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SRT or not with intermittent but low rising PSA after RP???

DeJung
Posts: 3
Joined: Jun 2017

Had RP in 2007. physical lump during rectal exam and biopsy with cancer. Gleason:3 + 4. PSA = 4.5

PSA was <1.0 for many years, then 1 in 2013 and 2014. Then 2 in Nov 2015.

Starting seeing a radiation oncologist in  spring of 2016. First PSA was 0.28.

Embarked on dietary and lifestyle changes ( 5 elements based on searching the literature) intended to increase PSA doubling time. Scheduled PSA test at 3 month intervals, wanting to see impact.

Next two PSA's were 0.26, then 0.25. Combination of extended holiday and other health issues which led to dimished adherance to the strategy led to the next two PSA's at 0.29 and 0.36.

Doctor strongly recommended not waiting any longer. Had MRI, PET. and PET with Axium did not reveal any metastasis. Two months ago, resumed dietary/lifestyle changes. Just prior to having the above tests, had a "final" PSA. Was 0.28!

Am now at a quandry.  Do I:

A. Embark on the plan of having  the SRT along with a six month regime of HT (which is the doctor's recommendation and he says that it has led to 85% cancer free rate at  10 years for patients like me.

B. Or, stay the course with my dietary/lifestyle changes and work harder at maintaining them 12 months a year?

Am now 73 and otherwise in excellent health. Think my doctor is superb, but also believe that most medical professionals do not believe that things such the diet/lifestyle makes any difference (aside from things like obesity or smoking, which are not issues for me)

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3257
Joined: May 2012

DeJung,

You have in-effect been cured, or a virtual sort of cure, for about 10 years now. Your PSA has not really been rising over the last year or more.

Why not continue what you are doing indefinitely ?   I believe RT is more-or-less available at any age; I would wait till I needed it.  But as you know we are not medically trained, and I have not studied salvage therapies at all; just what I have learned from the guys here, and a few books.

max

GeorgeG
Posts: 127
Joined: May 2017

Welcome to the forum. How did you get your PSA down from 2 in 2015 to 0.28?

 

george

 

DeJung
Posts: 3
Joined: Jun 2017

Sorry. A typo.

Was 0.2 with the less precise test. Then 0.28 with the more precise test. Went down to 0.26, then 0.25 during the strategy. Then up to 0.29 and 0.36 during 6 months when I did not/could not fully follow the strategy.Then down to 0.28 after less than 2 months of rigorously following the plan

VascodaGama's picture
VascodaGama
Posts: 2969
Joined: Nov 2010

DeJung,

Your story recalls the time when I looked for SRT, in 2001. It has passed already 16 years but the way to treat a RP recurrence is still the same; Radiation with or without Hormonal portion. The urological standards for these cases also have not changed continuing to use PSA thresholds to declare recurrence (at 0.20 ng/ml) and trigger intervention (at 0.40 ng/ml) for an earlier attack. However, one knows that radiation needs identified targets to be successful and the lack of such precise information (a due image exam identifying the location of the bandit) is still the Achilles' heel of the issue. We still got limitations in image ability when cancer is too small in size or when one is confronting micrometastases.

Your doctor may be of the group that believe in earlier intervention more than having proper targets, as commented by you in A "... it has led to 85% cancer free (not cancer free but biochemical recurrence free) rate at 10 years for patients like me". In any case such approach of treatment done guessing is just like flipping a coin in a decision. It can place you in the 85% group as it cannot. I agree with Max's opinion, radiation can be done any time and one wouldn't lose such a treatment benefit if done at PSA=0.4 or later.

Back in 2001 I was diagnosed at MSKCC as having micrometastases and that took me to ProstaScint and PET. I wanted to find those targets but, unfortunately, none of these tests were reliable in 2001, even if their principle as an image exam were and still are considered good, the agents used in the tests provided many false negatives and false positives. Such took me to decide in following a regimen of waiting (WW) involving periodical tests and image studies, and apart from the increasing PSA all images were negative till I had SRT in 2006 (recommended by my oncologist at JH) with a PSA of 3.6 ng/ml.

