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.

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."

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

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.

Martin receiving radiotherapy for prostate cancer

This is very similar to my experience. The video is sped-up, otherwise you'd be bored to tears. As you can see the treatments themselves are very easy on the patient. Over time, side effects may build up, but an IMRT treatment is about the easiest thing you can undergo medically.

Outcome of salvage radiotherapy for biochemical failure

Outcome of salvage radiotherapy for biochemical failure after radical prostatectomy with or without hormonal therapy.

Not sure how I missed this one--probably because I usually search "radiation" and not "radiotherapy"--but a study from MD Anderson in 2005 reaffirmed the idea that the earlier you start, the better, with salvage. Like Stephenson et al at Cleveland Clinic, they found that the best results were obtained when the man's pre-radiation PSA was 0.5 or less.

The MD Anderson study put men into two groups: favorable and unfavorable. Those in the favorable group had pre-RT PSAs of 0.5 or less, and positive margins. Unfavorable included everyone else. 81.7% of those in the favorable group had no PSA progression 5 years later, compared to 61.7% in the unfavorable.

I'm in the unfavorable group. The 61.7% chance of being progression free at 5 years (which would be spring of 2012 for me) matches up well with other research I've read.
___________________________________________________________

Int J Radiat Oncol Biol Phys. 2005 Sep 1;63(1):134-40.

Outcome of salvage radiotherapy for biochemical failure after radical prostatectomy with or without hormonal therapy.

Cheung R, Kamat AM, de Crevoisier R, Allen PK, Lee AK, Tucker SL, Pisters L, Babaian RJ, Kuban D.

Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA. mrcheung@mdanderson.org

BACKGROUND: This study analyzed the outcome of salvage radiotherapy for biochemical failure after radical prostatectomy (RP). By comparing the outcomes for patients who received RT alone and for those who received combined RT and hormonal therapy, we assessed the potential benefits of hormonal therapy. PATIENTS AND METHODS: This cohort was comprised of 101 patients who received salvage RT between 1990 and 2001 for biochemical failure after RP. Fifty-nine of these patients also received hormone. Margin status (positive vs. negative), extracapsular extension (yes vs. no), seminal vesicle involvement (yes vs. no), pathologic stage, Gleason score, pre-RP PSA, post-RP PSA, pre-RT PSA, hormonal use, radiotherapy dose and technique, RP at M. D. Anderson Cancer Center, and time from RP to salvage RT were analyzed. Statistically significant variables were used to construct prognostic groups. RESULTS: Independent prognostic factors for the RT-alone group were margin status and pre-RT PSA. RP at M. D. Anderson Cancer Center was marginally significant (p = 0.06) in multivariate analysis. Pre-RT PSA was the only significant prognostic factor for the combined-therapy group. We used a combination of margin status and pre-RT PSA to construct a prognostic model for response to the salvage treatment based on the RT group. We identified the favorable group as those patients with positive margin and pre-RT PSA < or =" 0.5" p =" 0.03).">

PMID: 16111581 [PubMed - indexed for MEDLINE]

Salvage Radiation: Nomogram updates

It looks like the Memorial Sloan-Kettering Salvage Radiation Therapy nomogram on Nomograms.org (direct URL: http://www.mskcc.org/applications/nomograms/prostate/SalvageRadiationTherapy.aspx ) has been updated. It's now easier to use and the response makes sense. It used to give your result as post-surgery rather than post-radiation.
I had been thinking that the nomogram was too pessimistic, compared to the paper version. But what I didn't realize was that four months after the paper version was released in the Journal of Clinical Oncology, an erratum was published that corrected a mistake in regards to pre-radiation androgen deprivation (hormonal therapy). The corrected PAPER version of this important tool is here: http://jco.ascopubs.org/content/vol25/issue26/images/large/zlj0150759390003.jpeg ; however, I see no reason to use it because the digital nomogram is much easier, quicker to use, and less prone to human error.

Now both paper and online versions tell me that I've got a 39% chance of being progression free at 6 years. That jibes pretty well with Catalona's research that showed that long term success with prostate salvage radiation is uncommon--only about 25% of patients overall are progression free at 10 years. Of those who had a complete response to radiation, as I did, Catalona found that 35% were free from PSA progression.

The full text of the original article (remember, the nomogram in this original article is not correct) is here: http://jco.ascopubs.org/cgi/content/full/25/15/2035.

If you have a rising PSA after prostatectomy, and you're considering salvage radiation, I encourage you to read the original article and use the online nomogram at Memorial Sloan-Kettering.

Sports editor journals his salvage radiation

Welcome to radiation.

"Ken Burger, executive sports editor of The Post and Courier[Charleston], was diagnosed with prostate cancer on Feb. 2, 2007, and documented his journey in a series of columns last year. Now, in a new series of columns beginning today, he'll update readers about the latest steps in his treatment..."

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.

LESS THAN 0.1 !

This is the best possible news. (Note: I had earlier blogged that it was 0.1, but the nurse had misspoken on the phone.)

Before surgery: 4.8 (but really, 9.6 because I was on a medication that artificially lowered it)
3 months after surgery: less than 0.1 (or "undetectable" on the standard assay)
6 months after surgery: 0.2
10 months post surgery: 0.6
Day before radiation started (about 11 months post-surgery): 0.7
IMRT for 8 weeks
3 months post-radiation: 0.1
4.5 months post-radiation: 0.1
and now, 6 months post radiation: < 0.1

I'm clearly in the "complete responders" group Andrew Stephenson has reported on. His study shows 49% of those who got a complete response within 9 months were free from disease progression 6 years later. That may not sound great to you (50-50 odds) but overall rates of success in salvage radiotherapy in the long run are not nearly that high. My odds in the short run are excellent.

Bullseye

First post-salvage radiation PSA test came back today. Zero point one. That's a great score in my situation. I'm probably, hopefully, still on a downward curve, so maybe the next PSA will be less than zero point one, or "undetectable" on the standard PSA test. I was dreading the digital rectal exam (DRE) because of the proctitis, but it didn't hurt at all and there was no sign of blood, which means to me that the proctitis is just about gone.

The doctor said he would have been happy even if the score was 0.3.

This is a great day.

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.