (longer periods of free biochemical failure) when comparing the combination therapy against solo RT. However, RT is the the therapy that kills the cancer. Nothing is lost by doing it alone. The outcome is checked with a series of PSA tests which results could not be trusted if the PSA was masked by ADT. Your father also avoids the ADT side effects and he can always continue with a sequential ADT in future if SRT fails to eradicate the bandit.

    Best

  • Pathfinder
    Pathfinder Member Posts: 55
    edited May 2018 #90

    Contained within the pelvic region ....

    I agree that you can advance with a salvage therapy since far metastases have not been detected in the exams you describe above. The proposed protocol is typical (70Gy in 35 sections). Adding ADT is an option that, according to clinical trials, did show 35% of improvement (longer periods of free biochemical failure) when comparing the combination therapy against solo RT. However, RT is the the therapy that kills the cancer. Nothing is lost by doing it alone. The outcome is checked with a series of PSA tests which results could not be trusted if the PSA was masked by ADT. Your father also avoids the ADT side effects and he can always continue with a sequential ADT in future if SRT fails to eradicate the bandit.

    Best

    Thank you VascodaGama for

    Thank you VascodaGama for your response. That helps us with regard to how we will approach ADT combination therapy.

    We also wanted to query something regarding RT. Some sources informed us directly that RT is a fairly standardised procedure. There shouldn' t be a lot of variation between hospitals. That said we still elected to travel to Shanghai to have the treatment done, rather than in the smaller home town. The Shanghai hospital however, doesn't specialise in tumour treatment, they just have the equipment to perform a course of RT. The main reason was that the surgeon who performed the RP is in the same hospital, and said he would confer with the RT doctor regarding the course. 

    We're a little down about the RT doctor, because he seems rather impatient (it happens in China). We are aware that in Beijing they have a more advanced set of equipment for performing RT whereby they apply a higher dose over a shorter time period, but we chose not to go to Beijing because of expense, the difficulty of living arrangements and being unfamiliar with the hospital.

    Did we make a mistake? The first dose of RT has been applied now in Shanghai and we're not sure whether it's possible to stop after the first does has been given and change hospital (we're told that that's not possible by the doctors). What we want to know is, is it true there isn't much room to get RT wrong? And that between hospitals we shouldn't expect a big variance of outcome.

    Of course we're looking for the best possible care, we just felt Shanghai was suitable, but now we're a little wary of the RT doctor and keep thinking about Beijing's superior equipment.

    Thank you for your advice and information!

  • VascodaGama
    VascodaGama Member Posts: 3,525 Member
    Outcomes vary in line with experience and quality of equipment

    I do not know how to respond to your query. I am not in China and do not know the details regarding the physicians (experience or specialty) and the facilities. In any case, the best outcome can be expected from the best isodose planning (designed by the radiotherapist) and the performance of the equipment that delivers the radiation (image guided capability or proper CT/MRI to define alignments). To such extent, experienced physicians and modern facilities are best.

    In regards to your comment in continuing the radiotherapy at a different hospital, such is possible if the newer institution is informed of the details of the isodose planning and what has been administered. Radiation is absorbed by the tissues which got limits in terms of Grays, so that over administration at the same place can be avoided.

    One aspect in IMRT sections is that the patient needs to live closer to the RT facilities because he will be receiving doses everyday (except Sundays) during two months. I see no trouble if your dad's doctor is an experienced radiologist and the equipment is modern. Old types cobalt machines were linked to nasty side effects. The worse risk is the lack of maintenance (calibration, tolerances and alignment) of modern machines that in critical cases lead to fistulas and the death of the patient. Surely the same applies to Beijing's hospital. 

    VG

  • Pathfinder
    Pathfinder Member Posts: 55
    Ok, thank you for that. We

    Ok, thank you for that. We will discuss. He has had two doses administered so far and is scheduled to have breaks on weekends.

