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Salvage RT at PSA 0.03?

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User
Posted 08 Nov 2018 at 21:53

I posted elsewhere already that my PSA has gone up from 0.01 to 0.04 in 4 months, 1 year post-op, so naturally worried I may need salvage RT. Some recent literature suggests salvage RT when the first PSA measurement reaches 0.03, eg

https://www.dropbox.com/s/iel8wk0msy8ekqg/ellis%20-%20reply%20uPSA%20j.juro.2015.11.016.pdf?dl=0

https://www.dropbox.com/s/7bcvfb2nq74cdlq/kang%20-%20uPSA%20j.juro.2014.11.017.pdf?dl=0

On this forum it seems urologists prefer to wait.

Any thoughts on this?

[Edit: I see now this thread is very relevant: https://community.prostatecanceruk.org/posts/t16112-Recurrence.
In particular, this link posted by francij: http://riskcalc.org/ProstateCancerAfterRadicalProstatectomyNew/
Perhaps not much to add then...
(before posting this I search ".03" but thread didn't show up!]

Edited by member 08 Nov 2018 at 23:11  | Reason: Not specified

User
Posted 09 Nov 2018 at 02:41

Excerpt from a letter yesterday from the senior prostate oncologist at the Royal Marsden Hospital:

“Some oncologists advocate salvage radiotherapy for a rising PSA alone. Others, where PSMA PET scans are available, would wait until the site of recurrence is evident on a PET scan. At present we do not know which strategy is the better one.

Talking to Mr (Bollinge) today, my impression is that his preference would be to delay radiotherapy until the site of recurrence is known. If he were to take that path then it would be extremely helpful to have state-of-the-art imaging if and when his PSA were to start rising. At present PSMA PET scans are not widely available.”

Cheers, John

Edited by member 09 Nov 2018 at 04:35  | Reason: Not specified

User
Posted 09 Nov 2018 at 00:28
Make sure it is 0.04 and not <0.04. Good news is there is little to be gained from treating earlier than 0.1 according to the nomogram you quoted so still plenty of time to consider your options. A PSMA scan might be a good idea - check out ulsterman.
User
Posted 09 Nov 2018 at 05:49

I had SRT with a PSA of 0.023, but a PSMA scan had identified where the cancer was (and my starting points and pathology were pretty awful).  More than just the PSA needs to be taken into account.  I was offered adjuvant RT shortly after surgery, but my oncologist urged me to wait until we had a clearer picture.  Unfortunately, things moved on pretty quickly anyway.

Ulster man

User
Posted 10 Nov 2018 at 13:59

The Ellis literature review noted that some small scale studies had concluded that 0.03 was an indicator of future recurrence but that larger studies had found no difference between men with a post-op PSA of

In the full report, it is clear that 'high risk' refers to men who had poor pathology (PNI, Gleason was upgraded, positive margins, etc) so the final conclusion was that 0.03 or above PLUS high risk might be a trigger for adjuvant or salvage RT but that a PSA of 0.03 - 0.1 is not an indicator on its own.

In terms of whether guidance should have changed as a result, this was just one paper by a researcher, a literature review of other people's research some of which is 14 years old. There will be thousands of reports like this, which probably draw significantly different conclusions depending on who was funding the report or literature review.

Edited by member 10 Nov 2018 at 14:01  | Reason: Not specified

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

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User
Posted 09 Nov 2018 at 00:28
Make sure it is 0.04 and not <0.04. Good news is there is little to be gained from treating earlier than 0.1 according to the nomogram you quoted so still plenty of time to consider your options. A PSMA scan might be a good idea - check out ulsterman.
User
Posted 09 Nov 2018 at 01:23
wicher, I am not sure you have read the reports correctly - for example, the first hyperlink you have given argues the other way, that literature reviews indicate little difference in outcomes between men <0.3 and men between 0.03 - 0.1 in terms of BCR and that a man with post-op high risk of recurrence should be offered a discussion about salvage RT if his PSA goes above 0.03. It doesn't say men with a PSA over 0.03 need salvage treatment.

Unless your post-op pathology was poor, I can't see any need or justification for adding an additional treatment (with all its unpleasant side effects and risks) that may be completely unnecessary.

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 09 Nov 2018 at 02:41

Excerpt from a letter yesterday from the senior prostate oncologist at the Royal Marsden Hospital:

“Some oncologists advocate salvage radiotherapy for a rising PSA alone. Others, where PSMA PET scans are available, would wait until the site of recurrence is evident on a PET scan. At present we do not know which strategy is the better one.

