Adjuvant radiation + ADT after surgery for SV+ prostate cancer

A new study just published in BJU International offers data suggesting the idea that all men found to have positive seminal vesicles (SV+) after radical prostatectomy should receive immediate adjuvant treatment with external beam radiation and  androgen deprivation therapy (ADT).

We should point out immediately that this is a retrospective analysis rather than a prospective clinical trial.

Bastide et al. assessed their records on 4,090 men, all given a radical prostatectomy between 1994 and 2008 at nine centers in France. From these 4,090 men, they were able to identify 199 patients who met all of four specific criteria:

  • A pathologic finding of positive seminal vesicles after radical prostatectomy
  • An effectively undetectable PSA level post-surgery
  • No evidence of lymph node metastasis at the time of surgery
  • Patient follow-up data for a minimum of 18 months

Analysis of the available data from these 199 patients provided the following information:

  • Patients could be categorized into four treatment groups post-surgery.
    • 82/199 men (41.2 percent) received no further treatment (Group A).
    • 41/199 men (20.6 percent) received adjuvant radiation therapy only (Group B).
    • 26/199 men (13.1 percent) received adjuvant ADT only (Group C).
    • 50/199 men (25.1 percent) received adjuvant radiation therapy and adjuvant ADT (Group D).
  • The average (mean) follow-up period was 60.3 months (range, 18 to 185 months).
  • 88/199 patients (44.2 percent) had biochemical recurrence of their disease.
  • The estimated probability for biochemical recurrence-free survival at 5 years was
    • 32.6 percent for men in Group A
    • 44.4 percent for men in Group B
    • 48.4 percent for men in Group C
    • 82.8 percent for men in Group D
  • The estimated probability for biochemical recurrence-free survival at 7 years was
    • 25.9 percent for men in Group A
    • 28.6 percent for men in Group B
    • 32.3 percent for men in Group C
    • 62.1 percent for men in Group D

The authors conclude that: (a) radical prostatectomy alone is not a sufficient form of treatment for most men with positive seminal vesicles; (b) the combination of adjuvant radiation therapy with adjuvant ADT offers a substantial survival benefit compared to the other options commonly in use.

The ability to define exactly which men are at high risk for clinically significant, progressive disease at the time of diagnosis and immediately following first-line therapy is a major challenge in the management of prostate cancer. Based on the data provided above, the authors are effectively suggesting that all men found to have positive seminal vesicles at the time of surgery should be given immediate adjuvant radiation and ADT to optimize their probability of long-term survival. However, this recommendation is not based on actual survival data. We do not know how many of these men actually died of prostate cancer, how many went on to have evident metastatic disease, or how many lived out the remainder of their lives without evidence of clinically significant progression (as opposed to biochemical recurrence).

It is well understood that biochemical recurrence after first-line therapy is not necessarily a proxy for prostate cancer-specific mortality, nor is it a proxy for the occurrence of prostate cancer metastasis. The appropriateness of adjuvant radiation and adjuvant ADT in men found to have positive seminal vesicles at the time of  surgery would appear to need to take some other factors into account, including the patient’s age/life expectancy, his comorbidity status, and his personal opinions about risk. On the other hand, what does seem to be clear from this study is that if it is determined that adjuvant therapy is appropriate for a man with positive seminal vesicles at the time of surgery, then the combination of radiation therapy and androgen deprivation would seem to be more appropriate than either radiation therapy or ADT alone.

40 Responses

  1. I would be in group D. … I have two thoughts here:

    I certainly had confidence when I moved forward with adjuvant therapies that doing something was better than doing nothing after my RP discovered positive seminal vesicles. I certainly did not have this data but I used logic and logic said kicking the cancer while it was down made sense. This study clearly supports that.

    However, it is very clear in this study that as time moves on adverse conditions increase. I will be at 5 years post-surgery in February 2012. I am still in the 82% of having not had a relapse by year 5. But year 7 shows a 110% increase in biochemical failure. And we don’t know with this study if after that point biochemical failure rates level off or continue to double. Ugh! This part of this study bugs me.

    Here are some more unknowns (some of which may be available in the full paper as opposed to just the abstract):

    (1) There is no breakdown of the number of lymph nodes taken at surgery or treated with radiation.

    (2) There is no breakdown of how long adjuvant HT was instituted.

    (3) There is no Gleason score breakdown, but I would be willing to bet that the vast majority of patients in this cohort were Gleason 7 and above.

