Yet another study shows importance of not dallying before salvage radiation

 Getting started early with salvage radiation improves the odds of success, yet another study shows. In this study, an important PSA cutpoint was shown to be 0.25 ng/ml:

"In a study reported in the Journal of Clinical Oncology, Derya Tilki, MD, and colleagues identified a prostate-specific antigen (PSA) level cutpoint, above which initiation of salvage radiation therapy after radical prostatectomy was associated with an increased risk of all-cause mortality in patients with prostate cancer."  Source: The ASCO Post, March 7, 2023. https://ascopost.com/news/march-2023/psa-level-at-time-of-salvage-radiation-therapy-after-radical-prostatectomy-and-risk-of-all-cause-mortality/

In my case, because my urologist wasn't watching me like a hawk, and because Christmas and New Year's hit at the time I was trying to make appointments, I started SRT much later than 0.25.  I was fortunate that it still worked, and apparently cured my cancer.

16 years after salvage radiation, my PSA...

Just had a PSA done--still less than 0.10.  I had been frantic a couple of years ago when I had two ultrasensitive tests done just over a year apart. The first one showed .02, and was the first PSA that was "detectable" since salvage radiation did its job in 2007. Then in 2021 I had another ultrasensitive test. It was 0.05, or more than double.  I went to a prostate cancer oncologist, who reassured me that it was probably nothing. He said he didn't order ultrasensitive tests for people like me (post-surgery, post-radiation). So we've gone with the regular assay.

If my PSA had really been rising at the rate it seemed to on the ultrasensitive test, I would have easily passed the 0.1 mark on the standard assay by now. The fact that it did not is quite reassuring.  I've now had multiple standard PSA tests, all "less than 0.1".  No threat.

Lymphoma, treatment for lymphoma, or more likely, my heart, is the real threat to making it as long as my parents have. Both parents are alive and well, in the 80s and 90s.  My grandmother is over 105! 

Anyway, that's it for now.  

Latest Salvage Radiation News

 Some recent discoveries in salvage radiation

Early salvage RT after prostatectomy improves outcomes: https://www.cancertherapyadvisor.com/home/news/conference-coverage/american-society-of-clinical-oncology-genitourinary-asco-gu/asco-gu-2022/early-salvage-radiation-after-surgery-improves-mfs-in-recurrent-prostate-cancer/  (Research continues to confirm that earlier is better if you need SRT.)

When to Add ADT to Early or Late Salvage Radiation: https://www.urotoday.com/video-lectures/prostate-cancer-genomic-classifier/video/2269-when-to-add-adt-to-early-or-late-salvage-radiation-dan-spratt.html (I didn't have ADT, otherwise known as hormone therapy, but in higher-risk cases it makes sense)

Salvage Radiotherapy versus Observation for Biochemical Recurrence: https://pubmed.ncbi.nlm.nih.gov/35159007/. (Salvage radiation was associated with better long-term survival, both in terms of being free of metastatic disease and overall survival.)

Salvage Radiation Nomogram Updated

This is exciting stuff for people contemplating salvage radiation after prostatectomy.

https://consultqd.clevelandclinic.org/2015/10/updated-nomogram-predicts-modern-outcomes-after-salvage-radiotherapy-following-radical-prostatectomy/

"A contemporary update of a 2007 predictive nomogram for salvage radiotherapy after radical prostatectomy offers a modernized forecast of cure compared to its predecessor."

"The updated 2016 nomogram takes into account the more recent trend of treating patients at lower PSA levels than in the past (“early SRT”). Randomized trials published since the original nomogram was created have demonstrated the benefit of early SRT in high-risk patients."

Various things on my mind..

It's Halloween. Here's hoping you have more treats than tricks this year.

My PSA 9 years, one month after salvage radiation (SRT) ended, is still less than 0.1.  I had an employer health screen earlier this month and checked it.

In the meantime, I have developed heart palpitations (preventricular contractions), a murmur (mitral valve prolapse) and right bundle branch block. None of these are currently dangerous in my case, according to my cardiologist, but they have my attention.  They're a reminder that despite apparently beating prostate cancer, I'm still mortal, still in late middle age, and one day the Reaper will come mowing for me.

Here's a question that I once asked, and I see asked all the time on discussion boards like HealingWell and CancerForums.net:

"I had a prostatectomy x years ago, and now my PSA is rising.  It's at 0.4, up from 0.1 a few months ago.  Should I get radiation? I hear there's only a 50/50 chance it will work."