Talking to Mr (Bollinge) today, my impression is that his preference would be to delay radiotherapy until the site of recurrence is known. If he were to take that path then it would be extremely helpful to have state-of-the-art imaging if and when his PSA were to start rising. At present PSMA PET scans are not widely available.”

Cheers, John

Edited by member 09 Nov 2018 at 04:35  | Reason: Not specified

User
Posted 09 Nov 2018 at 05:49

I had SRT with a PSA of 0.023, but a PSMA scan had identified where the cancer was (and my starting points and pathology were pretty awful).  More than just the PSA needs to be taken into account.  I was offered adjuvant RT shortly after surgery, but my oncologist urged me to wait until we had a clearer picture.  Unfortunately, things moved on pretty quickly anyway.

Ulster man

User
Posted 09 Nov 2018 at 17:49

Originally Posted by: Online Community Member
wicher, I am not sure you have read the reports correctly - for example, the first hyperlink you have given argues the other way, that literature reviews indicate little difference in outcomes between men
Unless your post-op pathology was poor, I can't see any need or justification for adding an additional treatment (with all its unpleasant side effects and risks) that may be completely unnecessary.

Hi Lyn, the first link (Ellis) concludes, I think referring to "high risk patients", that "The body of available literature would suggest that men at high risk for recurrence with a uPSA of 0.03 or greater should be strongly urged to consider early salvage radiation at that point,... There would be time to obtain 1 or 2 more PSA tests to confirm the  elevation and to look for a PSA increase." (I read this as any uPSA >=.03, or is it the1st post-op uPSA?).
Did I read wrongly? I hope so! In the two years since publication, there doesn't seem to be a change in guidelines as far as I can tell so even if I read correctly the conclusion wouldn't be broadly accepted I guess.

User
Posted 10 Nov 2018 at 09:34
Check out the other nomogram I published that includes outcomes down to 0.03 there is very little benefit to early salavage at really low levels (below 0.1). Unless you have a clear target like Ulsterman, or positive margins? Or really high risk. Either way you probably have time to wait for another test to be sure.
User
Posted 10 Nov 2018 at 13:00

I was offered to participate in the Radicals trial after my post op histology showed the cancer had breached the capsule and there was also intraductal cancer present. After a long discussion with a surgeon I decided to wait. That part of the radicals trial randomly selected patients for adjuvant radiotherapy and the others got no immediate radiotherapy.

My PSA rose quickly from undetectable in June to 0.7 by November and was doubling every 4 weeks. I had an enhanced MRI and an F18 choline PET scan which between them identified two separate recurrences.

I had three months of HT followed by radical salvage radiotherapy and am completing two years of HT after SRT.

If I had gone down the adjuvant route I’m not sure they would have targeted the recurrence areas as accurately and as forcefully. 

With a PSA of 0.03 or so a scan might not pick up anything although that is not certain.

Lyn is also correct about added side effects. I recovered continence pretty quickly after surgery. Now if I am tired I can get random leaks without warning. I also have post radia proctitis.

I wouldn’t change what I have done as I wanted to hit the sodding cancer really hard but you need to make any decision with pote side effects in mind.

Best wishes,

Ian

Ido4

User
Posted 10 Nov 2018 at 13:59

The Ellis literature review noted that some small scale studies had concluded that 0.03 was an indicator of future recurrence but that larger studies had found no difference between men with a post-op PSA of

In the full report, it is clear that 'high risk' refers to men who had poor pathology (PNI, Gleason was upgraded, positive margins, etc) so the final conclusion was that 0.03 or above PLUS high risk might be a trigger for adjuvant or salvage RT but that a PSA of 0.03 - 0.1 is not an indicator on its own.

In terms of whether guidance should have changed as a result, this was just one paper by a researcher, a literature review of other people's research some of which is 14 years old. There will be thousands of reports like this, which probably draw significantly different conclusions depending on who was funding the report or literature review.

Edited by member 10 Nov 2018 at 14:01  | Reason: Not specified

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 10 Nov 2018 at 15:17

Re francij: pretty sure it is =0.04, but will call the specialist nurse Monday to get some more info. Not sure how much I trust the nomogram for small PSA values though, I started reading the paper from which it was derived and they seem to suggest benefits of SRT at the earliest sign of recurrence (but don't give a level). Also the nomogram results for small PSA levels seem to be based on small numbers of patients.

Thanks Ian, it seems you haven't had much luck but glad the PSA is staying low now.

So quite a lot of people here with T3A and more problems post-op, T3A seems really quite a lot worse than T2C.

