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After radiation and HT

User
Posted 12 Aug 2023 at 13:55

Hi

I finished Radiation therapy and I am halfway through my HT. The thing is I am confused. Dr said he is pleased PSA is 0.4 but does this really mean anything. Surely this is just the suppression of PSA by the hormone treatment?

I also don't understand when will my nadir be achieved? Will this be after HT?

Also what number will this be? It all seems a bit unclear and it's doing my head in. Help please 

Edited by member 13 Aug 2023 at 00:36  | Reason: Not specified

User
Posted 12 Aug 2023 at 19:32

Hi Veerappan,

Interesting for me to read your post. I finished RT at the beginning of May and been on HT for over a year and am told I will be on it for another 2😟. What was your PSA when diagnosed and what was it before RT started? Mine was 36 at diagnosis and 0.9 at the start of RT. I get my first PSA test (3 months after RT) on Monday and I’m not really sure what would be classed as a good score. I guess if the doctor says it’s good then you’ve got to have faith in them.

I suppose your nadir could occur anytime but I would expect it to be nearing the end of HT, otherwise why would they keep you on it for so long after RT? I think if mine started to rise on HT I would be worried. I think having a good oncologist who can explain things to you is VERY important. if not contact your CNS who should be able to explain things to you.

All the best!

Derek

User
Posted 12 Aug 2023 at 21:34

Hi Veerappan,

Yes, your nadir will probably be towards the end of your HT. It might even be afterwards because Testosterone usually remains suppressed for some months after the last injection runs out and it could be after the HT but before Testosterone returns.

What was your PSA at diagnosis and what was it before RT (if measured then, which it usually isn't)?
How long is your HT for?

The HT brings PSA down very significantly, can be 10x reduction in first 3 months. This masks the effect of the RT. When testosterone returns, if you still have a prostate, PSA is expected to rise a bit, but not more than 2.0 above your nadir.

The RT will bring PSA down during the RT treatment too, but it can carry on bringing it down for 18-36 months afterwards as the cancer cells can take some time to die (although they should no longer be malignant, and hence can't spread). During this long tail decline, you can get PSA bounces where it bounces up for 6 months or so, before dropping down lower than the bounce started from, although this is usually masked by the HT.

User
Posted 13 Aug 2023 at 00:08

Hi veerappen, 

I also had RT and was on HT for two years. I agree with you about the confusion with PSA nadir and HT. I have never had a satisfactory explanation.

The HT is suppressing testosterone, which is "artificially" suppressing PSA. Hence in my opinion any talk of PSA nadir whilst on HT is meaningless. Once off HT it takes months for the testosterone to recover (for me it was 8 months) so I think though my PSA was <0.1 throughout RT and HT that was not a realistic definition of the nadir (though as far as I can tell that is what would be used by the medics). Once I came of HT my PSA remained between 0.1 and 0.2. My last PSA was <0.1 three years after finishing HT, so I think this is a very good definition of nadir (and if it ever goes lower, that would be a better definition). The fact my during HT and post HT PSAs were equal is fortunate, for me BCR will be defined as 2.1. 

At the moment your nadir is 0.4 it may go lower, but whether it is a meaningful number whilst on HT I doubt, but it is the only number you have at the moment so BCR for you is currently defined as 2.4 if you ever get a lower PSA it will lower your definition of BCR. 

 

Dave

User
Posted 13 Aug 2023 at 22:58

Originally Posted by: Online Community Member
I have a question: can HT actually eradicate micro mets? I did not realise this.

A senior clinicial and research oncologist who used to work at UCLH thinks this is a significant factor in in the better cure rates when HT is used with RT - micro-mets outside the RT treatment areas which might otherwise cause later recurrence probably don't survive.

Originally Posted by: Online Community Member
What is the point of RT on lymph nodes? My understanding is that the lymphatic system is like a highway so if it's present within the system, there are probably micro mets right across the system?

