Recently diagnosed with T3a, seeking treatment fast help!

nexusnijmegen · New User Joined: 25 Jul 2008 Posts: 6

Hi there. I have a question. My dad was diagnosed with PC 2 weeks ago in July 2008 and we are still reeling from the news. Initially it was diagnosed as a T2b, Gleason 4 + 4 = 8 cancer, PSA = 6.2. However what was the problem was that in February, PSA was only 2.0, which meant a very high rise velocity.

After reading from numerous sites and forums and discovering what it was, fast action was finally taken and he did a RP one week ago. Unfortunately, it was diagnosed that one lymph node was infected and infected up bladder neck. And diagnosed it to be T3a.

As such, the doctor suggested ADT. My question is, how long after RP can ADT be started? And since it has 'just spread' is there a way to do salvage radiation first as well as a precaution? Or do doctors just go straight for hormone therapy??

Thanks!

Replicant · Moderator Joined: 01 Nov 2006 Posts: 273

Lymph node involvement makes it less likely (according to researcher Andrew Stephenson' nomogram available at nomograms.org) that salvage or adjuvant radiation would work, but doesn't by itself rule it out. That would be a good question to ask a radiation oncologist.

I believe ADT can be started as soon as your dad feels like it, but there's no need to rush. Some doctors believe sooner is better, but others (Walsh, for example, citing a large VA study) would say it's okay to hold off for a while. At any rate, waiting a few weeks won't hurt as far as ADT goes.

And if it turns out that your dad is a candidate for radiation, ADT won't hurt and could possibly help.

What was your dad's Gleason after surgery? And did he have positive or negative surgical margins?

There won't be any easy answers here. I suggest consulting outside of urology, with a medical oncologist and radiation oncologist.

Best wishes.
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T3a, N0M0, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 <0.1, 12/07 <0.1, 4/08 <0.1, 11/08 <0.1
http://pcabefore50.blogspot.com

nexusnijmegen · New User Joined: 25 Jul 2008 Posts: 6

Hi there, thanks so much for the help because it is all panic right now..

Before surgery: PSA 6.2, G8, T2b, MRI scans all nothing

After surgery: G8 (4+4), T3a, one lymph node involved

But I don't really understand, why should ADT take time. To me it seems that it has 'just' escaped as of this moment. (maybe not) The doctor never spoke of positive or negative margins though... but he told us ADT, not even radiation.

I thought that to prevent bone metasesis ADT should be started immediately? Thanks for the advice - kind of panicky!

Replicant · Moderator Joined: 01 Nov 2006 Posts: 273

Remember, I'm not a doctor.

There are two camps--one camp says "There is no benefit to letting cancer cells grow before starting ADT".

The other camp says "Given enough time, men become hormone refractory and this is because some of the cells already existing do not respond to ADT, and over time, these cells become the survivors and the most prevalent. It doesn't matter whether you start now or later, because these cells don't care--however, start before you have metastases." That's how I understand and paraphrase that camp's point of view, as articulated by Walsh.

PCa is not like breast or pancreatic cancer, or the others that can move like wildfires.

The cancer has been growing for years--decades, probably. A few weeks won't make any difference, IMO.

Eventually all men become hormone refractory and ADT stops working, unless they die of something else unrelated in the meantime. Sometimes ADT can stave off the PCa long enough that the patient is never bothered by it, and they die at a ripe old age of a cardiopulmonary event, like most of the human race.

Walsh says, in italics, on p. 462: "There is one crucial concept here that you need to understand: ultimately--although it may take years--combined androgen blockade is going to stop working, just as every hormonal therapy does...It's because of the hormonally independent portion of the cancer--the cells that couldn't care less what hormones its host is taking, because hormones have no effect on this portion of the tumor." End of quote.

Now, the new drug in trials MAY change this equation. Only time will tell.

As to why the doctor is only talking ADT, I'm not qualified to answer--but I do know that most doctors are naturally biased towards their own specialties. If you really want to know if radiation is an option, get your dad to see a radiation oncologist. To answer questions about the timing of ADT, a medical oncologist--preferably one who specializes in PCa, is the one to see.

Some people would say that at this point, the urologist's job is over. While urologists all over the world DO administer hormone therapy, remember that they're surgeons by training, and that they do many, many things related to genitourinary problems--bladders, kidneys, prostates, sexual problems, incontinence, etc...while a medical oncologist does hormonal and chemo therapies ALL the time. Same with radiation and radiation oncologists.

It would be advisable to broaden your father's medical team.

When Senator Kennedy got his diagnosis of brain cancer, he convened a roundtable of experts--on radiation, chemo, surgery, from multiple leading medical centers. All the docs got his records. If they couldn't come to the meeting, they dialed in. And after hearing them present their viewpoints and debate treatment strategies, he made his decision.

Obviously, only the wealthy and powerful can do this. But ordinary folks like us can scale this down to our means--by consulting with all relevant specialties.