Edited by member 10 Nov 2018 at 15:17  | Reason: Not specified

User
Posted 10 Nov 2018 at 15:29
Strange, isn’t it, that the foremost cancer institution in Britain, the Royal Marsden Hospital in London only tests PSA down to <0.04?

Anyway, that was my reading from last week, so Hallelujah, I’m cured!

For now😉

Cheers, John.

User
Posted 11 Nov 2018 at 09:46

Great news John!

User
Posted 16 Jun 2020 at 18:03

Interesting overview article here: "Early SRT at the first sign of PSA rise granted better disease control." (Not too surprising I suppose). No mention of the 0.03 threshold by the way, rather 0.1 is mentioned.

Edited by member 16 Jun 2020 at 18:04  | Reason: Not specified

User
Posted 17 Jun 2020 at 07:07
User
Posted 17 Jun 2020 at 09:45

Interesting article summarising the outcomes of the Radicals trial. Thanks for sharing.
I was offered the chance to take part in this trial In 2015 but decided not to after histology upgraded my PC to T3a. This was after a long chat with my doctors.

Having had salvage radiotherapy once biochemical recurrence happened I hope its done the job. 

Ido4

User
Posted 17 Jun 2020 at 13:58

I had SRT. It failed. Most show initial success only for it to recur because micro metastasis is happening in some distant location. Unless your specialist firmly recommends SRT, it’s a gamble - one which can play havoc with nearby lymphs. It set the scene for incontinence down the line and at the point where it was delivered, did enough tissue damage to cause cancer to later infiltrate my urethra and bladder. This was my experience. Yours could be much better. Think carefully.   

Edited by member 17 Jun 2020 at 14:02  | Reason: Not specified

User
Posted 17 Jun 2020 at 20:58

Bazza

All things considered I hope you are coping. 

I don't normally write negative  posts but there are a few similarities between your post SRT situation and mine. You mentioned the world gamble, my guy calls it a very educated guess.

Hopefully in the future, detection of spread will improve. 

Take care. 

Thanks Chris

 

User
Posted 18 Jun 2020 at 18:22
And yet my medics held off until I reached 0.24 as they said that 0.2 was their threshold. They didn’t even sniff at the idea of early srt.

According to bazza most srt fails anyway. So why bother.

And here people are saying early intervention is best.

Which one is right? Are the medics just making random guesses?

User
Posted 18 Jun 2020 at 22:38

My doctor offered RT last November at 0.10, which I took up as PSA was steadily going up and research suggests a small advantage for very early RT. Waiting until 0.5 seriously increases risk, 0.2 not so much I understand. I got a psma pet scan at .09 which showed nothing, advantage of waiting longer could be that the scan is more likely to show something and RT can be directed better...

But yes prostatepete I think a lot is guesswork, my doctor said as much...

 

Edited by member 18 Jun 2020 at 22:39  | Reason: Not specified

User
Posted 19 Jun 2020 at 00:52
Early intervention is usually referring to SRT when biochemical recurrence occurs; biochemical recurrence is defined as 0.2 or three successive rises over 0.1 so your onco was a little slow but not overly, Pete. And while it is true that men who need salvage treatment (of any kind) are statistically less likely to ever achieve full remission, that isn't the same as saying it is a waste of time ... salvage treatment leads to remission in more than half of cases or can push the next recurrence so far down the line that you never know it happened.

John didn't want to accept that he had a recurrence, he resisted SRT, he gave in, he stopped the hormones early because he hated the side effects. Eight years on, his PSA dodders around 0.1 and we get on with life. Yes, there will be a rise in PSA at some point and yes, he will then become 'incurable' but it might be 20 years from now and who knows what new treatments may have been discovered by then? When I first joined this forum, abiraterone and enzalutimide weren't even being trialled, it was members on here who were the first guinea pigs; early chemo hadn't been thought of, it was members here who were the first guinea pigs; I remember when the first member here was asked to trial something with a mysterious code name which made him very, very ill but became Radium 223. The developments are so rapid it is breathtaking.

Bazza has been so unlucky; at every stage, his doctors have believed they were offering a treatment that would get rid of the cancer (because all the data - and let's face it, with 45,000 men diagnosed every year, there is a lot of data - says that most prostate cancers will behave a certain way and respond to certain treatments) and yet his cancer has been unusually determined & persistent every step of the way. My heart breaks for Bazza because this was his deepest fear right from the start, and it came to pass even though, statistically, he should be in remission and living his best life.

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

 
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