PSA recurrence after surgery

Welcome
sbj,

Welcome to the forum and I'm sorry that your PSA history seems to indicate a recurrence of PCa.

The PSA rise you experienced seems to follow the classic recurrence curve associated with a return of prostate cancer. Most urologists consider that a rising PSA above 0.2 ng/ml is evidence of recurrence and you seem to be there. You may wish to go to one of the PCa nomograms (visit the Sloan-Kettering site) and plug your PSA scores into the free calculator and determine your PSA doubling time and PSA velocity. Without knowing the exact day/month your PSA reading were taken, it looks to me that your PSA DT is fairly long (probably greater than three years) which is usually indicative that an early salvage treatment will be very successful.

It sounds like the IMRT treatment your doctors are scheduling is standard protocol for a case like yours. The only question you may wish to pursue at this point is what type of machine and delivery method is being used. Some newer types of IMRT can be delivered with a higher degree of accuracy than older models which will help reduce radiation to uninvolved organs and tissue and result in fewer and milder side effects. You may wish to look at some of the various new methods that include the Varian models, Calypso, and so forth over traditional IMRT delievery systems. I would also want to discuss with your doctors what lymph nodes (if any) they intend to address and why.

Because of the inflammation to the remaining prostate tissue in your prostate bed, they generally wait three months before looking at PSA scores again.

Studies have shown that salvage IMRT in conjunction with hormone treatment has a higher overall success rate than IMRT alone but there are side effects associated with HT. You ought to discuss the pros and cons of this option with your medical team.

As always, I would seek a second opinion before going forward but it my non professional opinion, you seem to be taking a prudent and appropriate course of action.

Best of luck to you and please keep us in the loop as you go forward.

K

Salvage radiation?
J:
More information from your pathology report could be helpful here in understanding your case. Nonetheless, your doubling time is slow, something on the order of 15-18 months using the most current figures with year and month available. The longer before a detectable psa appears, the more likely the recurrence is local to the prostate region. This is good news in your case. At your current age of ~75 years, even with only the treatments we have available today, you are unlikely to die of prostate cancer. Therefore, your treatment decisions could not have been better. Radiation can be quite successful in eliminating small amounts of disease residual in the prostate area. Even if it just slows the growth of your tumor this means you would have even more time allowed.
Assuming you have normal functioning of bladder, urethra and colon today, then radiation is reasonable. Any weak function in this area can be affected by the radiation. A colonoscopy, if not done within the last 5 years or so, might be a good idea before starting your course.
In successful radiation it takes time to determine success, sometimes years. Failure is usually apparent sooner. Your current schedule of every 3-4 months seems reasonable for future psa.
I do not understand your Gleason of 4-7. Can you be more specific?

Kongo said:

Avodart and PSA
Hi, Beau

I too have read some of those trials that show Avodart can curb the rise of PSA and agree with you that prostate tissue left behind after RP can cause some small amount of PSA. Avodart suppresses the DHT (dihydrotestosterone) in the blood which will cause the prostate (and presumably the remaining prostate tissue after an RP) to shrink. I belive though, that you have to use some caution with interpreting PSA levels with this and other testosterone blocking drugs as they tend to "mask" the true PSA reading and the result you get after starting the drug is not really as low as the readings might indicate, but I would leave it to someone more knowledgable about the affect on our body chemistry by these drugs to explain that.

Potential side effects of Avodart are loss of libido and impotence but I understand that these side effects are much less a factor than with an earlier DHT inhibitor like Dutasteride. One unrelated positive side effect of Avodart is that it apparently reverse male pattern baldness so perhaps you can get a twofer here.

These would be good options for SBJ to discuss with his medical team and perhaps there might be benefit to him if he joined the ongoing trial.

K

Avodart and PSA
Do you know how a person could determine if a PSA rise was due to a recurrence of PCa or due to benign prostate tissue being left after th RP? Maybe the rise from benign tissue stablilizes (reaches a nadir or plateau)... kind of like radiation therapy ... but in reverse.

tarhoosier said:

Salvage radiation?
J:
More information from your pathology report could be helpful here in understanding your case. Nonetheless, your doubling time is slow, something on the order of 15-18 months using the most current figures with year and month available. The longer before a detectable psa appears, the more likely the recurrence is local to the prostate region. This is good news in your case. At your current age of ~75 years, even with only the treatments we have available today, you are unlikely to die of prostate cancer. Therefore, your treatment decisions could not have been better. Radiation can be quite successful in eliminating small amounts of disease residual in the prostate area. Even if it just slows the growth of your tumor this means you would have even more time allowed.
Assuming you have normal functioning of bladder, urethra and colon today, then radiation is reasonable. Any weak function in this area can be affected by the radiation. A colonoscopy, if not done within the last 5 years or so, might be a good idea before starting your course.
In successful radiation it takes time to determine success, sometimes years. Failure is usually apparent sooner. Your current schedule of every 3-4 months seems reasonable for future psa.
I do not understand your Gleason of 4-7. Can you be more specific?

decision for myself also
i have the same decision to make. salvation radiaton or hormonal therapy. i do not like what h/t does to you. the side effects suck. so i am thinking of the radiation only. my bladder, urethra, are in good condition. kongo mentioned the method of radiation and i will look into that. my psa has risen much more than sbj. it is now 5.8. i had a bone scan 4 months ago and it showed nothing. 7 years since my surgery so how do i know if the cancer has spread outside the prostate bed? i'm tired of thinking about cancer.

