Hold off on salvage RT for path PT3b w/ 3 undetectable PSAs?

I was T1c also but 3+4. but $+3 after surgery and I had bilateral seminal vesicle invasion...

My Biopsy and surgical reports are here

You are welcome to down load them. I bought into that theory of earlier the better and I stand by it. With probably ractal invasion at the age of 44 I was not going to stick to the standard of care in 2007 and I'm glad I didn't. I also kicked in 28 months of hormonal therapy and this was while PSA was zero after surgery. So my radiation and hormonal therapy were ahead of any PSA rise after RP. I have never had such a rise and after 7 years still good and treatment free for 4 years now.

How old is your hubby?

It's a tough call. Many docs would not subscribe to my path but I do and thats all that mattered for me. I credit the path I chose for it and blessings above but today is a good day without my very high risk features running my life. These are very personal decisions and I send love and hope.

And welcome aboard. Thank you for sharing.

Thank you for your quick responses. Your advice, personal journeys and caring help get us through this crazy time. Hubby is 59, 58 at surgery. PSA at biopsy was 3.7. Eight weeks post-surgery PSA was 0.02, then 14 weeks out was 0.03 with doc feeling increase was glitch, then 5 months out was again 0.02. Hoping for another undetectable with this Monday's test. Lymph nodes were biopsied and negative at time of surgery, MRI and CT scan for bone/lymph node requested in February by Rad Onc came back negative. Continence is great. ED is improving and seems to get better with time. Saw surgeon April 1 and he again reiterated no radiation and PSA in three months. Saw Rad Onc in February and he wanted PSA checked monthly. I think he felt a recurrence was imminent with hubby's path report and was firing up the ray gun! He seemed pleasantly surprised at the undetectable results. We know to watch for increases, and to especially pay attention to doubling time and limit rise to 0.1. Will let y'all know what the next PSA results are and again ask for your wisdom.

I guess I should clarify,
The 0.2ng/dl mark be be a decent level to get ahead of and may get ya to silimar data compared to ART+HT. The problem is that a PSA rise above 0.2 ng/dl can easily be achieve between 3 or 6 month PSA tests.

Allen, do you have the full paper. The abstract is not clear on PSA testing intervals.

Allen i missed something here. please link the paper to the abstract or please let me know you do not have it and I will get it?.

When I click on it it wants me to log in and pay 30 bucks.

Here's the full text conclusion which does not exactly match the abstract...

Conclusions
Progressively and significantly better tumor control rates with SRT after radical prostatectomy are achieved with a lower PSA at initiation and with a higher RT dose. This study provides Level 2a evidence for initiating SRT at the lowest possible PSA. It also suggests that escalating RT dose would yield higher tumor control rates. The evidence indicates that early SRT can achieve high rates of tumor control, potentially comparable with those of adjuvant RT. Although evidence from a randomized controlled trial of ART vs early SRT is lacking, the current body of evidence supports consideration of a management strategy for patients after radical prostatectomy in which waiting for biochemically demonstrated failure before RT might be both prudent and effective.


Attached is the FULL text pdf.  

This is interesting but weak.  The other trials I listed contain level 1 data.  But that stated, catching a relapse at 0.05 as is suggested in this paper could deliver benefits equal to ART but it is hypothesis.

"Although well beyond the scope of this study it can be said that, using the ultrasensitive assays in our practice, we consider a rising postoperative PSA >0.05 ng/mL as a reliable indicator of biochemical failure, which justifies the initiation of SRT before PSA reaches a level of >0.2 ng/mL."

My point before is at what testing interval should PSA be done to assure that you get there early enough as opposed to ART which eliminates that possibility of relapse opportunity altogether?  It is not stated in this paper at all and thus perhaps the next thing to do is contact Dr. Kind and ask him how frequent is PSA taken after RP in these cases?  And for how long is that frequency maintained?

I'll use my case as an example.  I had adjuvant radiation and HT.  My PSA was tested every 4 months while on HT as it coincided with my LHRH dosage.  But my testing changed to every 6 months when I stopped HT.  The last two years have been annual.  On this schedule for PSA testing it may be possible to catch a rise between 0.05 and 0.2.  BUT...

Most Patients after RP and NOT on HT would probably be tested in the first three months then every 6 months for two years and then tested annually forever.  It would seem that a seminal vesicle positive guy is "hoping" he would catch it in that window.  But we do already know he has been tested with an aggressive disease.  It's entirely possible that annual testing would mis a window of opportunity and fall outside the "safe zone"

Tony,
Thanks for providing the full text. It includes a lot of interesting analysis.

