Facing possible SRT, PSA .068 3 1/2 years post RALP

After pondering on this issue, I will join the two eminent ROs based on the following thinking:

If cancerous cells are 'hiding' in the prostate bed (a distinct possibility), I would not want them to metastasize to other parts of the body while waiting for the PSA to rise to a somewhat arbitrary level of 0.2. 

I agree that such salvage radiation therapy may not hit the cancer cells where they are hiding, but it's the best 'shot' you have. Even if you did wait for the PSA to break the 0.2 threshold, it's by no means certain that it will be possible at that time to locate where the cancer cells are 'hiding'.

More in general, medical decisions are often based on 'statistics' and this is certainly true of prostate cancer.

Pratoman,

Cancer travels to distant places via the blood stream but it doesn't do that so easily or even settle at a distant place at will. Firstly it must avoid trapping at the filtration sentinels, the lymph nodes. Those cells that manage to pass then will confront the inauspicious newer environment where it will try living. Localized affected cells will ring the alarm triggering the immune system that will persistently regulate the problem, killing the bandit and disposing off the unwanted buggers.
It takes time for such successful occurrence to take place (if any) and it would depend on a timely period of weakness of our other systems (a moment of stress, a sickness of tissues at the newer environment place, etc). In the study of above link they found only 16% of far metastases cases in ten years of survival post RP. In other words, you could expect to have far metastases at present if your cancer case has existed in your systems back in 2005.

No one here is saying that you have recurrence today but the increased PSA and the the story you told us leads to think on such a possibility. Accordingly, as Old Salt comments above you may go through SRT before reaching the NCCN recommended thresholds. After all, the pathological stage in 2015 should have been pT3aN0MX which places your case into this discussed dilemma of ART vx SRT. You are also a G7 (low) intermediate risk case. You did not radiate two years ago but intend to radiate in two years from now (calculated PSA of 0.2 ng/ml for its doubling). The only missing piece is if the field for the radiation covers extensively the localized areas that should include deep lymph nodes, at the expense of more risks and side effects. Far metastases, if any, can always be radiated later as it would not stand in the areas planned for the SRT of today.

In any case, this is a difficult moment of your life. It is difficult to all us when confronting the time of a decision on an action regarding PCa. In your shoes I would stick by your own threshold no matter what others think. You do not need to rush. Just be sensitive and follow what you trust and feel comfort as that will be the best choice and we all will applaud you for the courage. We try being helpful but cannot decide for you.

Best,

VG

Hi, we know each other, and we have discussed this before. But I see you joined CSN nearly three years ago, but have only posted a couple times outside of this thread.

You also know that I had adjuvant radiation one year after prostatectomy, but our cases are completely different.  So my experience really has no bearing on your situation.  So it really comes down to the numbers.  Your meetings with top doctors have resulted in an estimated 4 out of 5 chance of successful SRT at this point, so only a one in five chance of the remaining cells being located outside of the treatment zone.  If I understand those estimates, then it actually sounds pretty good.

Of course, the doctors are hesitant to "over treat", so the possibility of causing you some SE's of radiation with a 20% possibility that it will do you no good.  On the other hand, you DID have a positive margin (whether or not it was cut away during surgery) increasing the likelihood that you have or had cancerous cells remain locally in the prostate bed.

Furthermore, you had a SECONDARY grade 4 component in your Gleason, but only after re-evaluation.  It might be safe to assume that there was not much of it, and that most of your cancer was Gleason grade 3.  Grade 4 is the type most likely to spread locally, outside the prostate.  But as I understand it, grade 5 is the type that is more likely to metastasize to remote areas of the body.  Fortunately you had RP including a thorough dissection, therefore if there had been a tert 5 for example then it would have been reported (am I assumign that correctly?)

So the short version of this is: 80% likelihood of being locally confined, possible positive SM being most likely grade 3, which does not metastasize.

So there may be a chance that the low grade cancer cells will fail to thrive and your PSA will stop rising. That would tend say do nothing for now and hope it stabilizes before spreading any further. OR zap now and hope it's all still local and there are no damaging side effects.  The worst thing to come out of RT - other than possible SE's, is that if the treatment area is not broad enough, then you missed the target using your one and only shot, and the area cannot be re-treated in the future.  But if it has already spread outside that area, then you wouldn't be re-treating it anyway, right?

If you do go for SRT the question becomes whether or not to starve the cancer with ADT. But then you lose the ability to measure the success or failure of the RT, at least for a period of months or possibly years... like me.  I've completed 18 months on Lupron, and my PSA is undetectable, but I won't know until another 18 months have passed whether my PSA will stay 0 or will rise slightly and stay there, or will it continue to rise again?  So right back to where you are right now my friend.  Except in the meantime I threw everything possible at it.