My slight sense of optimism that I gained after my last consistent PSA result was shattered at four o’clock this morning when I hopped online in a fit of insomnia to check my PSA test results from this week. I’m back on the upward climb again with a PSA of 0.13 ng/ml.
My spiffy spreadsheet predicted a value of 0.129 ng/ml, so it wasn’t unexpected. Just my hope for a more stable PSA went out the window.
Obviously, I’ve got some serious thinking to do in the weeks ahead.
The predictive part of my spreadsheet shows the increase will continue at a rate of about 0.011 ng/ml every four months. In April, I would be at 0.140 and in August at 0.151. Is that rate slow enough to delay any decision about salvage radiation therapy a while longer? I don’t know.
Do I get involved with the imaging trial at UCLA to see if we can determine where the cancer is before undergoing salvage radiation therapy? I don’t know.
Or do I just say screw it and start the salvage radiation therapy in early 2019? I don’t know.
Stay tuned for the answers. That, or for pictures of ostriches with their heads buried in the sand.
Dan's Journey through Prostate Cancer 
Dan, I’m real sorry to hear about the rise, Even though, as you said it was not unexpected. Forgive me if I’m being repetitive I don’t know if I’ve mentioned it before but when I was debating whether to do salvage radiation and HORMONE therapy, I spoke with the radiation oncologist who both advised to act at .07 , once a clear trend was established, saying that recent studies show that earlier is better.
I feel your angst, at the thought of radiating a spot not knowing if that’s really the trouble spot. I had the same angst. In the end I decided I didn’t want to have to look back and say should’ve would’ve could’ve
FWIW, my list of 40 radiation treatments was on November 16th. My last shot of Lupron was November 20th. The side effects of hormone therapy, or annoying at worst. I’ve gained about 5 pounds, and I get the hot flashes and sweats, but they are mild short and manageable.
And the side effects of the radiation treatments were zero, zero, Nada. Maybe they are still to come, but right now I’m down south for the winter and enjoying every day, especially knowing I don’t have to do a PSA test until April or May.
Maybe my experience will help you in your struggle to make a decision I hope so, but I don’t have to tell you it’s a very personal decision that only you can make. Best of luck whatever you decide
Ken.
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Thanks, Ken. Having your insights is helpful and I’ll definitely include them in my thought process.
Dan
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Regarding side effects from radiation therapy, did you not have any urogenital side effects, for example decreases in erectile function? Feel free to email me if you do not want to post a response on this blog. wecanwinagain@gmail.com
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Bummer about the increase of your PSA. I had the same thing happen a year ago. It slowly started to creep up 4 years after surgery so a month before 5 years out I opted for radiation . I did salvage radiation and hormone therapy over the holidays last year. 33 days of radiation was not too bad. You get a warm blanket and any music you like while the machine does its thing. The hormone therapy sucks unless you already have no testosterone! I guess the ugly part is anticipating the next PSA in February. I always get edgy before I go in.
I don’t know about you, but after the recurrence I pretty much think about it sometime during every day. And I am truly a glass is half full guy. It just pops into my mind.
I wish you good luck on your next round!!
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Clark was your case PT2 tumor?
Negative margins?
Any bad outcome on your pathological report?
Thank you
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Hi Clark,
Thanks for sharing your experience. I definitely relate to the anxiety before each PSA test—it’s just part of the deal, I guess. I also hear you about cancer popping into your thoughts daily. It’s been the same for me, although I’ve gotten to the point where I do my level best not to dwell on it. It seems to be working for the last 4 months; these results will likely change that for a while to come.
Dan
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Not the same position as you (rising PSA after chemotherapy and on hormone treatment) but I don’t know either! Let your subconcious do all the work.
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Thanks, Tim. For the last four months since my previous PSA test, I’ve been pretty successful in doing just that.
Dan
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It’s clear you still have a good attitude, which is really helpful. The decision you’re facing has no clear best choice. Ultimately, I think you’re going to forced make it based on your gut feel.
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The consideration that argues for the imaging trial first is that you may find out where it is. If you go with “blind” irradiation, will they be able to tell early on if they got it, presumably by dropping PSA?
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I am concerned that you are clearly having a PSA spike, though modest in terms of actual amounts being in the hundredths column, but do not seem to be concerned about when you start SRT. Are you aware of the recent medical studies that state that better results are obtained from SRT when they are started sooner, as soon as the spike occurs, rather than later, for example at the arbitrary 0.2 level? You would be in the best possible sub-category — you have had years at zero PSA, and so can be assumed to have had full recovery of all functions, and are still at the beginning of the spike and not at the dreaded 0.2 level after which the beneficial effects of SRT decrease. I can try to send you the articles, though you likely have already seen them. I wish you the best of luck in this journey. You are not alone. Jim
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THIS LIST HAS BEEN EXPANDED. SECTION 1 ARE ARTICLES AUTHORED BY DR. KEVIN FORSYTHE A RADIATION ONCOLOGIST WORKING AT OREGON UROLOGY INSTITUTE IN EUGENE, OREGON. SECTION 2 ARE ARTICLES FROM VARIOUS AUTHORS WITH A NATIONAL SCOPE.