It is an analysis of the other studies cited and is not itself a clinical trial. That doesn't make it "weak" - it explores the data from those Level 1 studies (EORTC 22911, SWOG 8794, and ARO 9602) in greater depth and provides a meta-analysis. As King rightly points out, the RCTs do not address the question of adjuvant (i.e., treating immediately or before evidence of disease progression) vs salvage (i.e., treating after evidence of progression). What they address is adjuvant vs observation - not everyone who waited got salvage RT. There was a clear advantage in stemming biochemical evidence of disease (bNED) (but not in survival in 2 of the 3 studies) to adjuvant over waiting, but the advantage goes away when analyzing their data comparing outcomes of those who got adjuvant vs salvage. In fact, we are still waiting for any Level 1 (RCT) evidence of adjuvant vs salvage. Lacking that, King attempts to find clues in the available data.

He raises the caution that adjuvant treatment may be over-treating many. He finds that if one looks at the control arms of the 3 RCTs, 44%-54% never needed salvage treatment. Assuming a similar rate is true in the adjuvant treatment arm, the recurrence-free survival looks about the same for adjuvant and salvage treatment. Looking at the data in these RCTs, King finds that salvage treatment actually has an advantage over immediate adjuvant treatment, as long as the PSA is low enough. He writes, "If one
 extrapolates the relationship in Fig. 1 for SRT to low PSA levels
 (<0.2 ng/mL), namely, that of the ART trials, then the bNED
 approaches 64% for SRT and is substantially higher than the 39%-
46% of the ART trials."

The point I take from it is that based on the data in those clinical trials, there is an advantage to treating before PSA reaches .2 rather than waiting, but how much before .2 remains an open question. Since only one of those clinical trials (ARO 9602 - Wiegel) used an ultrasensitive test, the King analysis of the available data is not robust enough to draw conclusions about the benefit of adjuvant treatment in that range. Lacking those data, King nevertheless states that in his practice, he treats when PSA is greater than .05. 

To your point about the frequency of testing, most recurrences show up early. The staging (pT3b) is technically correct, but it indicates a higher risk level than may actually be the case because there was no cancer found in the mucosa, only in the proximal part. A recent review found that this kind of SVI is not associated with increased risk of recurrence. Therefore, more frequent PSA tests would not be warranted by this alone.

I finally read the whole Table1A in the King et al paper. This study is all over the map on inclusion in that table with only a small quantity of SV+ men. Even Stage pT2c men are inclusive but with high Gleason sums. That's a real problem. I do know that many of these men choose adjuvant therapy and should not. And I would agree with King et al that there results of SRT v ART is compelling to watch and wait. But look again at the "BJU Group D is way better than waiting" post I showed. When you separate pT3b from even pT3a there is a HUGE difference in survival and biochemical failure rates in favor of ART with HT. This is a very different demographic of inclusion than the King et al paper as it is broken out better.

Good morning. Sorry for the delay in posting. Husband, John, and I both came down with bronchitis. The April 21 PSA came back 0.02 (this is the fourth post-surgery PSA at undetectable). Met with surgeon who still insists on no RT, then met with Rad Onc who still insists on starting RT end of May. The Rad Onc brought up his concerns, which mirror yours, about getting beyond the level of PSA that makes RT the most effective. He wants to make certain we catch the PSA at its lowest level. Right now we're more stressed waiting on PSA results than worrying about RT side effects. John has decided to schedule the RT and move on. I know fagitue is a common issue, but are there other things to be concerned with that could interfere with John doing his job? He works out of our home, is a sales guy (high end customer service/leadership training) and usually does extensive travelling which will be curtailed til radiation is done. He does a great deal of phone networking, coordinating, international sales conferences, etc. We want to plan as best as possible so that everyone and every contingency is covered in case he needs backup. There has not been a discussion on use of hormones, and the Rad Onc is adamant in his belief that he doesn't need them, that the amount of gy's (70.2) will do the trick. We still plan to see a Med Onc to have them on the team as well, but the Rad Onc felt they wouldn't start hormones either. I keep going back to thinking the "debulking" from the surgery could be a cure. That the gleason 6 positive margin was minimal and less likely to spread, that the SVI being direct and not distal plays into the cancer being removed, that the tertiary 5 was in the body of the gland and removed and didn't have an opportunity to take hold someplace else. It's like high-stakes gambling, either way it's played. Roll the dice and try to minimalize the fallout. Thanks for all your information, guidance, advise. John's slogan since all this started is "technology will save my a**." So in five years or so when radiation side effects really start to kick in, hopefully science will as well.