Adjuvant radiation after RP -- what's the best strategy?

[Guest guest]

I had robotic surgery done three months ago and following surgery I was staged pT3a (everything negative except extracapsular extension present). Now that 3 months have passed, I am now faced with the difficult decision if/when to perform radiation treatment (adjuvant RT). The SWOG study, last updated in 2009, seems to be the standard of care for post-surgery adjuvant radiation (see http://www.aboutcancer.com/prostate_T3_0609.htm) and based on this study, a 20% improvement in the recurrence rate was seen when radiation was initiated 3 months after surgery.However, questions remain – ultrasensitive PSA measurement did not exist when the original SWOG study began. Would a more appropriate strategy today for initiating radiation therapy following surgery would be when a rise in PSA is seen but at a much lower measureable PSA level, such as waiting until PSA rises to 0.02, rather than radiating at 3 months even with an undectable (<0.01) PSA? This would prevent unnecessary radiation of some fraction of patients who's cancer was cured with surgery alone. The question, of course, is whether radiation is equally effective when radiating at 0.02 PSA (which could be several years after surgery!) as it is at 3 months after surgery. Have any studies been done or is there any supporting evidence for such a strategy? I need to make a decision and at this moment, after seeing two different well-respected radiation oncologists, the opinion is divided between them.Here are my stats:Pre-surgery: PSA = 4.9 Gleason 7 (3+4) 6/12 cores positive, all on R lobe, 30%/80%/90% involvement Palpable tumor on DRE Extracapsular extension evident on endorectal MRIPost-surgery: Seminal vesicles and lymph nodes negative (9 excised) Negative surgical margins Tumor extended from the apex to the base of the gland Established extraprostatic extension present in the right para-apex, right mid and right para-basal areas of the gland Additional foci of prostatic adenocarcinoma, Gleason score 4+5=9 and 3+3=6 are present in the right and left base, respectively Gleason 7 (4+3), tertiary pattern Grade 5 Perineural invasion present Any help or advice much appreciated! --- Rich

[Guest guest]

The approach my Urologists and Oncologists

took was to wait until I was healed from surgery completely before starting any

radiation treatments. For me that was closer to 6 months than three.

My surgeon gave me the ok at 4 months but the radiation Oncologist wanted to

wait until I was completely continent before starting anything. The

primary reason was radiation can affect your ability to control your urine.

Your best bet is to make sure you are in the best state before starting the

radiation. My Oncologist also recommended hormone therapy for 12 –

24 months after radiation to improve its chances for success. I remember

it was part of a study but I don’t remember which one. Since I had

positive margins it they new I still had cancer and I have been taking an aggressive

approach towards it. If you are unsure if you still have cancer then I

would monitor it closely and take quick and aggressive action at the first sign

of an increase in a PSA. Remember this will be your last chance at a

cure. Once it escapes the pelvic bed you and only manage it.

From: ProstateCancerSupport [mailto:ProstateCancerSupport ] On Behalf Of Rich Assarabowski

Sent: Thursday, July 14, 2011 7:59

PM

To: ProstateCancerSupport

Subject:

Adjuvant radiation after RP -- what's the best strategy?

I had

robotic surgery done three months ago and following surgery I was staged

pT3a (everything negative except extracapsular extension

present). Now that 3 months have passed, I am now faced with the

difficult decision if/when to perform radiation treatment (adjuvant

RT). The SWOG study, last updated in 2009, seems to be the standard

of care for post-surgery adjuvant radiation (see http://www.aboutcancer.com/prostate_T3_0609.htm)

and based on this study, a 20% improvement in the recurrence rate was seen when

radiation was initiated 3 months after surgery.

However,

questions remain – ultrasensitive PSA measurement did not exist when the

original SWOG study began. Would a more appropriate strategy today for

initiating radiation therapy following surgery would be when a rise in PSA is

seen but at a much lower measureable PSA level, such as waiting until PSA rises to 0.02, rather

than radiating at 3 months even with an undectable (<0.01) PSA?