SECTION 1
• Sexual quality of life following prostate intensity modulated radiation therapy (IMRT) with a rectal/prostate spacer: Secondary analysis of a phase 3 trial.Hamstra, D. A., Hamstra, D. A., Mariados, N., Mariados, N., Sylvester, J., Sylvester, J., Shah, D., Shah, D., Gross, E., Gross, E., Hudes, R., Hudes, R., Beyer, D., Beyer, D., Kurtzman, S., Kurtzman, S., Bogart, J., Bogart, J., Hsi, R. A., Hsi, R. A., Kos, M., Kos, M., Ellis, R., Ellis, R., Logsdon, M., Logsdon, M., Zimberg, S., Zimberg, S., Forsythe, K., Forsythe, K., Zhang, H., Zhang, H., Soffen, E., Soffen, E., Francke, P., Francke, P., Mantz, C., Mantz, C., Rossi, P., Rossi, P., DeWeese, T., DeWeese, T., Daignault-Newton, S., Daignault-Newton, S., Fischer-Valuck, B. W., Fischer-Valuck, B. W., Chundury, A., Chundury, A., Gay, H. A., Gay, H. A., Bosch, W., Bosch, W., Michalski, J., Michalski, J.
• Continued Benefit to Rectal Separation for Prostate Radiation Therapy: Final Results of a Phase III Trial.Hamstra, D. A., Hamstra, D. A., Mariados, N., Mariados, N., Sylvester, J., Sylvester, J., Shah, D., Shah, D., Karsh, L., Karsh, L., Hudes, R., Hudes, R., Beyer, D., Beyer, D., Kurtzman, S., Kurtzman, S., Bogart, J., Bogart, J., Hsi, R. A., Hsi, R. A., Kos, M., Kos, M., Ellis, R., Ellis, R., Logsdon, M., Logsdon, M., Zimberg, S., Zimberg, S., Forsythe, K., Forsythe, K., Zhang, H., Zhang, H., Soffen, E., Soffen, E., Francke, P., Francke, P., Mantz, C., Mantz, C., Rossi, P., Rossi, P., DeWeese, T., DeWeese, T., Daignault-Newton, S., Daignault-Newton, S., Fischer-Valuck, B. W., Fischer-Valuck, B. W., Chundury, A., Chundury, A., Gay, H., Gay, H., Bosch, W., Bosch, W., Michalski, J., Michalski, J.
• Phase II Trial of Concurrent Sunitinib and Image-Guided Radiotherapy for Oligometastases.Tong, C. C., Ko, E. C., Sung, M. W., Cesaretti, J. A., Stock, R. G., Packer, S. H., Forsythe, K., Genden, E. M., Schwartz, M., Lau, K. H., Galsky, M., Ozao-Choy, J., Chen, S. H., Kao, J.
• Intensity-modulated radiotherapy causes fewer side effects than three-dimensional conformal radiotherapy when used in combination with brachytherapy for the treatment of prostate cancer.Forsythe, K., Blacksburg, S., Stone, N., Stock, R. G.
• Predictors of metastatic disease after prostate brachytherapy.Forsythe, K., Burri, R., Stone, N., Stock, R. G.
SECTION 2
(1) https://www.europeanurology.com/article/S0302-2838(16)00372-9/pdf
Mayo Clinic. “Few Side Effects Found From Radiation Treatment Given After Prostate Cancer Surgery.” ScienceDaily. ScienceDaily, 29 September 2009. http://www.sciencedaily.com/releases/2009/09/090928131212.htm
(2) https://www.europeanurology.com/article/S0302-2838(16)00372-9/pdf
Salvage Radiotherapy After Prostatectomy: Two Sides of the Coin
Spratt, Daniel E.
European Urology , November 2016, Volume 70, Issue 5 , 758 – 759
(3) https://www.health.harvard.edu/blog/new-study-recommends-immediate-radiation-when-psa-levels-spike-after-prostate-cancer-surgery-2016122910868
Immediate radiation when PSA levels spike after prostate cancer surgery helps reduce risk of recurrence
POSTED DECEMBER 29, 2016, 9:30 AM
Charlie Schmidt
Editor, Harvard Medical School Annual Report on Prostate Diseases
Following surgery to remove a cancerous prostate gland, some men experience a biochemical recurrence, meaning that prostate-specific antigen (PSA) has become detectable in their blood. Since only the prostate releases PSA, removing the gland should drop this protein to undetectable levels in the body. Detecting PSA could signify that prostate cancer cells are lingering, and forming new tumors before they can be seen with modern imaging technology. PSA isn’t always reliable for cancer screening, but it is a very sensitive marker of new cancer growth after initial treatment.
