Options when adjunct or salvage radiation can't be used?

crw41atacc

I am almost 5 months out from radical prostatectomy.

1st PSA at 3 months was 0.39 (quite high) and 0.40 at 4 months. This suggests a doubling time of about 27 months, although that can change over time. I was Gleason 3+4 (40% 4) with cribiform pattern. The margins were positive at both sides and the base. He only took out 4 nodes (-). There was seminal vesicle invasion on 1 side,.

There will certainly be residual disease in the prostate bed, perhaps other parts of pelvis, and perhaps distant mets (which didn't show up on the 1st PSMA).

The urologist referred me for adjunct radiation, PSMA scan pending. At this number (0.4) the scan has only 50% sensitivity and could very well be negative except for the prostate bed. There is a significant probability of micrometastatic Pca in beyond the pelvis.

If PSAM shows mets, I am obviously excluded.

I am pretty sure I am excluded anyway by:

1. History of pelvic radiation 43 years ago (got 3,200 rads for testicular cancer). So, it likely the risks outweigh the benefits given exposure to the bladder, urethra, colon, rectum etc. My prior dose was 30Gy. The typical dose for adjunct is close to 65Gy. Due to a double hit - lots of bad things can happen that could dramatically affect quality of life immediately.

2 The past few weeks I have had some new gross hematuria (4.5 months post op). My only risk factor for that exposure to radiation in the past. I'll need a work up, but most likely cause is a synchronous bladder cancer (most common 2nd malignancy in TC survivors who underwent radiotherapy).

While getting my work up for the bleeding (cystoscopy, CT urogram, and possible ureteroscopy) I will be meeting with both a radiation oncologist and medical oncologist to discuss the best options.

It seems I am headed toward palliation with the most likley option to start being ADT. The cause of the hematuria is TBD and will likely require definitive TX of some sort.

In summary, what are the options for BCR at 3months (basically residual disease) in a patient who is not a candidate for adjunct or salvage radiation.

Marlon

I'm not an expert and not having gone through what you're experiencing, but my impression is that chemo could also be an option. And still not an expert, but I have to think that the difference between .39 & .40 is within a margin of error or accuracy for a laboratory method that is testing at that low a level. Hopefully somebody else will chime in with more knowledge.

Old Salt

Welcome to this forum, although I am sure you would rather not be here. It seems to me that you are a candidate for 'triple therapy':

Triple therapy for prostate cancer is a combination of three treatments used to treat metastatic hormone-sensitive prostate cancer (mHSPC). It typically includes: 

• Androgen deprivation therapy (ADT): This blocks the hormone testosterone, which fuels prostate cancer growth. 
• Chemotherapy (docetaxel): A cytotoxic drug that kills cancer cells. 
• Androgen receptor pathway inhibitor (ARPI): A medication that blocks the action of the androgen receptor, preventing it from binding to testosterone and promoting cancer cell growth. 

Benefits: 

• Improved overall survival compared to ADT and chemotherapy alone
• Reduced risk of castration-resistant prostate cancer
• Prolonged time to progression 

Indications: 

• Men with mHSPC who have high-volume disease or are at high risk of disease progression 
• Patients who have not previously received chemotherapy for prostate cancer 

Types of Triple Therapy: ADT + docetaxel + abiraterone acetate (ARPI) and ADT + docetaxel + darolutamide (ARPI). Side Effects: 

• Increased risk of side effects due to the combination of treatments
• Bone marrow suppression, leading to increased risk of infection
• Nausea, vomiting, fatigue
• Peripheral neuropathy 

Considerations: 

• Triple therapy is not suitable for all patients with mHSPC. 
• The specific combination of treatments and the order in which they are administered may vary depending on the individual patient. 
• Close monitoring and management of side effects are essential. 

It's important to consult with a qualified healthcare professional to determine if triple therapy is an appropriate treatment option for you.

No, I did not write that, AI (CoPilot) did, but it does say what I wanted to, except better than I would have been able to.

Clearly, the recommendation is to hit the cancer hard.

crw41atacc

From what I have read, there is no benefit in low volume disease, only high volume,

Clevelandguy

Hi,

I would look into Proton beam therapy which can be used after traditional radiation has failed. Proton beam is a different type of fixed focal length radiation. When the PET scan picks up the cancer, you zap it with the Proton beam. No PET scan pickup, live a normal life until the next PET scan. Prostate cancer is slower growing so the time between PET scans is not that critical in my humble non medical opinion. Some doctors might want to do ADT drugs to reduce testosterone and weaken the cancer. Be careful, some ADT drugs have some nasty side effects. I have included a link for you to study.

https://www.mayoclinic.org/departments-centers/proton-beam-therapy-program/sections/overview/ovc-20185491

Dave 3+4

centralPA

1st PSA at 3 months was 0.39 (quite high) and 0.40 at 4 months. This suggests a doubling time of about 27 months, although that can change over time.

It”d be tough to infer a doubling time from that noisy signal.

I am guessing (hoping) that you essentially had the equivalent of 0.40 +/- a small number of PCa left behind, and that ADT will likely squash it for a good long while. At least long enough so you can deal with the other gators maybe closer to the boat.