Along these years as a survivour the image capability improved alot, in particular regarding specific radiopharmaceuticals that target prostatic cells. For instance the isotope 68Ga PSMA that is specific to PCa has proven to be reliable but this too has shown limitations when the PSA is lower than 0.40 ng/ml. Surely other radiotracers also identify cancer but these are more generalistics. Axumin PET (Fluciclovine F18) is known to be reliable for PCa when the PSA is over 1.8 ng/ml, which is not yet your case.

My suggestion would be for you to consult an experienced radiologist, discuss with him on the differences in approaches (with and without positive image), decide on an accommodated treatment trigger threshold (PSA) and follow your B protocol.

Our cases are not to be compared, but I have been waiting for an increase of the PSA to assure me a positive image study with PET so that I can still expect cure from an oligometastatic treatment. This is to be done in a close future as my PSA has reached now to 1.84 ng/ml.

Best wishes and luck in your journey.

VGama

DeJung
Posts: 3
Joined: Jun 2017

Thanks for the support.

Axium was all that was available for me here - and it did not reveal any location details.  It would appear that the Bombesin PSMA that is being used in Germany may be more accurate in the PSMA 0.2 to 0.4 range. There are trials running in Austin and Los Angeles but I do not qualify. Those are treatment trials not diagnostic. Think Stanford is running doing some work with it as diagnostic. Have thought about flying to Germany to get it done there but am ambivalent about the roi.

My understanding of the current research is that they now believe that there is about a 3% improvement in success rate for SRT with each 0.1 change in PSA  - even down to the PSA = 0.1 level. Hence my quandry. A change of 0.3 means about a 10% reduction in probability of succces.

Yes, you are correct, the benchmark for "cancer free" is the biochemical reccurance number of 0.2, which is not exactly "cancer free". But if that is the benchmark to say that cancer has returned, it is only consistent to use the same benchmark to determine if it comes back again.

VascodaGama's picture
VascodaGama
Posts: 2969
Joined: Nov 2010

DeJung,

When the treatment is done on guessing the modality that provides the highest chances in success should be the preferred choice, however, those statistics involving the PSA as reference do not include the aspects regarding the loss of quality of life. They only focus on cure.
The thresholds recommended by NCCN guidelines leads most of the SRT do be done at very low levels of PSA which excludes any possibility in identifying targets via image exams. This signifies earlier intervention which may be doomed to fail if cancer exists away from the projected field of attack. Surely one must assume that luck plays a role when doing a blind therapy. Nothing is assured but the risks from the treatment. I think it better to avoid it if the circumstances so permit it.

Chemotherapy is also a possibility for those experiencing recurrence. Chemo is more stealth than radiation as it kills cancer wherever it exists and is not dependent on image studies for application but on cells dividing fast. No one can control chemo once this is administered. One can only stop the treatment in the mid of its total protocol. The side effects will also include those caused by damage to healthy cells caught in between. Modern salvage therapies use combine treatments of RT plus chemo or hormonal, therefore more propitious to loss of quality living. On the other end, RT can be limited to areas less propitious to damage.
One can discuss with his radiologist to avoid critical areas known to be nasty for side effects, protecting his quality of living.

The typical SRT includes the whole prostate bed (bladder area and colon) and localized lymph nodes bundles (iliac and aorta). This is where most recurrences are found in its initial stage but the whole area is never infested in a single case (in particular in those patients with low PSA levels). They radiate all to assure success because they have no identified targets.
Colitis, prostatitis and localized nerve damage are typical occurrences after SRT. Some guys get more affected than others. In nasty cases we see reports on fecal and urinary incontinence hard to be treated, or even cases of fistulas.

The trip to Germany for the image exam is most recommended. I would go further and get Lu177 in a nuclear test (PET or Gamma camera) that apart from identifying targets it may kill the bandit for good. This is the therapy of the future to treat cancer. A bomb that identifies and kills on the spot.

Best,

VGama 

Clevelandguy
Posts: 428
Joined: Jun 2015

Hi,

If it was me I think I would start with the least side effect things I could do 1st like HT(yeah I know there are side effects).  Keep going for more testing to find out where the cancer is located then get into the more high power stuff like chemo or SRT if your PSA does not continue to decline or level off.  Your PSA readings are still not off the chart yet so maybe try something, then monitor, then try the next most agressive treatment, ect, ect.  Don't know if they have perfected any of the immune type treatments where they modify the T cells to go kill the cancer cells.  Good time to start doing some homework!

Dave 3+4

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