  • Pathfinder
    Pathfinder Member Posts: 55
    Urgent advice needed

    Guys, there's a problem, and I'm concerned. 

    My father in law has had 11 RT treatments as part of his course. The PSA check today was 0.299. Two weeks ago prior to starting treatment it was 0.251. 

    After all the extensive tests prior to starting RT there was no sign of cancer detected anywhere in the body, leading the doctor to believe that the cancer cells were still located in the pelvic region. As such, the RT treatment concentrates only on the pelvic region.

    On consulting the doctor regarding this PSA rise, he concurs it shouldn't rise. He says it may be to do with the PCa itself or another factor. We can only surmise the following:

    - The PCa has moved to a part of the body beyond the pelvic area (although this is fairly unlikely based on the short time since prostate removal surgery, hormone therapy and results of the tests, but certainly not impossible given the nature of cancer.)

    - The equipment being used or the operator is not good enough and the way the treatment is being performed is at fault

    - The PSA reading is wrong and part of a wild fluctuation.

    Now, asking for advice, I have this nagging voice that keeps telling me we should have gone to China's no.1 hospital for RT in Beijing, even though Shanghai is still considered good. In the event that I elect to move treatment to Beijing, how complex is it to pause the treatment, and for how long is it safe to pause and resume treatment (window of arrangements essentially)? Is it still possible to do this after 11 treatments.

    Additionally, in your opinion, would it be sensible to pause the treatment regardless of where it's resumed to redo bone scans, PSMA PET CT and MRI's for the body another time?

    If possible I'd like to get as many of your thoughts as possible regarding this, so if you have any experience or ideas about any of these things, please don't hesitate to chime in. 

    Thank you all again for your invaluable support.

     

  • VascodaGama
    VascodaGama Member Posts: 3,525 Member
    PSA during and post RT

    I am surprised on your post and curious that they checked the PSA in the mid of the RT administration. The radiation treatment will cause inflammation and such will increase the PSA which result has no significance to judge cancer status. This is a normal occurrence and the increase can only mean that some cells are receiving the rads blow. This is GOOD.

    I wonder the experience of the radiologist involved in the treatment. Your comment on doctor's suggestion that "it shouldn't rise" is completely out of pace. Are you sure that the person in China informing you on the above was correct? The comment you lay here "... he concurs it shouldn't rise ..." is the opposite of what the doctor may have said but your relative listen erroneously.

    Typically, after completing the treatment, the first PSA test is done two month later (one month the earlier) but the one which will have significance to judge the treatment is at the 6 month mark. The outcome is usually judged at the one year mark. In my case of RT, PSA nadir was found at the 13 months post the end of the last section.

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  • Pathfinder
    Pathfinder Member Posts: 55

    PSA during and post RT

    I am surprised on your post and curious that they checked the PSA in the mid of the RT administration. The radiation treatment will cause inflammation and such will increase the PSA which result has no significance to judge cancer status. This is a normal occurrence and the increase can only mean that some cells are receiving the rads blow. This is GOOD.

    I wonder the experience of the radiologist involved in the treatment. Your comment on doctor's suggestion that "it shouldn't rise" is completely out of pace. Are you sure that the person in China informing you on the above was correct? The comment you lay here "... he concurs it shouldn't rise ..." is the opposite of what the doctor may have said but your relative listen erroneously.

    Typically, after completing the treatment, the first PSA test is done two month later (one month the earlier) but the one which will have significance to judge the treatment is at the 6 month mark. The outcome is usually judged at the one year mark. In my case of RT, PSA nadir was found at the 13 months post the end of the last section.

    ????????????????????

     

     

    Wow, really?

    Really?

    Well the issue is twofold. One, this is China, it's hard to find anyone who knows exactly what they're doing, and two, the doctor is the person who performed the PC surgery and not the radiologist, so perhaps it's not his area of expertise. Still, I would think he would know better about this since he's the one who designed the RT plan in cooperation with the radiologist.