This would prevent unnecessary radiation of some fraction of patients who's

cancer was cured with surgery alone. The question, of course, is

whether radiation is equally effective when radiating at 0.02 PSA (which could

be several years after surgery!) as it is at 3 months after surgery.

Have any

studies been done or is there any supporting evidence for such a strategy?

I need to make a decision and at this moment, after seeing

two different well-respected radiation oncologists, the opinion is divided

between them.

Here are

my stats:

Pre-surgery:

PSA = 4.9

Gleason 7 (3+4)

6/12 cores positive, all on R lobe, 30%/80%/90% involvement

Palpable tumor on DRE

Extracapsular extension evident on endorectal MRI

Post-surgery:

Seminal vesicles and lymph nodes negative (9 excised)

Negative surgical margins

Tumor extended from the apex to the base of the gland

Established extraprostatic extension present in the right para-apex, right mid

and right para-basal areas of the gland

Additional foci of prostatic adenocarcinoma, Gleason score 4+5=9 and 3+3=6 are

present in the right and left base, respectively

Gleason 7 (4+3), tertiary pattern Grade 5

Perineural invasion present

Any help

or advice much appreciated!

--- Rich

[Guest guest]

Rich Assarabowski

>

> I had robotic surgery done three months ago and following

> surgery I was staged pT3a  (everything negative except

> extracapsular extension present).   Now that 3 months have

> passed, I am now faced with the difficult decision if/when to

> perform radiation treatment (adjuvant RT).   The SWOG study,

> last updated in 2009, seems to be the standard of care for

> post-surgery adjuvant radiation (see

> http://www.aboutcancer.com/prostate_T3_0609.htm) and based on

> this study, a 20% improvement in the recurrence rate was seen

> when radiation was initiated 3 months after surgery.

Rich,

I haven't seen any more current studies and I hesitate to offer

any advice at all.  If the experts don't know what to do, who am

I, a guy with no expertise whatsoever, to offer advice?

I think the best I can do is comment on the article that you

cited.  In my reading of it I found the last paragraph very

persuasive.  It explained the case for adjuvant radiation

and laid out a number of factors to consider in making the

decision.  The factors were:

The case for treatment is that three important trials support it

whereas there is only " faith, not data " to support the view that

waiting for a PSA rise using ultrasensitive testing will provide

equivalent results.

The factors to consider were:

  1. Patient risk of metastasis.

     Your pre-oparative PSA was low but you had some very high

     risk, i.e., high Gleason score, cancer on one side and

     intermediate risk on the other.

  2. Patient risks due to radiation.

     " Irritable bowel, bladder neck contracture, and urinary

     incontinence " are possible reasons for waiting.

I presume that you can get a PSA test now, three months post-op.

If the PSA is detectable, it's not a no-brainer but the case for

getting radiation becomes pretty strong.  If the PSA is

undetectable, then you've got to make the tough decision.

Clearly, there are a lot of personal, psychological factors

involved.  Even if the statistics on risk were absolutely

perfectly accurate, they still don't tell you what to do.

Knowing that there is a 20% improvement in outcomes doesn't tell

you which side of the 20% you are on.

If it were me, I just might make the decision based on how much

confidence I had in the radiation oncologist who would do the

treatment.  Does he or she seem careful, smart, honest,

experienced?  Do you think he is going to really do the best job

he can of optimizing the dose and aiming the beams both to kill

any cancer and to protect sensitive areas?  If the doc doesn't

pass muster can you find a better one who will?

For me, I also think I'd be more inclined to maximize opportunity

to cure the cancer rather than minimize the danger of side

effects.  But then a lot would depend on how much risk of side

effects there were.  We have a number (about 20%) for the amount

of extra opportunity we get, but no number for the side effect

risk.  A good and honest rad onc may be able to help you with

some explanation of the nature and risks of side effects he's

seen.

Best of luck, and do keep us informed about your situation.