Well, how old are you?  That's a key question.  If you're 85, you may well want to skip radiation, see how your PSA tracks, and look into hormone therapy if things progress far enough.  If you're 45, I would run, not walk, to the best radiation oncologist I could find.  The reason is that if you're young enough for prostate cancer to progress and kill you, you need to pursue a cure.  Hormone therapy (ADT) won't cure you. If you're elderly, it might be as good as a cure, but if you're young, it's only going to--maybe--stall the cancer.  A 50/50 chance?  It's more nuanced than that, if you want to look into nomograms. Most people don't.  When you get prostate cancer under 50, your youth is a double-edged sword. You will heal faster from treatment, but you have decades for it to come back and...BOO! get you. 

These days, compared to when I was treated, there is a chance you can locate mets with a sensitive scan, and attack those spots specifically. But your PSA has to advance significantly first, and the higher your PSA before salvage radiation, the lower your chances for success (google Andrew Stephenson and salvage radiation outcome).  

Sometimes a layperson or even a doctor will advise the patient that they can wait until PSA gets to something like 2.0 ng/ml.  But that's not wise.  (Again, look up what Andrew Stephenson at Cleveland Clinic found out in long-range studies).  

So if you're a young guy, say, 50 or younger, and you are diagnosed with prostate cancer, my nonprofessional advice to you is to strongly consider a treatment with a known track record, like surgery.  It seems to have a slight edge in long term success for younger patients--less so with older ones.  And, youngster, if your PSA starts climbing after surgery, look into salvage radiation and don't delay. 

If you've had a prostatectomy, salvage radiation is probably going to be a walk in the park. So don't get overly anxious about it. It's a painless, easy treatment. If you have side effects, they'll probably be mild and temporary.  There's no guarantee it will work, but let's say your chances are 50/50.  Isn't that better than zero?  With any luck, you'll be like me, looking forward to some spectacular cardiopulmonary event to shuffle off the mortal coil.

Cue Haunted Mansion music.  (It's Halloween, after all).

My PSA remains less than 0.1.
It was 8 years ago now that I was going to the hospital every morning, Monday through Friday, and laying down while the invisible X-rays did their magic. It was hard to believe something was actually happening to the cancer cells deep inside. But it was!  It was!

My History of Prostate Cancer.

A long time ago, in a pelvis far, far away:




Age 38
8 Dec 2000
bothered by frequent urination, went to primary care phys.
PSA 4.5
PCP said prostate was boggy
referred to Urologist
Biopsy Ordered

Jan 2001
Biopsy:  negative for cancer, findings consistent with prostatitis

Age 39
16 Jul 2001
PSA 4.1

20 March 2002
PSA 6.1
START Cipro 500mg daily for 3 wks, Motrin 800 mg daily

Age 40
30 May 2002
PSA 5.7
Free PSA 11.9%
CONTINUE Motrin
Urologist believes probably prostatitis

30 Sep 2002
PSA 7.3
Free PSA 11.3%
START Avodart
STOP Motrin
ORDER Biopsy

November 2002
Biopsy:  negative for cancer, but PIN III found

31 Jan 2003
PSA 2.2
Stop Avodart

Age 41
03 Sep 2003
PSA 4.9
Restart Avodart

23 Jan 2004
PSA 2.2
Continue Avodart

Age 42
24 July 2004
PSA 2.5
Continue Avodart

26 Jan 2005
PSA 3.3
Continue Avodart

29 Apr 2005
PSA 2.9
Continue Avodart

Age 43
11 Jan 2006
PSA 4.8 (on Avodart)
Abnormal DRE
Biopsy ordered

7 Feb 2006
Biopsy finds cancer
PIN also found
No perineural invasion
Gleason 3+4
20% on right
5% on left

Age 44
14 April 2006
SURGERY
Robotic prostatectomy
Positive margin at apex and left lobe
No perineural invasion identified
Extension into capsule, but not through
Gleason 3+4
70% of gland involved
stage t2c NX MX


16 May 2006
PSA less than 0.1

15 Aug 2006
PSA 0.2

14 Dec 2006
PSA 0.6

REFERRED FOR RADIATION

Day before radiation commenced, PSA = 0.7

Radiation Jan-Mar 2007.  PSA quickly fell to less than 0.1 and remains there as of early 2013, now age 51.
No side effects from radiation at this point.

Blood draw today

Had blood drawn for PSA (and cholesterol) today, which coincidentally is the 6th anniversary of the start of my salvage radiation.  Probably get the results by the end of the month.  Not nearly as nervous as I have been in the past.