    We just spoke to the doctor this morning about this issue. His suggestion is to continue RT for 2 weeks and then check PSA again. His reasoning seems to be that because the PSA rise is consistent in speed with his regular PSA rise (around 0.05 increase every two weeks - before it was 0.25, now it's 0.3) his concern is that despite all the tests the cancer may have left the pelvic area, meaning the concentration in that area alone is not effective. He doesn't seem to think that the fluctuation correlates with RT because it's not wild enough and follows the PSA's previous trend. At least that's what we can glean from his comments., 

    Additionally, checking the official guidelines and getting advice from a paid online doctor, it seems that ADT combined with RT has 20% more effectiveness in successful RT and improving life expectancy. Following this advice we wanted to start ADT today to hit the cancer as hard as possible, but now we have this quandary of the doctor wanting to wait 2 weeks before rechecking the PSA. Under ADT there will not be an effective reading of the PSA two weeks from now. 

    In this situation it's complicated for us to figure out the next step. I suppose it is possible that despite all the extensive testing in the body, distant metastases may have occurred but not have been found, but it's impossible to say without further testing, which may not be available during RT.

    Any advice is appreciated!

  • VascodaGama
    VascodaGama Member Posts: 3,525 Member
    Doctors from the old-guard

    I think it better for you to follow his doctor's advice. He is the one on the ground and surely knows what he is doing. I think him to be from the old-guard caring and treating according to the traditional guidelines. He may not follow the latests practices/recommendations (NCCN, version 2, 2018) but that doesn't mean he is doing a bad job. Survivors in this forum are not doctors and do not give professional advices but lay opinions. We try being helpful explaining what we know or has experienced. I also think that the advices from paid online doctors should be taken just as informative. You need to trust the doctors involved in his treatment (even if in China), but can and should be inquisitive and discuss all matters when a final decision is required. For the time being I think you should continue the treatment as initial planned.

    By tradition, urologists are the ones in charge of treating prostate cancer, who will also be the surgeon performing the prostatectomy. All other physicians involved in the therapy (Pathologists, Radiologists, Oncologists, Nurses, Technicians and Equip-operators) will be called upon by the commandant to execute their part when this is required. These specialists do not contest the urologist but follow his requirements.

    The job of an urologist in sequential treatments are minimal once the prostatectomy is done, however, they still are the ones by norm responsible and will overlook the continuing treatment of that particular patient. This is an antique behavior and very questionable today in all forms for treating cancer. Prostatectomies are no more the golden standard in treating PCa.

    The methods used by your doctor are considered as normal practice. He didn't follow the combination therapy of ADT plus RT (your post of May 13) but you did not insist in having it too. Someone in China has signed the papers agreeing with the protocol. In any case, nothing is wrong by checking the PSA periodically along the treatment. The bad would be to give up with RT in the mid of the full scope of application just because the PSA has increased.

    Now it is the time for everybody to wait, let the treatment continue naturally and latter check the behavior of the unmasked PSA. Any additional intervention (ADT) should only take place if recurrence (biochemical failure) is found. The norm to judge such case is; Three continuous increases post a nadir. Do not rush.

    Your dad will start having constant bowel movements and irritation when urinating. These are natural symptoms caused by the radiation that can last over two months. His doctor will provide medication and your dad should avoid certain foods to alleviate the problem. He needs to continue drinking loads-of-water 30 minutes before each RT section.

    Best wishes for an eventless treatment,

    VG

  • Pathfinder
    Pathfinder Member Posts: 55
    Hey, thank you once again for

    Hey, thank you once again for your response. Navigating this surely is problematic but I think I have a slightly clearer picture of the options now. There are a few points I'd like to discuss.