    Alan

[Guest guest]

Rich, the conundrums just keep coming, don't they? THe SWOG study you cite is an excellent one and it should have changed the standard of care, though doctors follow their own standards, or none at all. It showed that the disease in such men remained loco-regional for some time and was amenable to radiation. You are correct that the accuracy of psa assay may have been less in those days. It is also true that the development of radiation and the knowledge of other salient treatment issues has advanced dramatically since then also. I think that the RT improvement easily surpasses the psa improvement. Myers used to comment occasionally here and 3-4 years ago he commented on this very study and its value. It is in the archives somewhere. The point of healing is a good one. If it takes more than 90 days to recover from surgery then radiation should wait, in my opinion. Being a slave to the study protocol is no good now that the study is complete.Any G4 or 5 is of concern. In most cases the G score trumps other issues. It has proven so often to be the controlling factor. In sum I think that radiation is a likely event for most men with your statistics and RT sooner than later is to be considered. Even without the EPE many surgeons would have said to consider adjuvant radiation. Healing and recovery of all function are foremost at this time. Within the context of this disease your surgeon did as well as possible and I think you have a long and fruitful life ahead of you. You do not mention your age at treatment, at least in this post. I had robotic surgery done three months ago and following surgery I was staged pT3a (everything negative except extracapsular extension present). Now that 3 months have passed, I am now faced with the difficult decision if/when to perform radiation treatment (adjuvant RT). The SWOG study, last updated in 2009, seems to be the standard of care for post-surgery adjuvant radiation (see http://www.aboutcancer.com/prostate_T3_0609.htm) and based on this study, a 20% improvement in the recurrence rate was seen when radiation was initiated 3 months after surgery.However, questions remain – ultrasensitive PSA measurement did not exist when the original SWOG study began. Would a more appropriate strategy today for initiating radiation therapy following surgery would be when a rise in PSA is seen but at a much lower measureable PSA level, such as waiting until PSA rises to 0.02, rather than radiating at 3 months even with an undectable (<0.01) PSA? This would prevent unnecessary radiation of some fraction of patients who's cancer was cured with surgery alone. The question, of course, is whether radiation is equally effective when radiating at 0.02 PSA (which could be several years after surgery!) as it is at 3 months after surgery. Have any studies been done or is there any supporting evidence for such a strategy? I need to make a decision and at this moment, after seeing two different well-respected radiation oncologists, the opinion is divided between them.Here are my stats:Pre-surgery: PSA = 4.9 Gleason 7 (3+4) 6/12 cores positive, all on R lobe, 30%/80%/90% involvement Palpable tumor on DRE Extracapsular extension evident on endorectal MRIPost-surgery: Seminal vesicles and lymph nodes negative (9 excised) Negative surgical margins Tumor extended from the apex to the base of the gland Established extraprostatic extension present in the right para-apex, right mid and right para-basal areas of the gland Additional foci of prostatic adenocarcinoma, Gleason score 4+5=9 and 3+3=6 are present in the right and left base, respectively Gleason 7 (4+3), tertiary pattern Grade 5 Perineural invasion present Any help or advice much appreciated! --- Rich

[Guest guest]

Thanks to all for the comments. I forgot to mention in my original post that my first post-surgery PSA was measured at 0.01, 6 weeks after surgery. According to the nurse at the doctor's office, the lowest values that are possible (at their facility anyway) are either 0.008 or 0.01 which they consider undetectable. I have my second PSA on Monday (12 weeks after surgery) and a third one at 18 weeks after surgery. Anything more than undectable would certainly give me good reason to proceed with radiation, with or without ADT. I have an appointment with my surgeon on August 18 to discuss what to do next. Other info – I’m 59 years old and in good health, on a cardio diet and taking several supplements (pomegranate, Indole-3-Carbinol, curcumin, D3). At 8 weeks I was down to 1 pad/day and now at 12 weeks I’m still wearing a pad, but with only occasional drips,mostly stress-related. I wear a pad about ½ the time. --- RichRich Assarabowski > > I had robotic surgery done three months ago and following> surgery I was staged pT3a (everything negative except> extracapsular extension present). Now that 3 months have> passed, I am now faced with the difficult decision if/when to> perform radiation treatment (adjuvant RT). The SWOG study,> last updated in 2009, seems to be the standard of care for> post-surgery adjuvant radiation (see> http://www.aboutcancer.com/prostate_T3_0609.htm) and based on> this study, a 20% improvement in the recurrence rate was seen> when radiation was initiated 3 months after surgery.