    I am hopeful by having a surgeon that removed 10 nodes, and a radiation oncologist that irradiated iliac and inguinal nodes during adjuvant therapy, and by having an “on the ball” prostate cancer oncologist that we can do better than the numbers expressed in this study.

  2. Tony:

    I think it is dangerous to over-analyze these retrospective data, which include patients treated as long ago as 1994, long before the availability of things like IMRT. It is the relative effectiveness of the four approaches that is important here, not the specific outcomes from the specific approaches. There is no doubt whatsoever that the technical ability of both surgeons and radiation oncologists have improved significantly over the past 17 years.

    Exactly how many lymph nodes a surgeon removes from an individual patients does and should depend more on what he thinks is appropriate for that patient (given what he can see and access with relative ease) rather than some absolute need to remove a minimum number of lymph nodes. The removal of lymph nodes is associated with risk for significant post-surgical complications. Removing lymph nodes just to meet some minimum number may well be appropriate as part of a prospective, randomized clinical trial, but is probably not appropriate in the management of individual patients unless there is good reason to do so.

  3. Mike,

    I can’t help but grab every angle of this study, and others I have seen like it, as it directly relates to me. This is better data than I had when I jumped into adjuvant therapies.

    I understand your point about customizing each case but having this set of circumstances, at the age of 44 when I had RP, to me meant being aggressive in my approach. Simply put, at this point I am very glad that I am not in category A, B, or C.

    I know the inappropriateness of using other studies that show a more aggressive approach with the lymphatic system improves better biochemical data and survival data and would improve these findings. But this was my point. I have reasonable expectations that newer techniques in removing more nodes, or irradiating them with IMRT can and will more than likely improve the numbers shown here in this study. It’s the same hunch I had when I started out and decided to add these adjuvant choices when this study didn’t exist …

    I believe that patients now should be informed after surgery finds SVI+ in their pathologies about all adjuvant therapy options and about the possibility that an aggressive approach with adjuvant therapies with the regional lymphatic system could be and is likely beneficial.

    It seems like a “no brainer” to me … Dangerous? It appears to me that SVI+ disease is also dangerous …

  4. Yes … Understood … But you were just 44 years old … Does the same degree of aggressiveness seem appropriate in a man with the same characteristics as you who is aged 69 and has a mild but pe-existing heart condition? That’s a very different question, but might apply to me in 5 years time.

  5. Maybe. It’s still an appropriate discussion that should be held. In my opinion no doc should decide this, the patient needs to. The doc should explain his concerns about co-morbitities at that time but I would also assume it would have been appropriate that that doc already had that discussion before he walked the patient into the operating room. After all, if pre-existing co-morbidities for an aggressive approach were a concern before surgery they clearly could have been discussed. It’s possible that just having radiation therapy could have been sufficient.

    One thing I try to instill into new members at HW or in our Us TOO group is that a newly diagnosed patient should be looking past their initial therapy options. Their concern should not be just radiation versus RP, for example. It should also be about what’s next if necessary. … At that point I talk about adjuvant versus salvage options.

  6. Your approach is admirable. … However, the ability of the “average” patient to cope with all of these issues at the time of first diagnosis and initial treatment is — as you well know — limited. Some people need to take these steps one at a time! And the best scenario in my mind is when the patient and the doctor come to mutually acceptable decisions about all treatments together.


  7. Agreed. But in the end the doc gets to skip the treatment morbidities so I would reserve my right to overrule him. I think the best take home message is that adjuvant therapies can be very beneficial when things are not as we had hoped with initial treatment. Each and every patient should understand the levels of therapy beyond initial treatment, preferably BEFORE ever taking on a 1st local therapy…

    Your point that most patients are not ready for these decisions shortly after hearing the words “you have cancer” is so very true. I was lucky in that I brought my wife but we still had a bit of work to do. We really need the docs to do their part and make sure that patients are educated enough about these things before proceeding with therapy.

    Perhaps I am thinking out loud wishfully?

  8. Ignorant questions:

    — What exactly is the process for pathological exam of seminal vesicles?

    — Is there any relationship between positive surgical margins and SVI?

    — Would every surgeon performing RP always check for SVI?

  9. Dave:

    There are NO ignorant questions!