Kongo said:

Prostascint Scan
Cal,

You may wish to investigate a relatively new method of detecting cancer outside the prostate bed known as the prostascint scan. It takes three days and involves the use of radioactive antibodies that attach themselves to cancer cells which can then be read using a special scan in conjunction with MRI and CT. Not all hospitals offer it but if you are in or near a larger metropolitan area you should be able to find it. Just enter "prostascint" in google and you'll find plenty of information.

K

Prostascint Scan
never heard of it but i have looked it up. i will definitely bring this up with my urologist. thank you Kongo.

sbj said:

hank you Kongo for your
hank you Kongo for your follow-up in answer to my questions. Doubling time: 12-months worst case; 18-months best. There was some distortion in earlier readings due using different labs. Same lab, readings became more consistent. I did consider salvage of prostate bed + HT, but was turned off by reports of bad side effects from the hormone treatment. For the same reason, I also decided against having a wider salvaging beam to radiate the pelvic lymph nodes. A sampling of pelvic lymph nodes taken during surgery did not show any cancer there at that time.

The radiation technique is known as TomoTherapy, and I quote: "a treatment system that combines intensity-modulated radiation with the image precision of a CT scan to guide radiation exactly to the tumor areas." I have no knowledge of the radiation generator itself. Tomo is supposed to be highly accurate. Is this what you were referring to?

Tomotherapy
sbj,

Tomotherapy is a very highly accurate form of delivering IMRT type radiation to the affected area and has the ability account and adjuist for organ movement through it's CT scan process. I have a close friend who is going thorugh treatment with this system now and is very satisfied with the procedure and apparent accuracy of the system. He chose tomography as his primary source of treatment along with a 12-month Lupron protocol.

Best of luck to you as you go forward.

k

sbj said:

Salvage radiation
Tarhoosier: thanks for the follow-up to my questions. I have been told that post-surgery Gleason was 4, with a "tiny bit of 7 in righthand top quadrant." Colonoscopy done about 6-months ago. Bladder normal.

SBJ; A relook into the irradiation plan
SBJ

I am glad that you have reached a conclusion to your salvage treatment. I also had SRT after a failed surgery, but I choose a plan that included the lymph nodes (inner iliac), because they are usually the places from where cancer metastasizes. I think that you have done research on the details of your decisions; however it would be wise to relook into this aspect of irradiation plan because a repeated radiation of the same area is restrictive and has lots of complications. Here is the comment of Dr Charles "Snuffy" Myers who is regarded as one of the most prominent oncologists on prostate cancer. He quotes;

“….If surgery was the initial treatment, radiation should also be considered. Here there is a major controversy. Do you radiate the prostate bed or extend the radiation to the pelvic lymph nodes? I am biased because I keep seeing men who had radiation to their prostate bed and now have recurred. When we look, we find the cancer in the pelvic lymph nodes only in many of these patients. Radiation to those pelvic nodes then serves to put the patient into complete remission. So, I am a strong advocate of radiation to the prostate bed and pelvic lymph nodes…”

For the full article look here; http://prostatecanceradvice.org/about/myers/androgen-deprivation-therapy-after-surgery-or-radiation/

In my surgery 9 lymph nodes were dissected and all were free of cancer. These nodes are the ones easily to be accessed for dissection but there are others that can be reached/treated only with radiation.

I hope that you discuss about the above with your doctor and get to a final conclusion and peace of mind.
VGama

sbj said:

mrspjd,
Am at the stage of waiting for the first session. Have committed to prostate bed only radiation. Decisions was not taken lightly. But I now wish I had signed up when PSA was around 0.1, instead of dithering over the hope the rise was due to leftover benign tissue etc, etc.
In consideration of HT I did not ask or analyze the drugs used, since I have little knowledge of their different degrees of effectiveness, and from what I have read, there is still so much argument over those numbers. I just felt I could not stomach the addition of HT's peculiar side effects. As regards local nodes, then the radiation doctor said that side effects are generally worse the wider the range of salvage. Even with Tomo.

Right now I am highly frustrated and anxious over the delay that is occurring between when I had all the scans/tests for salvage rad and the start of the sessions. Today is the 8th business day since the set-up session and I can only wonder why it takes so long - the cancer of course not waiting, but continuing its deadly spread. I've called the doctors office and am told that I might get the call next Monday. Again, I ask why so long? Why not 24-36 hours? What do you and others think of this amount of wait time?

I'm not sure of the exact post surgery Gleason number, other than what I have said - Gleason 4 with a touch of 7. The surgeon did tell me the cancer was totally contained within the prostate shell with no spread to local node sample.

sbj
I "hear" you loud and clear, but know that a few days or weeks may not make much difference, but the anxiety is still there. In PJD's case, he absolutely wanted the local pelvic nodes treated along with the prostate (he did not elect surgery). His tx was completed in Oct 2010, and he is doing fine with no side effects from the IMRT. Please read Vasco's newest post today carefully, as it, along with the link he posted, explains the thinking about why including the tx of the local lymph nodes may be an important consideration. Also, if the protocol for the addition of HT is a short term course (6 mos), it might also be worthwhile to give that a 2nd look. If the side effects were causing issues, then you could discontinue the usage and expect the side effects to resolve.
Best,
mrs pjd