[Guest guest]

PMFJI --

You say:

>>>

> Negative surgical margins

>

<<<

Doesn't that mean that all the cancerous tissue was removed by the surgeon?

Is the " extracapsular extension " not connected to the original prostate-based

cancer?

>

> I had robotic surgery done three months ago and following surgery I was

> staged pT3a (everything negative except extracapsular extension present).

> Now that 3 months have passed, I am now faced with the difficult decision

> if/when to perform radiation treatment (adjuvant RT). The SWOG study, last

> updated in 2009, seems to be the standard of care for post-surgery adjuvant

> radiation (see http://www.aboutcancer.com/prostate_T3_0609.htm) and based on

> this study, a 20% improvement in the recurrence rate was seen when radiation

> was initiated 3 months after surgery.

>

> However, questions remain - ultrasensitive PSA measurement did not exist

> when the original SWOG study began. Would a more appropriate strategy today

> for initiating radiation therapy following surgery would be when a rise in

> PSA is seen but at a much lower measureable PSA level, such as waiting until

> PSA rises to 0.02, rather than radiating at 3 months even with an undectable

> (<0.01) PSA? This would prevent unnecessary radiation of some fraction of

> patients who's cancer was cured with surgery alone. The question, of

> course, is whether radiation is equally effective when radiating at 0.02 PSA

> (which could be several years after surgery!) as it is at 3 months after

> surgery.

>

> Have any studies been done or is there any supporting evidence for such a

> strategy? I need to make a decision and at this moment, after seeing two

> different well-respected radiation oncologists, the opinion is divided

> between them.

>

> Here are my stats:

>

> Pre-surgery:

> PSA = 4.9

> Gleason 7 (3+4)

> 6/12 cores positive, all on R lobe, 30%/80%/90% involvement

> Palpable tumor on DRE

> Extracapsular extension evident on endorectal MRI

>

> Post-surgery:

> Seminal vesicles and lymph nodes negative (9 excised)

>

> Negative surgical margins

>

> Tumor extended from the apex to the base of the gland

>

> Established extraprostatic extension present in the right para-apex,

> right mid and right para-basal areas of the gland

>

> Additional foci of prostatic adenocarcinoma, Gleason score 4+5=9 and

> 3+3=6 are present in the right and left base, respectively

>

> Gleason 7 (4+3), tertiary pattern Grade 5

> Perineural invasion present

>

>

>

> Any help or advice much appreciated!

>

>

>

> --- Rich

>

[Guest guest]

Negative surgical margins = No evidence of cancer calls at the boundary of the cut à Nothing left behind by the surgeonExtracapsular extension = Evidence of cancer cells on the surface of the prostate à Cancer cells penetrated the capsule and may be still present in the body, even though the surgeon achieved negative surgical marginsPMFJI --You say:>>>> Negative surgical margins> <<<Doesn't that mean that all the cancerous tissue was removed by the surgeon?Is the " extracapsular extension " not connected to the original prostate-based cancer?>> I had robotic surgery done three months ago and following surgery I was> staged pT3a (everything negative except extracapsular extension present).> Now that 3 months have passed, I am now faced with the difficult decision> if/when to perform radiation treatment (adjuvant RT). The SWOG study, last> updated in 2009, seems to be the standard of care for post-surgery adjuvant> radiation (see http://www.aboutcancer.com/prostate_T3_0609.htm) and based on> this study, a 20% improvement in the recurrence rate was seen when radiation> was initiated 3 months after surgery.> > However, questions remain - ultrasensitive PSA measurement did not exist> when the original SWOG study began. Would a more appropriate strategy today> for initiating radiation therapy following surgery would be when a rise in> PSA is seen but at a much lower measureable PSA level, such as waiting until> PSA rises to 0.02, rather than radiating at 3 months even with an undectable> (<0.01) PSA? This would prevent unnecessary radiation of some fraction of> patients who's cancer was cured with surgery alone. The question, of> course, is whether radiation is equally effective when radiating at 0.02 PSA> (which could be several years after surgery!) as it is at 3 months after> surgery. > > Have any studies been done or is there any supporting evidence for such a> strategy? I need to make a decision and at this moment, after seeing two> different well-respected radiation oncologists, the opinion is divided> between them.> > Here are my stats:> > Pre-surgery:> PSA = 4.9> Gleason 7 (3+4)> 6/12 cores positive, all on R lobe, 30%/80%/90% involvement> Palpable tumor on DRE> Extracapsular extension evident on endorectal MRI> > Post-surgery:> Seminal vesicles and lymph nodes negative (9 excised)> > Negative surgical margins> > Tumor extended from the apex to the base of the gland> > Established extraprostatic extension present in the right para-apex,> right mid and right para-basal areas of the gland> > Additional foci of prostatic adenocarcinoma, Gleason score 4+5=9 and> 3+3=6 are present in the right and left base, respectively> > Gleason 7 (4+3), tertiary pattern Grade 5> Perineural invasion present> > > > Any help or advice much appreciated!> > > > --- Rich>