Lymph nodes are filters, so it doesn't immediately go through. If found only in the immediate lymph nodes draining the prostate, there may not be any more, or they may be so small it falls into the micro-mets category which hopefully won't survive the hormone therapy and loss of the primary tumour. RT will kill cancer in the lymph nodes in the target treatment area, often leaving the nodes still working.

User
Posted 14 Aug 2023 at 06:23

Fear the worst, expect the best and be prepared for anything. My limited understanding from pouring over this site is that it should be a much lower PSA but results can variable.

Whatever the PSA your cancer will be receiving a good old battering and will no longer be advancing.

Good luck Decho.

V

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User
Posted 12 Aug 2023 at 19:32

Hi Veerappan,

Interesting for me to read your post. I finished RT at the beginning of May and been on HT for over a year and am told I will be on it for another 2😟. What was your PSA when diagnosed and what was it before RT started? Mine was 36 at diagnosis and 0.9 at the start of RT. I get my first PSA test (3 months after RT) on Monday and I’m not really sure what would be classed as a good score. I guess if the doctor says it’s good then you’ve got to have faith in them.

I suppose your nadir could occur anytime but I would expect it to be nearing the end of HT, otherwise why would they keep you on it for so long after RT? I think if mine started to rise on HT I would be worried. I think having a good oncologist who can explain things to you is VERY important. if not contact your CNS who should be able to explain things to you.

All the best!

Derek

User
Posted 12 Aug 2023 at 21:34

Hi Veerappan,

Yes, your nadir will probably be towards the end of your HT. It might even be afterwards because Testosterone usually remains suppressed for some months after the last injection runs out and it could be after the HT but before Testosterone returns.

What was your PSA at diagnosis and what was it before RT (if measured then, which it usually isn't)?
How long is your HT for?

The HT brings PSA down very significantly, can be 10x reduction in first 3 months. This masks the effect of the RT. When testosterone returns, if you still have a prostate, PSA is expected to rise a bit, but not more than 2.0 above your nadir.

The RT will bring PSA down during the RT treatment too, but it can carry on bringing it down for 18-36 months afterwards as the cancer cells can take some time to die (although they should no longer be malignant, and hence can't spread). During this long tail decline, you can get PSA bounces where it bounces up for 6 months or so, before dropping down lower than the bounce started from, although this is usually masked by the HT.

User
Posted 13 Aug 2023 at 00:08

Hi veerappen, 

I also had RT and was on HT for two years. I agree with you about the confusion with PSA nadir and HT. I have never had a satisfactory explanation.

The HT is suppressing testosterone, which is "artificially" suppressing PSA. Hence in my opinion any talk of PSA nadir whilst on HT is meaningless. Once off HT it takes months for the testosterone to recover (for me it was 8 months) so I think though my PSA was <0.1 throughout RT and HT that was not a realistic definition of the nadir (though as far as I can tell that is what would be used by the medics). Once I came of HT my PSA remained between 0.1 and 0.2. My last PSA was <0.1 three years after finishing HT, so I think this is a very good definition of nadir (and if it ever goes lower, that would be a better definition). The fact my during HT and post HT PSAs were equal is fortunate, for me BCR will be defined as 2.1. 

At the moment your nadir is 0.4 it may go lower, but whether it is a meaningful number whilst on HT I doubt, but it is the only number you have at the moment so BCR for you is currently defined as 2.4 if you ever get a lower PSA it will lower your definition of BCR. 

 

Dave

User
Posted 13 Aug 2023 at 00:22

Derek, Dave and Andy

Thank you. I was 10.6 PSA. After 6 months and two injections of Zoladex it was still 3.9 and that quite disappointed me. The missus is over the moon with 0.4 but I am a little more sanguine as it seems a false reading, as it is being controlled by HT. Reading the comments of both Dave and Andy, my conclusion is that basically I need to wait till the end of two years. I don't like the idea of a bounce Andy that scares the hell out of me. Thanks to you all. I wanted a chat but didn't know what to say. 

V

Edited by member 13 Aug 2023 at 01:21  | Reason: Not specified

User
Posted 13 Aug 2023 at 00:26

Dave

Sounds very positive. Are you considered cured now?