    We followed your advice and visited the doctor with more detailed queries. The way he sees it is as follows: He believes that we should wait 2 more weeks continuing on the RT course, and then retesting the PSA. If the PSA shows a drop, then he suggests not using ADT yet. This is because he believes ADT use should be prolonged for as long as possible because it only has a limited time for effectiveness. By waiting 2 weeks and seeing the PSA result we will have a clearer idea of whether or not the RT is having an effect and then be able to make a decision from there. He thinks  that the cancer should still be confined to the pelvic area because the PSA is still low, although he can't rule out distant metastases either. If after 2 weeks the PSA has risen by a big jump, that would suggest distant metastases because it would show that the RT is not having an effect. In this case he would suggest using ADT immediately. If the PSA is the same or only slightly higher than now, perhaps metastases isn't the case, but he may suggest ADT anyway.

    My quandary is this: All the guidelines, forum moderators and online doctors for whom we took paid advice, suggest ADT and RT combined from the start of the RT treatment. Now, please correct me if I'm wrong, but is this because RT weakens the cancer cells? And therefore by weakening them it makes them more susceptible to being wiped out by radiation? Because that makes some sense to me. The doctor of course said it's our choice and we can start ADT tomorrow if we prefer. The ADT will continue for 6 months before stopping and then the PSA will be retested to see what has happened post RT and the effectiveness of the treatment.

    I'm torn here. I see pros and cons on both sides. On one hand I would like to prolong the use of ADT as much as possible, because my father in-law already took ADT for almost a year post surgery. There's no guarantee, but I worry that on/off use of ADT will diminish its effectiveness more rapidly, and since it's the last line of defence it makes me hesitate and wonder if, after 2 weeks, the PSA has fallen, we can't just prolong it further. On the other hand you only get one chance at RT in a specific area (in this case, pelvic). And I want to make it as effective as possible. If combined ADT and RT is the best chance we have to kill cancer cells - assuming they're in the pelvic area - then I don't want to jeopardise that opportunity in any way. In another two weeks he will have reached the 22nd RT treatment out of a course of 35 - almost finished. I'm worried by then that the opportunity to effectively combine treatments may be on the late side.

    I hope this is all clear. Any questions please feel free to ask. I do understand your suggestion to listen to the doctor, but he's certainly not pushing us either way and also agrees with the general guidelines of combined RT, just maybe he doesn't want to use ADT unless deemed absolutely necessary. Thank you once again for your invaluable help.

  • Grinder
    Grinder Member Posts: 487 Member
    correction?

    You said:

    "suggest ADT and RT combined from the start of the RT treatment. Now, please correct me if I'm wrong, but is this because RT weakens the cancer cells? And therefore by weakening them it makes them more susceptible to being wiped out by radiation? "

    Did you mean to say "is this because ADT weakens the cancer cells"? Is your question regarding the role of Androgen Deprivation Therapy in cell actvity?

    This is excerpted from cancer.gov to help understand the role of androgens in prostate cells, both normal and cancerous:

    "Androgens are required for normal growth and function of the prostate, a gland in the male reproductive system that helps make semen. Androgens are also necessary for prostate cancers to grow. Androgens promote the growth of both normal and cancerous prostate cells by binding to and activating the androgen receptor, a protein that is expressed in prostate cells (1). Once activated, the androgen receptor stimulates the expression of specific genes that cause prostate cells to grow (2).

    Early in their development, prostate cancers need relatively high levels of androgens to grow. Such prostate cancers are referred to as androgen dependent or androgen sensitive because treatments that decrease androgen levels or block androgen activity can inhibit their growth.

     

    Most prostate cancers eventually become "castration resistant," which means that they can continue to grow even when androgen levels in the body are extremely low or undetectable. "

    The goal of ADT is the suppression of androgens by inhibiting the production of testosterone... the androgens activate prostate cells, whereas if they are deprived of androgen, they remain dormant, until they become "castration resistant".

    Hopefully de Gama can explain better how that should or should not play a role in  the treatment.

     "Cell growth" can refer to both cytoplasmic volume increase of the individual cell, or cell division and replication. In this case I suspect it means replication, causing the cancerous cell colony to grow.

