ASTRO Congress News

[scarbrtj]

I hate that I'm now going to incorporate Pascal's Wager into consultative visits.

Best sentence to combat what academic med onc said... "Do you want to be aggressive with your cancer treatment?" People usually respond immediately to that question.

I would tell the guy flatly, it's likely that he has disease elsewhere and the chance of successful salvage is low, but it's not 0%. If he wants to be AGGRESSIVE, it is his only potential pathway to cure, with the understanding that there is also a non-0% chance of side effects.

IMHO any adjuvant treatment discussion, whether med onc or rad onc: always a Pascal's wager.

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[seper]

how about good old ProstaScint? PSA 1 --> 2 should get picked up.

 

[scarbrtj]

how about good old ProstaScint? PSA 1 --> 2 should get picked up.

I think the axumin(-) significantly lowers the pre-test positive probability for the prostascint.

 

[medgator]

This is what he wants to do, but the academic center med onc said post-op RT would be “highly toxic” and said no benefit with negative margins

Sometimes academicians make bad recommendations.

 

[evilbooyaa]

Just want to throw out something interesting: I had a patient sent to me pre-surgery with low intermediate risk disease (3+4 in low volume, PSA 6, cT1c). decided to go for surgery and was found to have pT2N0 disease with negative margins, etc.

4 weeks post-op, his PSA was 1.0. Repeat a month later was 2.0. BS and CT was negative. I recommended salvage RT. Patient went to an academic center and they said it was metastatic and start on ADT and Xtandi. Said savage RT would not be helpful because margins were negative.

So I looked it up and there are 5 studies that look at the benefit of salvage RT. Only 2 of the 5 found margin status to be a significant predictor of the benefit of salvage RT. One factor that was consistently seen as a predictor for the benefit of salvage was PSA doubling time and clearly his was short.

I just found this interesting. I heard from I don’t know how many people that margin status was all that mattered, but turns out it isn’t as important as one of the clear factors that he had which wasn't mentioned once...

I mean with a post-op PSA that high with pT2 disease and truly negative margins, they are most likely right on the presence of metastatic disease, but with no evidence of disease on standard imaging or Auxumin PET, I would still offer the patient RT.

Did he see an academic center Rad Onc or med-onc? Some people have opinions much stronger than the data present to support them and put things as fact which if you're actually practicing EBM is more nuanced. And academic med-oncs being anti-RT is not surprising. To call somebody with no proven metastatic disease as 'definitely' metastatic is shoddy oncology IMO.

I do think salvage RT does have some toxicities (especially acutely) so I wouldn't use it 'for funsies' but I think without well-defined metastatic disease I would not punt on this patient.

Did he have a LN dissection? Is there potential nodal disease that was unresected with any borderline suspicious LNs (even < 1cm in the pelvis)?

 

[BobbyHeenan]

Yes and it was negative

At least they looked I guess.

If it was me I think I'd take a 6 month ADT and RTOG 0534 style pelvic radiation and roll the dice that I wouldn't have be on long term ADT...like Scarb is mentioning above.

 

[scarbrtj]

I mean with a post-op PSA that high with pT2 disease and truly negative margins, they are most likely right on the presence of metastatic disease, but with no evidence of disease on standard imaging or Auxumin PET, I would still offer the patient RT.

Arguments for localized dz and/or localized RT:
1) Nomograms predict ~50% risk of ECE disease (I should say~50% chance of in-prostate dz only) for cT2 PSA6 Gl3+4 patients preop
2) Negative axumin and bone scan
3) Decreased risk of metastatic disease with Gleason primary 3, PSA<10 at presentation; only ~1% of patients similar to this one expected to have metastatic disease
4) Rate of pathology discordance relatively high; negative margins may be positive margins in another pathologist's hands
5) Patient had substantial PSA decrease after surgery suggesting even if metastatic dz most of dz burden was local; this argues for local RT even w/ metastatic disease as there is prob benefit with local RT in met dz

Arguments for metastatic disease and/or against local therapy:
1) Magnitude of PSA rise after surgery: 1->2, and lack of PSA<0.1.
2) Post-op RT is toxic

And it's "likely" he has metastatic disease? Hmm. I'd say 50/50 at best, +/- 25% heh.

 

[Mandelin Rain]

1 month doubling time? PSA of 1.0 after "complete" resection. I'd hazard it's 95% likely (+/-5%) that he has disease outside the bed.

 

[radiation]

Just want to throw out something interesting: I had a patient sent to me pre-surgery with low intermediate risk disease (3+4 in low volume, PSA 6, cT1c). decided to go for surgery and was found to have pT2N0 disease with negative margins, etc.