    (1) The seminal vesicles can be biopsied just like the prostate if the urologist suspects that they may be positive for cancer. This is not common today. Usually the seminal vesicles are only examined pathologically after they have been removed at the time of surgery along with the prostate. The “process” for pathological examination of the SVs is the same as for the rest of the prostate, microscopic examination of thin slices of the SVs after staining to highlight possible areas of cancerous tissue.

    (2) There is no specific relationship between positive surgical margins and SVI that I am aware of — although clearly men with a lot of cancer in their prostates tend to be at greater risk for both positive surgical margins and SVI. By contrast, there is a relationship between Gleason score and SVI. Men with Gleason scores of 7 and higher tend to be at significantly higher risk for SVI than men with Gleason scores of 6 and lower.

    (3) Since it is standard practice to remove the seminal vesicles along with the prostate itself at the time of surgery, yes, the pathologist (not the surgeon) would always check the seminal vesicles for any indication of prostate cancer. By contrast, it is the surgeon who makes the decision whether or not there is a need to remove samples of the pelvic lymph nodes and ask for a pathological examination of the nodes.

  10. Thanks for that.

    So how long has SV pathology examination been a standard practice?

  11. For at least the last 30+ years and probably longer.

  12. Like Tony, I am in group D and also in my 40s. I am almost 3 years out from surgery, a little over 2 years from radiation, over 1.5 years from ADT ending, and 1 year from testosterone recovery into normal range. I am always interested in these studies that appear (with caveats) to support my decision, but I am not sure that this does. Here are some questions I have.

    1. When measuring time to biochemical recurrence, is this time from surgery, time from radiation ending, time from ADT ending, or time from testosterone recovery post ADT? The statistic is often mentioned in these studies but I have not seen it defined. Is there a standard definition? Seems to me it would make a difference.

    2. In the ADT alone branch, is this temporary treatment or continuous throughout the study period?

    3. What happens to those in group A, or B even, who receive radiation (+ADT?) early upon recurrence?


  13. Richard:

    As I initially said to Tony, you shouldn’t over-analyze the data from retrospective studies like this.

    I can tell you that it is customary to assess time to biochemical recurrence in studies like this from the time of the surgery. However, I can not give you answers to your second or third questions. You’d need to see if there was more detailed data in the full text of the paper.

  14. You gentlemen are very thoughtful. I had Gleason 9 prostate cancer involving 60 percent of the gland and seminal vesicle invasion but negative nodes at surgery. I had been advised not to bother with surgery since the cancer would be incurable, and that radiation with androgen deprivation was the only reasonable treatment. Fortunately, I found a urologist who was willing to do the surgery. PSA was not detectable at 6 weeks, but had risen to 0.06 at 9 months. We decided to proceed with radiation. The radiation oncologist insisted on 2 years of ADP. Even though I questioned him in detail, he was not really forthcoming in discussing any of the possible drawbacks of the treatment. Six weeks after radiation finished, my PSA was again not detectable, and my testosterone level was also not detectable.

    Now, here is the thing (for me): Before starting radiation, I was feeling great. Exercised daily, worked a full schedule, had a wonderful relationship with my wife thanks to injectable prostaglandin. Even radiation left me with minimal rectal or bladder problems. BUT, the GNRH agonist has produced a misery which I could not have anticipated — depression, weight gain, severe muscle cramps and weakness, general loss of stamina, inability to reach climax during relations, and a rising cholesterol.

    It is all right to intellectualize prostate cancer. But anatomy and PSA levels are only part of the story. We are all going to die some day. And while I do not want that to occur any sooner than necessary, I would like to enjoy the days I have rather than trying to squeeze out a few more years at the price of losing the joy of living. So, while my head tells me I might benefit in some way from androgen deprivation therapy, my heart tells me that it may well have been a mistake to get that first injection.

  15. Manning,

    Thanks for that reality check. You are spot on I think.

    FYI, I had adjuvant ADT for 12 months. My oncologist thought longer than that was too harmful to the heart, etc., but I know they all have different opinions. I am with you on how unpleasant it is and I was very glad to stop. Now, 18 months afterwards, I feel pretty much OK again. My physical fitness took a knock and reached an alarming low after ADT ended, but this has improved since I got back on my bike 3 months ago. I think I could really get back in shape if I put in the work. Unfortunately radiation side effects (not ADT) are getting in the way at the moment.

    Good luck


  16. Richard,

    Thanks for the feedback. Sounds like you have had a pretty rough time; worse than mine. I hope that time will prove a great healer for you.