V

User
Posted 13 Aug 2023 at 03:15
V,

We don't know your histology and it may be that you originally had a very high PSA in which case latest PSA of 0.40 may be OK. As has been explained, RT generally produces a gradual reduction in PSA over !8+ months. HT on the other usually causes a very substantial drop within a couple of months or so but thereafter decreases at a much slower rate. In time the effects of RT will also begin to gradually pull the figure down.

Do remember that not everybody responds the same way when it comes to HtT and RT so PSA results really need to be looked at as a trend over time to be a stronger indicator and not just by taking one reading against another.

Usually, Patients who produce satisfactory PSA and scan tests over several years may be said to be 'n remission'. The word 'cured' is generally avoided as PCa can sometimes 'take off' again even many years later in patients who seemed to be PCa free, the reason why

men should at least continue to have PSA tests.

Barry
User
Posted 13 Aug 2023 at 09:43

Hi decho I was told hormone therapy was for 3 years then they said I could finish after 18 months as it becomes ineffective after then and doesn't make any difference I finished  after then and my psa remains undetectable gaz

User
Posted 13 Aug 2023 at 10:59

Originally Posted by: Online Community Member

Hi decho I was told hormone therapy was for 3 years then they said I could finish after 18 months as it becomes ineffective after then and doesn't make any difference I finished  after then and my psa remains undetectable gaz

Hi Gaz,

Do you mean 18 months after RT or 18 months in total?
I would love to have that outcome, however one of my friends finished his RT and then 3 months later had his PSA come back as undetectable, so when he met with the oncologist asked him if because his results were good he might be able to come off it early and was told in no uncertain terms ‘No!’. Same Oncologist as me so I doubt I would get a different answer but might be brave enough to ask!

Derek

Edited by member 13 Aug 2023 at 11:00  | Reason: Not specified

User
Posted 13 Aug 2023 at 11:16

Originally Posted by: Online Community Member

Dave

Sounds very positive. Are you considered cured now?

V

Yes it is very positive. As Barry says "cured" isn't a realistic word to use with prostate cancer, because there is no way to know whether one or two cells are still present, which may grow. "Total remission" is more correct though to me that implies the cancer will definitely return, which is also not certain.

The reality is that there is a percentage chance of recurrence after a given time period. I had high risk cancer, at the time of diagnosis; even with treatment there was a 30% chance of recurrence by 10 years. I have responded well to treatment and there is evidence that the chance of recurrence at 10 years post treatment is now 2%.

If I try to explain this to my mates at the pub, their eyes glaze over, and they wish they hadn't asked. So I will use phrases like "considered cured" or "there is no evidence of cancer" to keep things succinct.

 

Edited by member 13 Aug 2023 at 11:18  | Reason: Not specified

Dave

User
Posted 13 Aug 2023 at 11:39

Oh dear ! Is there any consistency? I thought the uniform approach was 2 yrs and 8 injections,?

 

V

User
Posted 13 Aug 2023 at 12:44

I've had this discussion with a few oncologists.

For my own treatment, I was told 18-36 months HT at the outset, as a high risk patient. I read several research papers which variously show the significance of getting PSA low before starting HT, either for better outcomes, of for less need for adjuvant HT (i.e. HT after the RT). My PSA had dropped from 47 to 5 after 6 weeks on HT and onco was going to book RT at 12 weeks on HT. I decided I wanted to get my PSA down to 0.1 before RT, and calculated that would be at 21 weeks at this rate of drop, and onco was very happy to delay but not past 6 months - he'd had a couple of high risk patients do that but their PSA started rising before ever reaching their target. The paper which suggested getting down to 0.1 before RT claimed there was no point in continuing HT after RT in this case. Neither I nor my onco bought this, but nevertheless I figured this sounded like an advantage even so, hence that was my target, but I would continue with the HT afterwards anyway. I was taking the view that I'd grab what benefits I could get, even if it just gave me a 1% improvement in chances of a cure - the hormone therapy wasn't impacting anywhere near as much as I had feared it might. When I got to 18 months on HT, I asked my onco again, 18 or 36 months? Because my PSA had been undetectable since the RT, he said I could stop anytime I wanted to. Still the HT wasn't impacting me in any way I couldn't put up with for some months longer for the sake of another 1% chance of a cure, so I continued until 22 months.