4 weeks post-op, his PSA was 1.0. Repeat a month later was 2.0. BS and CT was negative. I recommended salvage RT. Patient went to an academic center and they said it was metastatic and start on ADT and Xtandi. Said savage RT would not be helpful because margins were negative.

So I looked it up and there are 5 studies that look at the benefit of salvage RT. Only 2 of the 5 found margin status to be a significant predictor of the benefit of salvage RT. One factor that was consistently seen as a predictor for the benefit of salvage was PSA doubling time and clearly his was short.

I just found this interesting. I heard from I don’t know how many people that margin status was all that mattered, but turns out it isn’t as important as one of the clear factors that he had which wasn't mentioned once...

Were you able to personally speak to the consulting physician at said academic center to hear their rationale?

 

[scarbrtj]

1 month doubling time? PSA of 1.0 after "complete" resection. I'd hazard it's 95% likely (+/-5%) that he has disease outside the bed.

"Outside bed" but inside pelvis: RT still useful. But for sake of argument let outside bed equal M1 disease. The med onc diagnosed M1 purely from these PSAs. The pretest probability--given a PSA <10, primary Gleason of three, stage T2 disease, and negative axumin and bone scan--for being M1 is ~1%. Now let's assume the PPV (positive predictive value) of this patient's PSA doubling from 1 to 2 in 1 month is truly 95% and the sensitivity of the test is 95% (very generous/optimistic)... how high would the specificity of PSA doubling time (DT) need to be to give a PPV of 95%?

.............disease......
..........(+).......(-)...
test(+)....95........x....
test(-)....5.........y....
..........100.......9900..
1. PPV=95/(95+x); assumed PPV=0.95
2. 0.95=95/(95+x)
3. x=5
4. y therefore equals 9895; x+y=9900
5. Specificity = y/(x+y) = 9895/(9895+5) = 99.95%

Therefore, assigning a ~95% PPV for M1 disease on the basis of PSA DT *in this scenario, for this pre-test probability* would make PSA DT the most specific test for M1 prostate cancer known to man. It would make PSA DT one of the most specific tests in medicine. PSMA scans "only" have a specificity of ~95-99% so PSA DT would be ~2-3 orders magnitude more specific than PSMA scans i.e. no need for PSMA scans anymore just rely on PSA DT. As can be seen, assuming a PPV of 95% on the basis of PSA DT obviously leads to some absurd conclusions, or at least nose-scrunching.

I am saying you still have to consider the other factors in this case outside of the doubling time which is suspicious, granted, but in no way settles the situation to a 95% certainty level. Even if PSA DT has a high 95% sensitivity/specificity you can plug that back in to the 2x2 table and find the PPV is... 50%. If truly 95+% chance of met dz, the NNT for RT would be so high it would mean RT would be futile. But I do not think RT is futile here. And a ~50% PPV for the PSA DT given the totality of all the other factors is more "believable" than a ~95% PPV.

 

[thesauce]

I mean with a post-op PSA that high with pT2 disease and truly negative margins, they are most likely right on the presence of metastatic disease, but with no evidence of disease on standard imaging or Auxumin PET, I would still offer the patient RT.

Did he see an academic center Rad Onc or med-onc? Some people have opinions much stronger than the data present to support them and put things as fact which if you're actually practicing EBM is more nuanced. And academic med-oncs being anti-RT is not surprising. To call somebody with no proven metastatic disease as 'definitely' metastatic is shoddy oncology IMO.

I do think salvage RT does have some toxicities (especially acutely) so I wouldn't use it 'for funsies' but I think without well-defined metastatic disease I would not punt on this patient.

Did he have a LN dissection? Is there potential nodal disease that was unresected with any borderline suspicious LNs (even < 1cm in the pelvis)?

2 nodes on each side were negative. Yes he saw an academic radonc at that same institution (a couple months after the medonc and after my rec for salvage RT), who said no salvage RT

 

[thesauce]

"Outside bed" but inside pelvis: RT still useful. But for sake of argument let outside bed equal M1 disease. The med onc diagnosed M1 purely from these PSAs. The pretest probability--given a PSA <10, primary Gleason of three, stage T2 disease, and negative axumin and bone scan--for being M1 is ~1%. Now let's assume the PPV (positive predictive value) of this patient's PSA doubling from 1 to 2 in 1 month is truly 95% and the sensitivity of the test is 95% (very generous/optimistic)... how high would the specificity of PSA doubling time (DT) need to be to give a PPV of 95%?