    I think it is interesting that elsewhere on this web site is a reference to the new American College of Radiology guidelines which say that the use of adjuvant androgen deprivation therapy in conjunction with salvage radiation therapy after prostatectomy should be discouraged outside of a research protocol.

    With respect to the study referenced above, it looks like 50 of 4,090 French men seemed to have had some biochemical benefit from combination radiation and androgen deprivation after surgery. Of course, the study does not say the men lived better or longer or that fewer actually had real problems or early death from prostate cancer.

    To me, this is analogous to a laboratory experiment on mice which suggests that a new drug might work against cancer. But that would not justify the practice of giving the drug to all persons who have been treated for cancer by other means just in case the cancer is not all gone — especially if the potential adverse effects can be very harmful to the patient’s physical and mental well-being.

    By the way, I like my bike too. Much easier on the old knees!

    As they say, one day at a time …

  17. I had a radical prostatectomy in July. Surgery went well; unfortunately I had positive margins and seminal vesicle invasion (SVI). My Gleason score going in was 3 + 4 = 7 and was the same after the post-op pathology. Positive margins were Gleason 6 and the SVI was Gleason 3 + 4 = 7. At 8 weeks post-op my PSA was < 0.01. I'm 57 years of age.

    My surgeon, urologist, and two radiologists all agree on adjuvant radiation of the prostate bed. Because of my first PSA results they are recommending that I wait a little longer to gain better continence (which is at about 90%).

    The surgeon and one of the radiologists do not think I need to radiate the pelvic/lymph node areas (nor recommend it) whereas the other radiologist is recommending it along with ADT and prostate bed radiation. All three agree with short-term ADT (4-6 months) or at least do not have a problem with it. My lymph nodes were not biopsied so we have no definite knowledge of involvement.

    So, what to do? All of this seems to fall in a gray area so making the right decision is not straightforward. Adjuvant prostate bed radiation is a definite; ADT and pelvic area radiation are questions.

    Appreciate any insight.

  18. Warren:

    The short-term use of neoadjuvant ADT for 4 or 6 months is now supported by a good deal of data in cases such as yours — although it is always a judgement call. If you told me that they were suggesting 2 years of ADT, I would have had a different opinion.

    I can’t really comment on whether radiation of the broader pelvic area and the lymph nodes is justifiable or not. That is something where I think you need to rely on the expertise of your physicians. You appear to have a 3 to 1 decision against.

  19. Sitemaster:

    First, thanks for a great web site. I have obtained more information here in a short time than I did after months of searching the web on my own.

    Second, I have a question. Do you have any medical literature citations concerning the data you mentioned above to support ADT for 4 to 6 months but no longer? I am interested because I am now in my eighth month of ADT following prostatectomy and then radiation (including pelvic nodes) for Gleason 9 cancer with seminal vesicle invasion, positive bladder margins only, and negative lymph nodes at surgery. My PSA was 0.01 ng/ml 6 weeks after surgery, 0.06 ng/ml 9 months after surgery (at which time radiation and ADT were started), and < 0.01 ng/ml 6 weeks after completing radiation and 8 weeks after my first GnRH agonist shot. The radiation oncologist insists on 2 full years of ADT. Unfortunately, our relationship did suffer after I began to have side effects from the ADT which he seemed not to take seriously.

    I am certainly not going to disregard the advice of my treating physicians. But, I also think it is reasonable for me perhaps to challenge their assumptions which may not be supported by the literature.

    Once again, thank you for this web site.

  20. Dear Manning:

    I think it is important that I be very clear that the length of time a specific man may need to be on ADT as a component of adjuvant or salvage radiation + ADT can (theoretically) vary from as little as 4 months up to as much as 3 years. The nature of the wide variety of trials that have, in most cases, shown that adding ADT to radiation therapy in the adjuvant and the salvage settings is beneficial to minimizing risk for biochemical progression and prostate cancer-specific mortality do not — as far as I am aware — allow us to analyze subsets of the data based on things like Gleason score or post-surgical PSA levels.

    Your RAD/ONC’s insistence that — with a rising PSA post-surgery and a Gleason score of 9 — you need 2 years on hormone therapy would be seen as very reasonable by many clinicians. Indeed, until comparatively recently he would likely have insisted on 3 years of ADT. You could try arguing that since your PSA promptly dropped to < 0.01 ng/ml and has stayed there for 8 months this justifies coming off the ADT — with the condition that you would immediately go back on it if your PSA started to rise again. However, I can certainly understand your RAD/ONC's viewpoint.

