What if radiotherapy fails

Adt is the the LAST I MEAN LAST treatment you want to do it, ruins aman .. five years ago when I chose radiation they did not know what they know now about crib form they know now that Cribiform is radiation resistant if my grade 4 was not cribiform the radiation, most likely would have worked, but I still believe I made the wrong decision at my age I was 57 I should have taken it out a lot of it depends on what type cancer you have your gleeason score and everything else that goes with it. I personally think the radiation seeds actually work just as good as external beam and you have even less side effects right now I open myself up to rectal cancer and I have bowel problems if I would’ve done the seeds, probably wouldn’t have had these side effects , and yes I can do a focal treatment now if iI want cryotherapy would give me 50% chance but since it’s crib form and there’s always a chance of micro mestasisn and it became back a third time in the prostrate, and it was too close to the ureathra . Then I’d have no choice, but ADT because they would not be able to treat it focal again in surgery, then would be extremely difficult am choosing to remove the whole thing and hope for the best.

There are a variety of salvage treatments after radiation. Cryotherapy and HIfu are both candidates. The old argument, that prostate removal gives you a second bite at the apple, doesn’t make much sense. Since the cure rate for radiation and removal are effectively the same, surgery doesn’t seem to offer any advantage This makes sense, since radiation can treat a wider field and cure those cases where the cancer has escaped the capsule but is still confined to the prostate bed. In my case, I started with removal, but pathology showed extracapular extensions I subsequently required salvage radiation and ADT. Had I started with radiation, maybe I only would have needed one treatment.

There are no guarantees no matter which treatment you chose. Both are equally effective The reason I would chose radiation is because of the better side effect profile

Eric

Hi -

My two cents worth...

At age 76 (June of 2023) I was told by my Cleveland Clinic urologist and radiation oncologist that ADT and IMRT radiation was my best option. Started ADT (Lupron, three 6 month injections) shortly before 28 days of radiation).

The daily radiation was annoying but I had no issues with the procedure. My PSA went from 20 (pre-treatment) to <.03 and has stayed there. I have been told that is due to the combination treatment.

The Lupron (ADT) is another story. It may "starve" any remaining cancer cells by removing their favorite food (testosterone) but, for me, the side effects have really messed with my "quality of life." My testosterone level went from a relatively normal 512 ng/dL to <12 ng/dL. The resulting loss of muscle tone and stamina is truly annoying. The expected hot flashes have been mild and tolerable. Weight gain around the middle has left me "flabby." To use my grandkids terminology, my junk has shrunk - a lot! My libido is about zero.

I have been doing a lot of research about what happens AFTER ADT. I have found that at my age (77 next month) my testosterone may NOT recover or may take a very long time (years) to recover. I'm scheduled for my third Lupron injection in early April. The goal is to keep my testosterone low for a total of 18 months. I have decided to skip that last injection since my testosterone level will probably stay low longer than that anyway. I'll have blood work every couple of months to make sure both my PSA and testosterone levels stay low.

If the end result is that I have beat the cancer then everything I have mentioned above was worth it. I have developed mild radiation proctitis (rectal bleeding) which should resolve with time and some medication. It hasn't affected my daily routine at all. We're all different and react differently to the various protocols the doctors have devised over the years.

Guess that was more than "two cents worth." 😉

Good luck on your journey...

I am 59 years old and six weeks post robotic prostatectomy. I am dealing with the expected incontinence and erectile function loss and have great hope that I will improve vastly from where I am today. I do not regret my choice yet, I do hope that my continence will be far better than it is currently in the very near future.

Things I researched and considered when comparing radiation to surgery:

+ Radiation and Surgery offer very similar cure outcomes, I do not believe one is superior to the other. The fact the PSA does not become undetectable after radiation does not influence longterm cure.

+ You should have a long discussion with your provider regarding high risk features you may or may not have in your individual case. Prior survivors discussed cribriform changes (some types of changes can be radio-resistant when combined with BRACA features) and ADT combined with IMRT. If high risk features (Group 2 high risk or Group 3) exist you may be at risk for multi-modal (radiation and surgery) therapy. The order which you go with high risk may matter. I do believe (just my opinion) there are fewer longterm complications if you have surgery before radiation in the case of multi-modal therapy. If you are high risk and opt for surgery the surgeon may intentionally resect one or both nerve bundles in order to achieve negative margins (your individual features really matter). This should be a discussion that is had BEFORE intervention.

+ If you are G2 Intermediate risk or lower then multi-modal therapy should be irrelevant and you should be cured with a single intervention (fingers crossed).

+ All forms of therapy come with a price, there is truly no free lunch in this area. Surgery is far more likely to cause incontinence and radiation far more likely to cause rectal symptoms or problems. In my opinion, both forms of intervention are comparable in terms of erectile function 2-3 years after therapy. Surgery continues to improve and radiation continues to degrade over years. In the case of surgery, PICKING THE RIGHT SURGEON IS EXTREMELY IMPORTANT!!

I wish you well and feel this choice is the single most personal thing we do. After we pull the trigger we live with the consequences of our decisions. Having this group to interact with has helped me on my personal journey more than you would know.

jc

Must not know my story I had radiation done five years ago. They did not know that cribriform was radiation resistant so here I am after being treated with external beam radiation and a booster. My PSA dropped to 0.9, but I have had three consecutive rises 1.2 1.6 1.9 that’s not even two points but I was concerned went for testing and Yep cancer is still there so now I am having Radical salvage prostate surgery done and I’m not too happy about it. Look on YouTube Robert Reiters video. They are doing surgery there at UCLA If your lymph nodes are infected, they stick a dye in you and they know exactly which nodes have cancer rather than guessing.

It is definitely better being on my side of the decision for treatment.

Fox Chase is very strong especially for multi-modal therapy (not applicable in your case by what you posted). There are many other opportunities for surgical opinions near Philadelphia (New York, Baltimore, Cleveland come to mind) if you are concerned about your current surgeon’s experience.

I travelled 3 hrs from home for my surgeon of choice because it mattered that much to me.

Good luck my friend,

jc

Lots of follow-up treatments for RT failure. All of the focal treatments like HIFU, freezing, laser, the new Nanoknife treatment. HDR brachytherapy to the spot. SBRT to the spot. Whatever new thing they are working on while you kick the can down the road. Just doing AS on it, running out the clock. Manage with ADT.

Tough decision…a lot more ambiguity going down the RT road.

That makes sense! Thank you for that. I was clearly guessing, having only concentrated on my own circumstances.

We never stop learning, do we?

PSA is higher after radiation because there are still living, normal prostate cells in the body and they produce PSA. After a prostatectomy, there should be no more PSA at all because there is nothing in the body to produce it.

Hey Chris,

I did one six month shot of Lupron, along with Casodex in the beginning. My testosterone went down to near zero, as is expected, but never really fully recovered. I am now five years post treatment and am considering testosterone supplementation.

Eric