.............disease......
..........(+).......(-)...
test(+)....95........x....
test(-)....5.........y....
..........100.......9900..
1. PPV=95/(95+x); assumed PPV=0.95
2. 0.95=95/(95+x)
3. x=5
4. y therefore equals 9895; x+y=9900
5. Specificity = y/(x+y) = 9895/(9895+5) = 99.95%

Therefore, assigning a ~95% PPV for M1 disease on the basis of PSA DT *in this scenario, for this pre-test probability* would make PSA DT the most specific test for M1 prostate cancer known to man. It would make PSA DT one of the most specific tests in medicine. PSMA scans "only" have a specificity of ~95-99% so PSA DT would be ~2-3 orders magnitude more specific than PSMA scans i.e. no need for PSMA scans anymore just rely on PSA DT. As can be seen, assuming a PPV of 95% on the basis of PSA DT obviously leads to some absurd conclusions, or at least nose-scrunching.

I am saying you still have to consider the other factors in this case outside of the doubling time which is suspicious, granted, but in no way settles the situation to a 95% certainty level. Even if PSA DT has a high 95% sensitivity/specificity you can plug that back in to the 2x2 table and find the PPV is... 50%. If truly 95+% chance of met dz, the NNT for RT would be so high it would mean RT would be futile. But I do not think RT is futile here. And a ~50% PPV for the PSA DT given the totality of all the other factors is more "believable" than a ~95% PPV.

I agree with you 100%. That is one of the arguments we made: his pretest probability of having metastatic disease is 1% or even lower. There’s are studies out there with thousands of patients and not a single one had metastatic disease with these numbers

 

[thesauce]

Were you able to personally speak to the consulting physician at said academic center to hear their rationale?

Yes. All he said was he couldn’t make sense of the case any other way than it being metastatic

I explained that evidence-based medicine is not intuitive. The data shows that he would benefit from salvage RT, and either way it is the only curative possibility in the scenario and the guy is super young and healthy

 

[xrthopeful]

Prostate Cancer - Predicting PSA Recurrence Following Salvage Radiation Therapy

riskcalc.org

Based on the risk calculator, after salvage radiation, he has a 30 percent chance of being biochemical recurrence free at 5 years and 15 percent at 10 years. 10 year chance of mets is 40% with salvage.

It’s not wrong to give salvage RT (this is one case you HAVE to give ADT with), but I definitely see what the med onc is saying. But in a young guy, AFTER whatever next gen imaging you have available locally (PSMA or auximin) then I think reasonable to proceed knowing that chances are you’re not going to help, but it’s worth a shot.

 

[xrthopeful]

I agree with you 100%. That is one of the arguments we made: his pretest probability of having metastatic disease is 1% or even lower. There’s are studies out there with thousands of patients and not a single one had metastatic disease with these numbers

What studies are you talking about? Not a single one? You’re going too far the other way.

It’s not wrong to give him salvage, but decent chance he has micrometastaric disease. Less than one percent??

 

[Palex80]

The problem when weighing the risk of salvage RT versus not salvage RT is we often don't know, unless we treat the prostatic fossa...

Of course we all recall the patients progressing with macroscopic metastatic disease immediately after treating the prostatic fossa (without any or with only a marginal PSA decline post-RT) or the ones that developed macroscopic metastasis quite soon after it was decided not to treat the prostatic fossa, however:

I also recall patients where salvage RT was omitted and who did not show macroscopic metastasis.
The PSA kept rising and at some point someone decided to start an ADT.
We will never know if these patients would have been salvageable with RT in the first place...

These may also be the patients that were included in the 3 "SPA-trials", looking at Enzalutamide, Apalutamide, Daralutamide. Non-metastatic castration resistant patients, of which some were probably treated with ADT after failing surgery, because someone thought salvage-RT wasn't worth a try.

 

[scarbrtj]

What studies are you talking about? Not a single one? You’re going too far the other way.

It’s not wrong to give him salvage, but decent chance he has micrometastaric disease. Less than one percent??

You have misunderstood. Yes, men with PSAs of 1 and primary Gleason 3 and pT2N0 disease and multiply negative staging scans have ~1% chance of metastatic disease and before the PSA of 2 was returned a diagnosis of M0 was ostensibly made. If you run another "test" (ie repeat PSAs close in time and see if you can get one to go to 2) you can then change this ~1% probability upwards or downwards on the basis of the "test." The prevalence of metastatic disease is assumed to be low in this population and a PSA of 1->2 in 1 month is now being assumed to allow an outright diagnosis of metastatic disease; ie taking his probability of metastatic disease from 1%->95%. That's what the med onc is saying: a diagnosis of metastatic disease is obvious and is made. It's specious.

 

[Mandelin Rain]

I think in the setting of negative margin a post op PSA of 1 that doubles to 2 in a month means there is almost assuredly a metastasis of some sort. Nodal? Bone? I don't know. But unless the urologist left half the benign prostate in the pelvis or the pathologist completely screwed up, the PSA is coming from somewhere (else). Just common sense. No equations nor trial needed.