    The problem with the current literature is that it supports multiple points of view, with no ceratinty about any one point of view. Of course this is the "normal" state of play with nearly all the prostate cancer literature because the "new" data is commonly out of date by the time it becomes available as a consequence of developments that have taken place while specific trials are being carried out.

    It sounds to me as though the real problem here is that your RAD/ONC is not "hearing" your fundamental problem … which is that your quality of life is suffering so much on ADT that you either need to come off the ADT or you need him to give you a compelling reason why you need to make the commitment to stay on therapy for the full 2 years. The failure or inability of this physician to hear your concern and respond appropriately is not unusual. Unfortunately he has forgotten that he is meant to be helping the whole patient as opposed to simply trying to blast all cancer cells out of your body.

  21. Thank you for your very wise advice.

  22. Dr. Manning, we have a very similar history: Gleason 9, SVI, bladder invasion with negative nodes; robotic prostatectomy 5/8/2012 preceded by degarelix; 1-month post-op PSA was zero, but 5-month PSA was 0.12.

    Am now scheduled for salvage radiation therapy next week plus 80 mg Degarelix (again monthly) for 6 months. The degarelix dropped my serum testosterone to 33 but its is now 365. I had severe daily nausea for 3 months, but the original dose was 240 mg. Hope the smaller dose will be better tolerated. As a physician I have many questions and don’t hesitate to ask them. My physicians seem comfortable with this plan. Hope they are correct.


  23. Thanks for this communication, Doc. I came off Trelstar after a year; my last injection was December 2011; PSA in September 2012 was < 0.01. I feel good; minimal incontinence, libido now intact, erections with the help of pharmacology. My urologist is very oriented to quality of life, so he agreed with abbreviating my course of ADT to less than the originally planned 2 years. I know there is a high chance of rising PSA in my future, but right now I am happy for each day.

    Your PSA dropped after surgery and it is still pretty low, hopefully indicating only a local recurrence which will respond to radiation. I think, alas, that you are getting to the nasty part. But I can tell you that there is definitely light at the end of the tunnel.

  24. Dr. Manning,

    Thanks for the reply. This was my first post and I find that hearing what others have gone through is very helpful. My radiation oncologist is also an Internist so we communicate quite well since that is also my specialty. I am 75 and hoping for 10 more good years. My incontinence persists after 5 months — though only post-voiding leakage and requiring 1 pad. I went to school with Pat Walsh and am encouraged that his article in JNCCN which shows that salvage radiation in a patient with a PSADT > 6 months, positive margins, and a Gleason score of 8-10 has a 10-year prostate cancer-specific survival of 100%. Hard to believe. I had seven negative nodes and the pathologist told me my seminal vesicle invasion (SVI) was confined to the proximal end and did not spread to the tips and that this was a good sign. I had only contiguous spread. I am encouraged and definitely see light at the end of the tunnel.

  25. Sitemaster: in my literature review and reading of posts, I see little mention of Firmagon (degarelix). I received 140 mgm 6 weeks prior to my surgery. It was in a depot form and lasted many months. I tolerated it well for 3 months but then I began experiencing daily nausea. This lasted for 2 months and caused a 22# wt. loss. I got no relief from many anti-nausea meds until I tried Ativan which had it’s own side effects. Suddenly the nausea disappeared and now I feel great. My concern now is the fact that I am to receive this same ADT with my salvage radiation. Any body out there who has had Firmagon and had the same experience? Any LHRH with fewer side effects?

  26. Dear Dr. Kailanen:

    Degarelix (Firmagon) is the only approved androgen receptor antagonist. Your initial experience with this drug may have been because of the need for an initial loading dose of 240 mg for the first month of treatment. I understand from your other messages that your radiation therapy is to be carried out with adjuvant degarelix at 80 mg per dose. Correct? One would hope that this lower dose would not be associated with the same degree of side effects as you experienced before. However, you would be wise to have some Ativan around to be on the safe side.

    Because degarelix is the only approved androgen receptor antagonist, the only other way to get a similar effect in combination with your radiation therapy would be to use both an LHRH agonist and an antiandrogen like bicalutamide (so-called “combined” androgen deprivation therapy).