Patrick Walsh

I checked out the 2007 edition of Dr. Patrick Walsh's Guide to Surviving Prostate Cancer, co-written with Janet Farrar Worthington. This is an excellent, very accessible text and I highly recommend it. My only quibble is that while Walsh revised the section on salvage radiation to include a statement by Danny Song of Johns Hopkins:"Even men with Gleason 8-10 disease, if they had positive margins, a longer PSA doubling time, and received early salvage radiation, were able to attain four-year control rates of 81%," Walsh still ends the chapter with a large, bolded box that says if you have ANY of these things--Gleason 8 or higher, positive seminal vesicles/lymph nodes, PSA recurrence within a year--you're not likely to benefit from radiation! Not only does Walsh contradict Song's statement, but he ignores some landmark 2004 and later research by Andrew Stephenson that shows even if you have a high risk factor like a high Gleason OR fast PSA doubling time, it is very likely you will benefit from radiation as long as it is started before your PSA gets too high.

I'll get blood drawn in the next week or two for my 9 month post-salvage PSA test. I'll go see the doc in early January.

An encouraging article

"The PSA disease-free survival after salvage radiation for all patients is approximately 25-40% at five-to-ten years after radiation.7,8 Favorable patients (PSA less than 2.0, Gleason score less than 8, positive surgical margins) may experience PSA diseasefree survivals of 60-70%.8"

Sailer, Scott L. "Radiation Therapy for Prostate Cancer: External Beam, Brachytherapy, and Salvage" North Carolina Medical Journal. March-April 2006, p. 152. http://www.ncmedicaljournal.com/mar-apr-06/Sailer.pdf

Since I'm in the "favorable patients" category (PSA 0.7, Gleason 7, positive margins) I'm in the 60-70% 5-10 year disease-free survival group. I'll take those odds. Before meeting with my oncologists, I had thought my margins were negative and my odds were much worse. (To clarify this--usually you would think negative margins are a good thing, because it means there was no cancer found at the cut edge of the removed tissue. However, when you are trying to figure out whether your recurrence is localized or not, it can turn things in your favor to have positive margins. Why? It provides a logical explanation for the increased PSA. It means there was an increased chance cancerous cells were left behind in the prostate bed, and if that's where your PSA is coming from, rather than distant sites, your PCa may still be curable.)

Sailer also says:

If a patient’s PSA does not initially decline to zero, he likely had occult metastatic disease at diagnosis and would not benefit from localized radiation, unless the source of the residual PSA is a positive margin and the Gleason score less than 8.

Well, my PSA was below 0.1 initially, but who knows what it would have been on an ultrasensitive test? .06? .07? I would say that it's likely my PSA did NOT decline to zero initially, and I would have likely had metastatic disease (or maybe more properly "systemic"), BUT I have positive margins--which gives a possible explanation for the PSA--and my Gleason was less than 8. Sailer is restating my earlier pessimism--when I thought I had negative margins, I figured the cancer was out of the barn. With negative margins, where would my PSA be coming from? Distant sites? Very possible. As I wrote above, normally positive margins=bad and negative=good..except when you're evaluating a rising PSA after surgery and trying to figure out whether or not salvage will work. With positive margins, it increases the probability that my problem is still local. Again, no guarantees. But I'm much happier to be in the 60-70% likely to have durable benefit or cure rather than in the 10-20% probability of durable benefit.

And remember, if you're having a recurrence after surgery--you're a unique human being, not a statistic. These are probabilities only. An acquaintance of mine had similar circumstances--PSA rising rapidly after prostatectomy--but he had negative margins. Nevertheless, he seems to have received a benefit from radiation--his PSA dropped from 0.5 before radiation to 0.01 afterwards. That's very encouraging--and against the known probabilities. Hopefully he's cured. He didn't have IMRT, like me, but proton beam therapy at Loma Linda University Medical Center.

dry run

I had the dry run this morning. One of the therapists showed me the area from where they would monitor me and operate the accelerator. Then they took me into the room where I saw the machine for the first time...it looked a lot like this, but more of a beige color.and then they used it to take a few x-rays. After they were done the therapist showed me the x-rays from today, compared to CT scan taken when they put the alignment marks and tattoos on me. To me, and to the therapist, they looked EXACTLY the same. The cross hairs matched perfectly from one picture to another.

By now my doctor has met with the medical physicist and mapped out my treatment--how much radiation will go to which parts of me. Tomorrow the real treatments begin. The doctor advised me to make sure I have a full bladder, but not to the point of discomfort. That is supposed to help lessen urinary side effects of radiation.

Interestingly, the male therapist who helped me (let's call him Rick) looks younger than me and yet he too is a prostate cancer patient. Diagnosed last year, underwent the same robotic prostatectomy as me, at the same hospital. He hasn't gotten his first PSA back yet.

On my way back to work I stopped by a lab and had blood drawn, for PSA and CBC.