Doctors usually treat biochemical recurrence by irradiating the prostate bed, or the area where the gland used to be. Studies have shown that this treatment, which is called salvage radiation, helps to minimize the risk that prostate cancer will return and spread, or metastasize. But when to initiate salvage radiation has been open question, since PSA will also rise if small amounts of benign prostate tissue have been left behind after surgery. Many times, doctors don’t know if biochemical recurrence is really cancer, so they wait to see if the PSA levels will rise any further.
In October, researchers reported that giving salvage radiation as soon as PSA is detected could substantially reduce the risk of metastasis. “We found that early intervention with radiation could potentially improve cure rates,” said Rahul Tendulkar, M.D., a radiation oncologist at the Cleveland Clinic, and the study’s first author. “There’s no need to wait until PSA crosses an arbitrary threshold.”
Tendulkar and his colleagues combined nearly 2,500 post-surgical patients treated with salvage radiation at 10 different academic hospitals between 1987 and 2013. Of those men, 599 had cancers with a low risk of progression, while the others had higher-risk disease that was in some cases spreading into nearby tissues. Some of the men also had positive surgical margins, meaning that cancer cells might still be lurking next to where the prostate was removed.
According to their results, the incidence of metastases at five years following surgery was 9% among men given salvage radiation for PSA levels ranging from 0.01 to 0.2 nanograms per milliliter (ng/mL). By contrast, the metastasis incidence rate was 15% among men treated for PSA levels of 0.2 to 0.5 ng/mL. Both the American Urological Association and the American Society of Radiation Oncology recommend that salvage radiation be given when PSA levels reach or exceed 0.2 ng/mL. But Tendulkar says that level was defined years ago, before ultra-sensitive methods for detecting PSA became widely available.
“In this newer era of ultra-sensitive PSA testing we didn’t know if giving salvage radiation at lower levels would make a difference or not,” Tendulkar said. “Now we know that it does.”
Tendulkar says the decision to initiate salvage radiation can also be influenced by other factors, such as age, other health problems, and the aggressiveness of the cancer he was diagnosed with.
In an accompanying editorial, Paul Nguyen, M.D., a radiation oncologist at Dana Farber Cancer Institute, in Boston, MA, and an associate professor at Harvard Medical School, wrote that Tendulkar’s study “will become the gold standard” for men considering salvage radiation after surgical treatment for prostate cancer.
But the study doesn’t address an important question: Should men with high-risk cancer consider getting radiation after surgery even before PSA increases are detected? Studies designed to answer that question are now ongoing.
“This important study provides some much needed guidance that comports with my own clinical experience,” said Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org. “Patients should be aware that complications such as erectile problems and urinary side effects will likely worsen with salvage radiation.”
(4) https://www.oncologynurseadvisor.com/prostate-cancer/adjuvant-radiotherapy-superior-to-early-salvage-rt-in-prostate-cancer/article/741041/
Hwang WL, Tendulkar RD, Niemierko A, et al. Comparison between adjuvant and early-salvage postprostatectomy radiotherapy for prostate cancer with adverse pathological features [published online January 25, 2018]. JAMA Oncol. doi: 10.1001/jamaoncol.2017.5230 February 01, 2018
Adjuvant Radiotherapy Found Superior to Early-Salvage RT in Prostate Cancer
Fears of recurrence following treatment have led to decreased implementation of postoperative ART.
Adjuvant radiotherapy (ART) may lead to improved clinical outcomes among patients with prostate cancer postprostatectomy compared with early-salvage radiotherapy (ESRT), according to a study published in JAMA Oncology.
Current guidelines recommend postoperative ART for high-risk patients with prostate cancer, but fears of recurrence after treatment have led to decreased implementation of the therapy. Retrospective data have shown that ESRT delivery when prostate-specific antigen (PSA) levels become detectable may lead to effective long-term disease control in this patient population.
For this propensity score-matched cohort study, researchers assessed the outcomes of 1566 patients with prostate cancer who underwent ART or ESRT after prostatectomy. The researchers defined ART as radiation therapy administered to patients with undetectable PSA levels, and ESRT as radiation therapy delivered to patients with PSA levels between 0.1 and 0.5 ng/mL. Patients were ineligible for the study if they had nodal involvement or received androgen deprivation therapy prior to surgery.
Of the study patients, 1195 patient underwent ESRT and 371 patients underwent ART. The median follow-up was similar between both study arms (73.3 months and 65.8 months, respectively).
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• GUCS 2017: Adjuvant Trials in Post-radical Prostatectomy Prostate Cancer Feasible
After propensity-score matching, results showed that patients who received ART experienced improvements in freedom from biochemical failure, freedom from distant metastases, and overall survival compared with ESRT.
The authors concluded that “these findings suggest that a greater proportion of patients with prostate cancer who have adverse pathological features may benefit from postprostatectomy ART rather than surveillance followed by ESRT,” but also noted that these findings require further prospective validation.
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