    This is really an issue you need to discuss with whoever is recommending the degarelix. He or she certainly needs to be aware of your prior side effects related to treatment with degarelix. Combined androgen deprivation comes with its own list of side effects that are not dissimilar to those associated with degarelix, but at least one doesn’t have to deal with the loading dose (but now you aren’t going to have to deal with this either, if I have understood your other posts correctly). Nausea associated with LHRH therapy is (as with degarelix), known but uncommon, so I can’t really help you with whether you would have the same type of side effects in reaction to LHRH agonist therapy.

    With regard to other degarelix users … I have not come across other patients with your apparent level of nausea. The most common problem reported has been pain associated with the size of the initial loading dose of the drug.

  27. I am to begin radiation therapy with Firmagon injections as salvage therapy. Has anyone had experience with Firmagon in this setting and how long did you take the shots? I was told I would be getting 80 mg monthly for 6 months. Got the first shot last week. I also took Firmagon 6 weeks prior to my robotic prostatectomy. It reduced my testosterone to 33 ng/dl for 3 months and was associated with severe nausea. The nausea ceased as my testosterone rose to 365 ng/dl but now we are to go on it again because my PSA is now 0.12 ng/ml at 5 months post-op.

    Regarding the SVI. Not all SVI are equal. My pathologist told me my SVI involved the proximal SV and did not extend to the “tips”. There was contiguous spread from the prostate to the SV and this may not be as serious a prognostic sign. Are there any studies to show what is the most effective duration to take Firmagon with radiation.

  28. Dear Dr. Kaihlanen:

    As I thought I have stated previously (somewhere) in response to your questions above … (a) I am not aware of any good published data on the use of degarelix in combination with radiation therapy as an adjuvant or a salvage treatment for men with a rising PSA post-surgery, although such an approach can certainly be justified on theoretical grounds. (b) I have yet to come across any other patient who has ever told me that he was receiving a combination of degarelix + radiation therapy for treatment of a rising PSA.

    I am a little surprised by the pathologist’s comment about your SVI since my understanding it is not as simple as where the invasion occurs in the SVs; it also depends on the patient’s original PSA at diagnosis and his Gleason score.

  29. Do you think the reason you have yet to come across any other patients receiving this combination is because degarelix is so new and there are no completed studies at this time? I have noted there are studies under way using degarelix with varying duration in salvage therapy with radiation. It should be no different than using Lupron and Casodex. Agree? I received 80 mg last week and already the night sweats have increased significantly and I begin radiation treatments today. I am 75 years old and in great health but with Gleason 9, SVI invasion, bladder neck invasion, and positive margins; recurrent PSA 0.12, negative nodes x 7, no metastasis, and no vascular/lymphatic invasion. My doctors and I still remain optimistic and still hold out for a cure.

    Thanks for responding.

  30. Dear Dr. Kaihlanen:

    (1) Degarelix isn’t that new now. It was approved several years ago.

    (2) I am quite sure that the reason so few patients have (apparently) been treated this way is that there are no good data to support such treatment yet, although the cost factor may be an issue too.

    (3) As I have already indicated, the theoretical basis for using degarelix in this manner is very reasonable. Whether it works as well as (or better than) an LHRH agonist + an antiandrogen still needs to be proven.

    (4) It is perfectly reasonable that you and your doctors want to consider this combination of degarelix + external beam radiation as a therapy with curative intent. Hopefully, it will prove to be so for you.

  31. Dr. Kaihlanen:

    Check out the American College of Radiology web site and their Appropriateness Criteria regarding use of “androgen deprivation” with post-prostatectomy radiation. They discourage it.

  32. Dear Dr. Manning and Dr. Kaihlanen:

    These appropriateness criteria take limited note of individual variation in risk and need. There are plenty of specialists who would argue that a man like Dr. K., with a rising PSA and Gleason 9 disease, would be wise to have a brief period of ADT in combination with his radiation. In the end this is very much a judgement call made by an individual physician and the patient. Of course I have no information about the speed at which Dr. K’s PSA is rising (the PSA doubling time), which is also a key factor in this decision.

  33. It is hard to understand why they would discourage it. After reading Dr. Snuffy Myers book, it is hard to argue against any form of hormone therapy; he is such an advocate. As long as I can tolerate the low testosterone side effects, I will continue the degarelix. I am hoping the “more the better” (ADT and radiation). I never had my PSA doubling time because I had two zero PSAs and then when I had the 0.12 reading I was contacted immediately to begin the radiation salvage therapy. I am assuming it would be less than 6 months but that is only a guess. Thanks for you input.