I wish you and your father the best.

Johnw100 knows a lot more than I do about ADT, and I'm sure he will have something to say about that. As to the timing--I don't know. There seem to be studies on both sides of the fence. I'll defer to John's opinion on that subject.

Good luck!
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T3a, N0M0, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 <0.1, 12/07 <0.1, 4/08 <0.1, 11/08 <0.1
http://pcabefore50.blogspot.com

nexusnijmegen · New User Joined: 25 Jul 2008 Posts: 6

Thank you for your opinions! Its always nice to know about another opinion especially suddenly knowing / learning so much terminology and the works over the past couple of weeks!

I'll look more into ADT techniques, as long as I roughly understand what is going on, as in RUSHED into RP, and delay into ADT.

Replicant · Moderator Joined: 01 Nov 2006 Posts: 273

One thing I forgot to add.

I don't know whether or not your father would be a candidate for radiation. The combination of rapid doubling time, high Gleason, and spread of the disease may contraindicate a rescue attempt with pelvic radiation. However, IF HE IS a candidate--as determined by a good radiation oncologist-- then time is important.

If radiation is done after prostatectomy before seeing a rise in PSA, it's called adjuvant.

If radiation is done after PSA starts to climb, it's called salvage (that's what I had, for what it's worth).

Salvage radiation is best done early. (Adjuvant radiation is always done "early" by its very definition). Stephenson and others have shown that it's important to start before PSA hits 1.0, and optimally at 0.5 or lower.

While PSA BEFORE prostatectomy is fraught with controversy and inaccuracy in prediction, AFTER surgery it's a very useful indicator of what's going on. Your father's doctor should be watching him closely, checking PSA every 90 days at this point.
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T3a, N0M0, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 <0.1, 12/07 <0.1, 4/08 <0.1, 11/08 <0.1
http://pcabefore50.blogspot.com

nexusnijmegen · New User Joined: 25 Jul 2008 Posts: 6

Interesting... about the note about radiation. I was reading an [url]http://advancedprostatecancer.net/?p=353[/url] but I'm half wondering what puts him for any sort of radiation. Even prior to the operation the urologist asked the radiation oncologist which said that radiation is normally not done on Gleason 8 patients as a sole procedure.

Although I would ask again for a second opinion when he gets his first PSA test after the RP. (I wonder what would be the score, considering that it wasn't that high in the first place) I guess I am just apprehensive on the doctors speaking of ADT that early in the game, and the fact that my dad is still young.

Another question though, what are negative and positive margins? If there was cancer up the bladder neck does that mean positive margins? The only description written on the biopsy is current T3a, and we were told it is because of that one lymph node?

Replicant · Moderator Joined: 01 Nov 2006 Posts: 273

I guess the questions about margins is rather silly, since the cancer is definitely out of the prostate.

Positive surgical margins exist when cancer is found right up to the cut edge of the removed tissue.
Negative margins exist when there is a margin of cancer free tissue at the cut edge of the removed tissue.

Positive margins can shift odds in favor of salvage radiation working, since they provide a local explanation for rising PSA after surgery.
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T3a, N0M0, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 <0.1, 12/07 <0.1, 4/08 <0.1, 11/08 <0.1
http://pcabefore50.blogspot.com

johnw100

As such, the doctor suggested ADT. My question is, how long after RP can ADT be started?"

Studies have used the criteria of within 3 months.

Men with T3, lymph-node metastases, or positive surgical margins have done significantly better with hormonal traatment soon after surgery: they have also done better than men who had organ confined cancer who did not undertake adjuvant therapy.

For a long period Dr Zincke and Mayo Clinic have treated a lot of patients with lymph node involvement by surgery and hormonal therapy and have published detailed material on their results.

I can recommend two books written by doctors who have both used hormone treatment for their own high risk Prostate Cancer:

Lee Nelson MD published his comprehensive book "Prostate Cancer Prevention and Cure" a few years ago. He has some information on this aspect and also discusses diagnosis, stages, treatment options, lifestyle changes, diet, supplements etc.

Dr Charles Myers, Medical oncologist, has published a lot of research papers and his book "Beating Prostate Cancer: Hormonal Therapy & Diet".
His book is essential reading for anyone considering hormone treatment, as it includes detailed information on the treatment, this particular subject and Dr Zincke's approach.

nexusnijmegen · New User Joined: 25 Jul 2008 Posts: 6

Hi Jon. We got back from the doctors and did the PSA Test. Not sure of the readings yet but expected to be low since his PSA was low to begin with PSA = 5. But reading about poorly differentiated + low PSA isn't doing good to my nerves.

The urologist also suggested that we do ADT in two weeks - one month post surgery, and then maybe later do it intermittently. He seems to be painting a very optimistic picture of it although everyone is depressed.

But thank you for listening, its really nice to have someone to hear and listen when you feel like you are drowning.

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