Wishing you the best!

Old Salt

https://csn.cancer.org/discussion/comment/1721395#Comment_1721395

1. There's no target to irradiate
2. There are no trial results to document that proton therapy has fewer side effects than current (highly focused) radiation therapies like SBRT.

Josephg

https://csn.cancer.org/discussion/329058/options-when-adjunct-or-salvage-radiation-cant-be-used

Don't automatically assume bladder cancer because of gross hematuria. I had 3 bouts of gross hematuria after IMRT to the prostate bed. The cystoscopies revealed delayed inflammation as a result of the radiation, and eventually the inflammation healed over, and I've not had a bout of hematuria since.

Old Salt

It seems to me that the distinction between 'high volume' and 'low volume' disease is a bit artificial. It seems very likely that there are small clumps of cancerous cells 'floating around' that can't be identified by current scans. As I suggested earlier, hit it hard now that the 'volume' is still low. Unfortunately, it's likely that the side effects won't be easy on the body.

crw41atacc

To clarify, my radiation exposure to my abdomen and pelvis was 43 years ago. My surgery was almost 5 months ago. Gross hematuria is some type of GU cancer in a patient like myself until proven otherwise. I have no risk factors or reasons for hematuria other than my prior radiation exposure in the past.

As an aside, I am a retired physician. Given my knowledge and experience in the medical system, it is still very frustrating and difficult to get timely care, get people to follow up promptly, get people take the time to listen to you, and not be rushed along. Technology and computers improved many things, but destroyed the doctor patient relationship. You really have to be your own advocate and be proactive.

Clevelandguy

https://csn.cancer.org/discussion/comment/1721404#Comment_1721404

1. Yes there is no target yet to irradiate so wait till it shows up on a scan then radiate it.
2. Not interested in comparing side effects, the point is Proton therapy can be used after traditional radiation was used on a certain area. It’s another killing tool after traditional radiation has been used on an area and can’t be used again.

Dave 3+4

Steve1961

where is the cancer located if its on the lymph nodes down around the prostate bed you may be a candidate for radio guided surgery done at UCLA by dr robert reiter ..check it out i have pasted about before

Steve1961

https://csn.cancer.org/home/leaving?allowTrusted=1&target=https%3A%2F%2Fwww.google.com%2Furl%3Fsa%3Dt%26rct%3Dj%26q%3D%26esrc%3Ds%26source%3Dweb%26cd%3D%26ved%3D2ahUKEwjlgIKAhKOAAxW6m2oFHebnCNMQwqsBegQIEhAG%26url%3Dhttps%253A%252F%252Fwww.youtube.com%252Fwatch%253Fv%253D-ZXDohxylg0%26usg%3DAOvVaw2YI7sJ0VG3QjqJ4p-w0qfm%26opi%3D89978449

Steve1961

there is the link good luck

Old Salt

Did you ever discuss with a radiation specialist whether a second round of radiation is possible for your situation. Forty three years is a long time and some tissues can be irradiated a second time. I do agree that the side effects likely would be worse than 'normal'.

crw41atacc

I meet with the rad onc tomorrow. I then have cystoscope the day after.

There is a lifetime limit to medical therapeutic radiation to specific tissues. The bladder, colon etc. can only receive so many lifetime rads before things go bad such as tissue necrosis, fistulas, fibrosis etc. Some tissues can receive more than others. There is cumulative damage to the DNA with a latency period of about 30 years before new cancers show up. So, I think I have already answered my own question, but I want to see what he has to say.

After the prostate surgery, in the area where the pubic hair was shaved, I noticed a very unusual skin lesion that was about 0.5cm. The urology team never saw it or mentioned it. I went to the dermatologist who removed it. It was a rare form of basal cell cancer. The skin had never seen sunlight. It was caused by prior radiation therapy when I was younger.

The bigger immediate worry is what was the cause of the gross hematuria. Given the nature of the bleeding and my previous history, bladder cancer is at the top of the list. The other possibilities are just as ominous.

crw41atacc

I met with a radiation oncologist.

I have a decipher test pending - I know what it is, just not convinced it will provide information that will actually help.

My best bet may be Proton therapy. Unlike IMRT which uses a rotating gantry, Proton TX can utilize a single beam that can be directed to the patient laterally and more target - thus with a lot of ability to avoid or minimize exposure to the rectum/colon, bladder, and other structure which may have been radiated in the past. I will pursue a consult with the Cleveland Clinic once I have my PSMA results.

Also, pending the results of my hematuria work up. I have a cystoscopy today.

centralPA

https://csn.cancer.org/discussion/comment/1721486#Comment_1721486

I wonder if Pluvicto couldn't be an option for salvage therapy, since you represent a highly specialized case. If your PSMA can see it, the Pluvicto can attack it (I'd think).

crw41atacc

Don't know - its excreted into the bladder. Will inquire

crw41atacc

Fortunately, cystoscope was normal.

Need to have CT urogram to look at kidneys and ureters

Josephg

https://csn.cancer.org/discussion/comment/1721498#Comment_1721498

There you go, good news on the bladder.