  34. Please note my reply to Manning. Also thanks to you for your input.

  35. I have read the above posts and like the input.

    I am currently undergoing EXBT + HDBT+ 6 months of ADT. I have decided to only do 4 months ADT as I am tired of the side effects. One post mentioned that the quality of life issues may outweigh the benefit of treatment options. I have read the various articles and outcomes and have come to this conclusion. Prostate cancer is such a slow-growing cancer that focusing only on [prospective] research on humans with prostate cancer leads to a career with very few publications. We therefore get most of our information from retrospective studies and studies done by individuals who are trained very well in clinical treatment but poorly in research (some exceptions of course). This is just because of the length of time for determining if [a specific] treatment has an impact takes so long. My suggested solution, have the funding agencies, research hospitals, etc., focus on hiring researchers that have expertise in conducting clinical trials on cancers that allow numerous publications (short time needed to collect results) and do studies of prostate cancer as a sideline. We are getting most of the data from clinicians who are experts in clinical treatment of prostate cancer with little research expertise. And, not surprisingly, we have mostly articles that are difficult to interpret, address various treatments, and give conflicting results. I have a team of physicians that each have various opinions. They get their opinions from publications I hope. Individual designed treatments mean this, the doctor has a very limited and conflicting data set to read and, therefore, the patient’s guess is as good as the doctors. Let’s try to reduce the guesswork.

    By the way, I am a researcher so that is a bias I have. When I was diagnosed with prostate cancer, I was shocked by the research publications out there. God, some group just published a proposed study where they will compare length of hormone treatment in patients receiving both EXBT and brachytherapy. The fact that you can publish an article on how a study is designed shows how desperate the field is for decent research. As a patient, I was shocked. Can you imagine as a clinician trying to sort thru this crap?

  36. Just a follow up. I finished 68.4 Gy of radiation on December 28, 2012. I was receiving 80 mg Degarelix monthly during the radiation. I will continue the degarelix for 6 months in total, ending on April 1, 2013. My only concern is, should I continue it longer? I feel excellent, with only mild night sweats. I use a personal trainer weekly and take Paxil for the sweats and plenty of calcium and vitamin D. My last PSA was 2 weeks ago and was < 0.1. It was 0.12 when radiation began. I am hopefully optimistic with this aggressive approach, as are my doctors.

    Dr. K

  37. I had a RP in January. My first PSA post-surgery was 0.02; the second one was 0.01. I just had a blood test yesterday, with results due on Monday.

    This is my oncologist’s concern from my pathologic diagnosis: “Tumor extends to cauterized apical, left posterior-lateral, and base margins focally”. He said this is a positive margin and is suggesting 7.5 weeks of radiation. No discussion of ADT has been had. Is this the norm?

  38. Dear Bruce:

    There is no “norm” in situations like this. The fact that you did indeed have positive surgical margins does increase your risk for cancer recurrence and a rising PSA. However, the question of whether you or other men like you should or should not have immediate, adjuvant radiation therapy (with or without a short course of ADT) is utterly unresolved. There are a lot of data suggesting that you can afford to delay such radiation until there are clear signals of a rising PSA … assuming that you continue to monitor your PSA closely with testing every 3 months.

    Radiation oncologists have a tendency to recommend that men like you get immediate adjuvant radiation therapy; many urologic surgeons will tell you to wait until there is a clear sign that the radiation is necessary. Such recommendations tend to reflect the training and beliefs of the two types of physician.

    Other factors are also relevant (e.g., your age, your original diagnosis, your pathological stage post-surgery, etc.). If you use the Kattan post-surgical nomogram, you will be able to get a decent projection of whether you are going to have recurrent prostate cancer within 2, 5, 7, and 10 years post-surgery. If you think that probability is high, then maybe early adjuvant radiation therapy is a good idea for you, but in the end these are very personal decisions. The downside of early radiation therapy if you don’t really need it is (of course) the risk for additional side effects of treatment. And if your PSA stays down at 0.01 or 0.02 ng/ml or thereabouts, there are good reasons to think that you may never need any further therapy at all.

    No one can tell you with absolute certainty what is “right” or “wrong” in a situation like this — but lots of people have strong opinions!

  39. Thank you for the quick response and, as has been the norm, I remain in flux. I will do the nomogram and see what it predicts.

  40. I did the nomogram and the results are as follows; 98%, 96%, 95%, and 93% progression-free probability after surgery. I think I may pass on the radiation and just watch my PSA levels closely.

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