[Guest guest]

Rody

Wrote:Chuck I went the 14th for my consultation regarding my

Bone Scan, CT Scan. You will remember that I had suegery in 2008 with removal of

the Prostate. Pathologist showed 50% involvement but as he says was contained. What my new Urologist didn't know, and it was not in notes was the fact

that Dr. Amling after the surgery mentioned too me that there was a

" spot " away from the gland that he could not get to with the Robot. This was not mentioned in the UAB computer, nor final written report. I

went with fear to hear the worse news that it had matasized into the pelvic

region or just where ever. The Bone scan was Negative as were the CT scan. Lungs like a baby as I had stopped smoking thirty-five years ago. It had

been two years since my last PSA as I was to scared to see the

Urologist. So again in twenty four months my PSA went from 1.9 too 3.7

which was a 1.8 rise in those months. I did ask him why do I have such a

high reading without my Prostate? He said, that is a good question. He

explained different reasons, that yes tissue missed from the Robot. I go back in

three months for another review and he explained the Hormone treatment that does

not treat cancer but blocks Tetrestrone (sp). I will be on that for a time and

then get off for awhile. Some of the things I hear from

other members is Greek to me even though I have read everything I can get my

hands on. The lady that mentioned to me that I was probably ate up all over has

not spoken to me when I mentioned on Facebook that if the disease has matasized

there is no cure, Zero cure. That I heard from my Urologist also. He also said

Radiation will be discussed futher but not before the results of the Hormone

theraphy. He said he will get my PSA down to where it was after surgery in 2008

to a respectable 0.1. Is this Dr. Dreaming or is this possible. Just one other thing in 1999 when I was living in another city and

one of my friends that I graduated Gadsden High from was my primary physician. In 1999 my PSA was 2.2. That was my first test ever and I was fifty-one as I had

just retired from Delta Airlines. So you can see it took a few years for my PSA

to start the rise from 2.2 in 1999 to 8.4 in 2008. could the spot the other

Urologist told me that he could not get to have any thing to do with my PSA

count. I would think not; but what do I know? He did

find one vertabrae with deteriation (sp). And some bone loss below my knee

which I have delayed havng surgry on, for about one year. Just ligament

damage and Maniscus. That is about all I have to say and if you have something I

need to ask my Urologist in three monthds please give me a hint. Thanks for your time,RodyPS: FYI. My daughter works at UAB and worked

with the head of Cardiologist. He was on a treadmill three days ago and fell out

" DEAD " . Heart exploded. She also worked with Dr. Janic (sp) who

has patent on the stint, and helped him set up office at St. ph in New York. He is presently in Hole, Wy. By the way, the Cardiologist was 47. I

do not worry about death as there is not anyway to miss it. There has not been

but a few 's to die prematurely. Dad was 91 (never been sick) Mom was 86. About Dr. Janic,. My daughter did see a check for $500.000 from a surgical

company that makes the stint. A nice thank you jestor. There is one place you will not find an " Atheist " . That