If your treatment includes adjuvant HT, the period talked about is the total time on HT. It doesn't matter much when you have the RT during that period, although you do want it before you become castrate resistant, so you don't want to delay the RT past the point where PSA is dropping at a significant rate. In the UK, it's a bit unusual to have PSA measured during the neoadjuvant HT (before RT), but I asked and there was no resistance to doing so.

Longer periods on HT tend to be used for those with higher gleason scores or more known spread, and those whose PSA doesn't get very low or drop very quickly on the HT. It is thought that if you have micro-mets (too small to show on scans) outside the RT treatment area, 18 or more months on HT with the primary tumour no longer active may be sufficient to kill them, and prevent recurrence which they would otherwise have caused after HT.

User
Posted 13 Aug 2023 at 13:07

Mine was 18 months in total decho gaz

User
Posted 13 Aug 2023 at 17:01

Andy

Very useful information. I have a question: can HT actually eradicate micro mets? I did not realise this. Since you are so knowledgeable I have a second question. What is the point of RT on lymph nodes? My understanding is that the lymphatic system is like a highway so if it's present within the system, there are probably micro mets right across the system?

Than you.

V

Edited by member 13 Aug 2023 at 17:04  | Reason: Not specified

User
Posted 13 Aug 2023 at 17:44

I was maybe slightly different from many in that I was 9 months on HT befor starting RT. Nothing to do with me, down to poor communication between different health boards, mixed messaging on staging at diagnosis, and delay caused by Planning CT scan ruling out 39 sessions. I was down to 0.9 at th start of RT…it just so happened that my 3 monthly Prostap injection happened just at the start of RT, so I had a PSA test.
i have no idea what to expect when I get my PSA result  on Friday?

Edited by member 13 Aug 2023 at 17:56  | Reason: Not specified

User
Posted 13 Aug 2023 at 22:58

Originally Posted by: Online Community Member
I have a question: can HT actually eradicate micro mets? I did not realise this.

A senior clinicial and research oncologist who used to work at UCLH thinks this is a significant factor in in the better cure rates when HT is used with RT - micro-mets outside the RT treatment areas which might otherwise cause later recurrence probably don't survive.

Originally Posted by: Online Community Member
What is the point of RT on lymph nodes? My understanding is that the lymphatic system is like a highway so if it's present within the system, there are probably micro mets right across the system?

Lymph nodes are filters, so it doesn't immediately go through. If found only in the immediate lymph nodes draining the prostate, there may not be any more, or they may be so small it falls into the micro-mets category which hopefully won't survive the hormone therapy and loss of the primary tumour. RT will kill cancer in the lymph nodes in the target treatment area, often leaving the nodes still working.

User
Posted 14 Aug 2023 at 06:15

Dear Andy

Your responses, which are most welcome are very well informed.

V

User
Posted 14 Aug 2023 at 06:23

Fear the worst, expect the best and be prepared for anything. My limited understanding from pouring over this site is that it should be a much lower PSA but results can variable.

Whatever the PSA your cancer will be receiving a good old battering and will no longer be advancing.

Good luck Decho.

V

User
Posted 17 Aug 2023 at 10:28

Thanks Barry, I get your drift but I have a slightly different take on it and some of it is more about psychology and positive thinking than semantics. I don't like the word remission as it suggests a hiatus with the inevitability of recurrence. This then leads to the notion of living under a dark cloud. I chose my path of treatment with an understanding that it was focused on curative intent. I therefore like the word cured, it has connotations of liberation. The cloud has passed and therefore make hay whilst the sun shines. I also am aware that some clinicians are content to use the word cured after 5 years. 

That is my personal view and I prefer to face the day with hope rather than trepidation.

V

 
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