  • contento
    contento Member Posts: 75
    Pathfinder, I don't know if

    Pathfinder, I don't know if this will help your father in law  or not but a few years ago I had reoccurrent cancer and I had to decide whether or not to include hormone treatment as part of the recommented salvage RT protocol. My doc explained that the HT would sensitize and shrink the tumor making it more receptive to the radiation. The plan was for me to get ( 2 ) 3 month Lupron shots over a 6 month period along with Casodex. As you point out because your psa essentially goes to zero due to the HT you won't know if the RT was effective or not for about 6 months after your RT treatment. In the end I chose to do the HT with the RT based on the advice of the radiation oncologist that believed Id have a higher chance of success if I chose that route. I guess she was right as my psa was and still is non-detectable.

    Hope this helps --contento

  • Pathfinder
    Pathfinder Member Posts: 55
    @Grinder, yes that was a typo

    @Grinder, yes that was a typo, I was asking if the ADT weakens the cancer cells and makes the RT more effective in the process.

    Thank you for your detailed response. I was aware of how ADT works, but I hadn't had anyone clarify as to why combination of treatments is part of the guidelines. 

    @contento, that's extremely helpful and the clarification I was looking for regarding how combined therapy works. We have decided to combine ADT with the RT treatment immediately. This morning the radiologist who performed the 12th treatment of the course actually said he should be on ADT and was (kind of) surirpsied the urology doctor hadn't prescribed this already.

    Because we only have one shot at the pelvic region, and at the moment we have no choice but to assume that the cancer is confined to that region, in my opinion we should be hitting it as hard as possible. Therefore we have elected to start ADT immediately as of today.

    I feel very frustrated about all this. There's nothing wrong with the Shanghai operation per se, but there is a problem in China it seems when it comes to having concrete ideas about something. In some ways it feels as though the information we bring is affecting the doctors thinking, when it should really be the other way around and he should be educating us. 

    It bothers me that we have already had 12 treatments before starting ADT now, as that's 12 opportunities lost in a way, to have the RT work more effectively. Anyway, we can only hope that the recent PSA result isn't anything to do with distant metastases and our decision this morning isn't too late. 

    Now we will just see the course out and decide how long to keep the ADT treatment running post RT. I will update when there is some more information.

    Thank you all for your responses, I can't tell you how important this forum is to us, especially as I'm dealing with this in a foreign country where I don't speak the language very well.

     

  • lighterwood67
    lighterwood67 Member Posts: 329 Member
    Silver Bullets

    The folks on this site are giving you their experiences with this cancer and their extensive knowledge of the cancer.  From what I can tell there is no silver bullet for this cancer.  There are treatments which have yielded good results and results with no significant impact.  My decision for RP was based on what I was told from the surgeon and the radiation onocologists.  I was told that in my case the cancer was contained (had not escaped the prostate).  I did the surgery.  Surgery is permanent (removal of gland; 8 pelvic lymph nodes; bladder neck reconstruction). Before the surgeon removed my prostate, he took a section of tissue out at the bladder neck and gave it to the pathologists.  No cancer in that sample, so he proceded.  The surgeon was very thorough in providing the pathologists with tissue from several avenues (perineural, urethra, bladder neck, seminal vesicles, pelvic lymph nodes) for escape.  No cancer. I have talked to four people who have prostate cancer.  Three of them had some type of HT; RT; Chemo treatment.  One is Stage 4 going into hospice care; one just started, in his 50's, says he feels like he is 100 years old (no energy); one says he is doing fine, but wished he would have went with the RP, but at this time he is still ringing the bell (he is winning).  As the folks on this site have told you, all of the treatmentts have side effects.  I wish you well in all of the decisions you make and hope for the most positive outcome.  To me it comes down to sooner or later you are going to have to fly that airplane, hopefully you land safely.  Good luck to you on your journey.