Latest Salvage Radiation News

A small study indicates PSA doubling time of 6 months or less is predictive of failure after SRT.

http://informahealthcare.com/doi/abs/10.3109/21681805.2014.982168

Latest Salvage Radiation News:

"For the study, 388 patients with pT3-4pN0 prostate cancer with positive or negative surgical margins were recruited. After RP, 307 men achieved an undetectable PSA (arms A + B). In 78 patients the PSA remained above thresholds (median 0.6, range 0.05-5.6 ng/mL). Of the latter, 74 consented to receive 66 Gy to the prostate bed, and SRT was applied at a median of 86 days after RP. Clinical relapse-free survival, metastasis-free survival, and overall survival were determined by the Kaplan-Meier method.RESULTS:
Patients with persisting PSA after RP had higher preoperative PSA values, higher tumor stages, higher Gleason scores, and more positive surgical margins than did patients in arms A + B. For the 74 patients, the 10-year clinical relapse-free survival rate was 63%. Forty-three men had hormone therapy; 12 experienced distant metastases; 23 patients died. Compared with men who did achieve an undetectable PSA, the arm-C patients fared significantly worse, with a 10-year metastasis-free survival of 67% versus 83% and overall survival of 68% versus 84%, respectively."

http://www.ncbi.nlm.nih.gov/pubmed/25445556

Latest Salvage Radiation News

Freie Universität Berlin (Wikimedia Commons)

Researchers in Germany have completed a followup study on 151 patients. The median followup time was 82 months.
They found a 55% recurrence rate in salvage radiation (SRT) patients. This confirms several other studies around the world that show in the long term, most salvage radiation patients will show at least biochemical recurrence. (In the short run, it's just the opposite) . However, the study also showed very few prostate cancer deaths during the followup period. And the study confirmed other research since 2004: pre-SRT PSA level is a critical factor in predicting the outcome of salvage radiation.  The lower your PSA at the time of salvage radiation, the better.  The takeaway? If you're considering salvage radiation, don't dally.

Lohm G, Lütcke J, Jamil B, Höcht S, Neumann K, Hinkelbein W, Wiegel T, Bottke
D. Salvage radiotherapy in patients with prostate cancer and biochemical relapse 
after radical prostatectomy : Long-term follow-up of a single-center survey.
Strahlenther Onkol. 2014 Feb 28. [Epub ahead of print] PubMed PMID: 24577132.

Zero point five: a number to remember

Earlier is better when it comes to salvage radiation therapy (SRT) another study reports. This had been clearly identified by Stephenson et al., in the past. This time the study comes from Italy and is reported in European Urology: nearly 3/4 of men who had SRT at PSA levels of 0.5 or lower were alive and  free of biochemical progression nearly 5 years later.  (Being free of biochemical progression basically means undetectable PSA).

So if your PSA has risen after prostatectomy, and you're considering radiation as a second attempt at a cure, time is of the essence. If your doctor says it's okay to wait until you hit 1.0, or, God forbid, 2.0; run, don't walk, to get a second opinion from a radiation oncologist who is more up-to-date on the literature. 

A lot of the time with prostate cancer, time isn't that critical. But with salvage radiation, the clock is ticking.

Latest Salvage Radiation News

Researchers in Munich, Germany, studied 96 men at a single institution, and found that--as did earlier research done by William Catalona and others--that although most men show a significant drop in PSA after SRT, in the long run, most will see their PSA start to rise.  In this case, 35% remained free of PSA progression at 5 years post-SRT.

Outcome After Conformal Salvage Radiotherapy in Patients With Rising Prostate-Specific Antigen Levels After Radical Prostatectomy.

Klinikum rechts der Isar der Technischen Universität München

 

 

 

Predicting the Outcome of Salvage Radiation Therapy

I've been following the work of Dr. Andrew Stephenson, of the Cleveland Clinic, who for several years has been trying to predict the outcome of salvage radiation, like the treatments I had this spring.

He, along with experts in the field like Scardino, Kattan, Slawin, and others, have just published an important paper in the Journal of Clinical Oncology. You can read a summary of the work here.

I obtained the full text of the document (you can too--just go to your nearest public library and tell them you need interlibrary loan). The full title is " Predicting the Outcome of Salvage Radiation Therapy for Recurrent Prostate Cancer after Radical Prostatectomy" from JCO, May 2007, pp. 2035-41.

Stephenson and his colleagues looked at 1,540 patients across 17 medical centers in North America. All of these patients underwent salvage radiation (an attempt to rescue the patient when surgery fails to eradicate prostate cancer). The researchers created a nomogram to predict the outcome of salvage radiation. The nomogram is in the public domain and will be available soon in an easy to use web version at http://www.nomograms.org soon.

In general, Stephenson found as he did in earlier work, that the earlier you can get started with salvage radiation, the better. He writes "The 6-year response to SRT among patients treated at PSA levels of 0.50 n/mL or less appears to be durable because only two progression events were observed after 6 years among 32 patients at risk at 6 years (median follow-up, 90 months)" (p. 2037). Besides the pre-radiation PSA, other important variables are Gleason score, PSA doubling time (PSADT), surgical margins, hormone therapy administered along with or before radiation, and lymph node metastasis. In earlier work, Stephenson had found that of patients at high risk (because of a Gleason >= 8, or rapid PSA doubling time) many could still benefit from radiation, especially if they had positive surgical margins like I did. This new study validated this idea.


In my case, the nomogram shows I have about a 55-57% chance of being progression free at 6 years out from radiation. Those are pretty good odds, I think. The flow chart in the article, which for me goes like this:

Pre-RT PSA <= 2.0, Gleason 4-7, Positive margins, doubling time <=10 months and that comes out to 57% probability of being progression free at 6 years. This study goes back to way before the days of IMRT, though, and the average man in the study got less radiation than I did. So I think my odds are probably better than 57%, since the targeting of radiation and dose escalation are much better these days than was the case for most of the study participants. Of course, if my cancer was already systemic, then the radiation probably didn't do much good. I should get some idea soon--I had blood drawn yesterday and I get the results in one week. So check back, dear reader, on or after June 15--will this blogger get on with his life and career? Or will he start putting affairs in order? ?

Bad Omen

Not the first time I've seen this, but it's disturbing. A new report shows that a PSA that rises more than 2.0 in the year before treatment is the single most important indicator that a man has a very aggressive cancer. Mine was rising faster than that--it went up 2 points in only SIX MONTHS. That, according to the study, puts me at high risk of dying from prostate cancer.
I'm going to get a full-text copy of the report, because I have a lot of questions--such as, did any of the men have salvage radiation and how did that affect their odds of dying?

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.

the name of this blog

So what's the big deal with PCa before the age of 50? Well, it's not common. Visit the waiting room of your nearest urologist, or go to a support group meeting. You'll see what I mean. I was diagnosed at 43.
A recent study showed the median age at diagnosis was 68. ZERO percent were diagnosed under the age of 35. Only one half of one percent of the diagnoses in that time were in my age group--35 to 44. Over 91% of the time, diagnosis happened at 55 or older.
See what I mean?
Now that doesn't mean prostate cancer isn't lurking. Autopsy studies of men who died from other causes have found prostate cancer is lurking in a surprising number of relatively young men. But obviously, since prostate cancer only accounts for about 3% of male deaths, and the median age at death from PCa is 80 most of those men probably had a form of the disease that was latent. Most men die with prostate cancer, not from it. My PSA was rising quickly, however. (and still is, at least up until I start radiation). I would most likely NOT be one of those guys who dies in their 80's with the disease--I'd be one of those guys who dies in his 50's FROM it, if not for treatment.