place is in a FoxHoledefending his country, or

life....BilRite...4-14-08Someone asked the bear once

would you like to donate $10.00 to help bury a sportswriter. The Bear said here

is a twenty bury two....Quoting C

: PMFJI --You

say:>>>> Negative surgical margins> <<<Doesn't that mean that all the cancerous tissue was

removed by the surgeon?Is the " extracapsular extension "

not connected to the original prostate-based cancer?>> I had

robotic surgery done three months ago and following surgery I was>

staged pT3a (everything negative except extracapsular extension present).> Now that 3 months have passed, I am now faced with the difficult

decision> if/when to perform radiation treatment (adjuvant RT). The

SWOG study, last> updated in 2009, seems to be the standard of care for

post-surgery adjuvant> radiation (see http://www.aboutcancer.com/prostate_T3_0609.htm) and based

on> this study, a 20% improvement in the recurrence rate was seen when

radiation> was initiated 3 months after surgery.> >

However, questions remain - ultrasensitive PSA measurement did not exist> when the original SWOG study began. Would a more appropriate strategy

today> for initiating radiation therapy following surgery would be when

a rise in> PSA is seen but at a much lower measureable PSA level, such

as waiting until> PSA rises to 0.02, rather than radiating at 3 months

even with an undectable> (<0.01) PSA? This would prevent unnecessary

radiation of some fraction of> patients who's cancer was cured with

surgery alone. The question, of> course, is whether radiation is

equally effective when radiating at 0.02 PSA> (which could be several

years after surgery!) as it is at 3 months after> surgery. >

> Have any studies been done or is there any supporting evidence for

such a> strategy? I need to make a decision and at this moment, after

seeing two> different well-respected radiation oncologists, the opinion

is divided> between them.> > Here are my stats:> > Pre-surgery:> PSA = 4.9> Gleason 7 (3+4)> 6/12 cores positive, all on R lobe, 30%/80%/90% involvement>

Palpable tumor on DRE> Extracapsular extension evident on endorectal

MRI> > Post-surgery:> Seminal vesicles and lymph

nodes negative (9 excised)> > Negative surgical margins> > Tumor extended from the apex to the base of the gland> > Established extraprostatic extension present in the right

para-apex,> right mid and right para-basal areas of the gland>

> Additional foci of prostatic adenocarcinoma, Gleason score 4+5=9

and> 3+3=6 are present in the right and left base, respectively> > Gleason 7 (4+3), tertiary pattern Grade 5> Perineural

invasion present> > > > Any help or advice

much appreciated!> > > > --- Rich>

[Guest guest]

C wrote:

> PMFJI --

>

> You say:

>

>>>>

>>     Negative surgical margins

>>

> <<<

>

> Doesn't that mean that all the cancerous tissue was removed by the surgeon?

>

> Is the " extracapsular extension " not connected to the original

> prostate-based cancer?

That's a question I wondered about too.

What I imagined to be the answer, but don't know if it is, is

that the surgeon saw the tumor poking beyond the prostate wall

and cut it out with the rest of the prostate.  If so, then the

margins would still be negative if he managed to cut out a bit of

tissue all around the tumor and no tumor cells were found in that

" margin " tissue during the post-op examination.

However if someone can shed more light on this, I'd be very

interested in understanding it better.

I've also always wondered about the accuracy of the treatments we

receive.  A surgeon must excise every bit of cancerous tissue that

he can reach, also examining seminal vesicles and lymph nodes,

and cut as little non-cancerous tissue as possible.  A radiation

oncologist must determine the dosage and treatment pattern and

aim the beams or plant the seeds in just the right spots to kill

the cancer and leave the healthy tissue alone.  The post-op

pathologist must examine many slices of the prostate and go over

the entire surface of the extracted tissue with a microscope to

properly characterize the disease.

I would think that a little sloppiness, a little inattention, a

little hurriedness to finish in time for lunch, could make a

difference in the long run between life and painful death for the

patient.

That's one of the reasons that I want a doctor who impresses me

as a trustworthy and dedicated human being.

    Alan