 

[scarbrtj]

I think in the setting of negative margin a post op PSA of 1 that doubles to 2 in a month means there is almost assuredly a metastasis of some sort. Nodal? Bone? I don't know. But unless the urologist left half the benign prostate in the pelvis or the pathologist completely screwed up, the PSA is coming from somewhere (else). Just common sense. No equations nor trial needed.

Heh. Define "almost assuredly." That is some pretty high faith in what I think is a single lab value being measured against another single lab value w/ 1 month interval. To go from ~1% to ~95% probability on the basis of this one "test" requires PSA DT in this case to be phenomenally specific; it, of course, is not. "There is a significant variability between two serum PSA measurements obtained within a short-time interval, which is due to chance alone." Keep that in mind. Also we needn't conflate nodal and bone "metastasis." RT still helpful for nodal "metastasis" and it's not an M1 diagnosis... an M1 diagnosis which the med onc (wrongly) made. Unfortunately we don't allow quantum staging where a patient is a blend of M0 and M1. Treatment decisions are binary: do the tx, or don't. Metastatic staging is binary: M0 or M1. I argue there is *no* reason to stage this guy as M1 (would be a mis-staging by a tumor registry e.g.), thus no reason to omit RT. (BTW, pathology "screw up" rate is not ~0% if you define a screw up as one pathologist will call T2 where another will call T3a, or one will call negative margins and another will call positive margins... pathology is a human endeavor prone to error and disagreements. Well at least it's human for now.)

 

[Mandelin Rain]

Never said I wouldn't do the treatment. I would, because there is a decent enough chance the PSA is coming from a nodal metastasis and sometimes that's a salvagable situation. My point is that the PSA is coming from somewhere and it's not the bed. What the med onc said ain't all right, but it ain't all wrong either.

Linking articles of PSA variability among men with native prostates has no bearing when a man has no prostate. It's akin to believing a man with a greatly elevated Beta hCG is expecting because studies show variable levels during pregnancy. Umm, he doesn't have a uterus.

 

[xrthopeful]

all I can say is if you're going to treat this guy - you better have done advanced imaging studies, you need to treat the pelvis, and you need to give ADT.

 

[scarbrtj]

Never said I wouldn't do the treatment. I would, because there is a decent enough chance the PSA is coming from a nodal metastasis and sometimes that's a salvagable situation. My point is that the PSA is coming from somewhere and it's not the bed. What the med onc said ain't all right, but it ain't all wrong either.

Linking articles of PSA variability among men with native prostates has no bearing when a man has no prostate. It's akin to believing a man with a greatly elevated Beta hCG is expecting because studies show variable levels during pregnancy. Umm, he doesn't have a uterus.

Yeah I noticed you said you would do the treatment, yet you think the prob of M1 is 95%. If, at best, this means we are irradiating only 5/100 men who can possibly be helped, and we will maybe ultimately help only half of them, the NNT is, at best, about 40 which is pretty high/almost futile. Yet, you choose tx. By offering local RT a diagnosis of M0 is being made. Again, rightness or wrongness or M0 or M1 can't be in a superposition of states. When a tx is given (or decided to be withheld), the choice and dx is made. I like to have this discussion about PCI e.g. (because it seems to make people really mad). When PCI is given, a diagnosis of brain mets is being made. (No one writes it down, no one voices it... but it's being made. Else, the rad onc is a masochist or believes in the supernatural power of radiation to prevent cancer cells from migrating to an area.)

 

[xrthopeful]

I linked the risk calculator above which comes from the nomogram published in JCO. It's the best data we have to guide us.

His chance of salvage RT saving him from biochemical recurrence is low.

 

[medgator]

His chance of salvage RT saving him from biochemical recurrence is low.

Only curative option left for him.

Many would take the gamble to avoid lifelong ADT/lupron (way more toxic long term than xrt imo)

 

[Mandelin Rain]

Yeah I noticed you said you would do the treatment, yet you think the prob of M1 is 95%. If, at best, this means we are irradiating only 5/100 men who can possibly be helped, and we will maybe ultimately help only half of them, the NNT is, at best, about 40 which is pretty high/almost futile. Yet, you choose tx. By offering local RT a diagnosis of M0 is being made. Again, rightness or wrongness or M0 or M1 can't be in a superposition of states. When a tx is given (or decided to be withheld), the choice and dx is made. I like to have this discussion about PCI e.g. (because it seems to make people really mad). When PCI is given, a diagnosis of brain mets is being made. (No one writes it down, no one voices it... but it's being made. Else, the rad onc is a masochist or believes in the supernatural power of radiation to prevent cancer cells from migrating to an area.)

Nah. I said 95% disease outside the prostate bed. You're just doing a bad job of quoting me. I only didn't say 100% because I was recently accused of being EXTREME for discussing early retirement.

That of course includes both nodal and distant mets. I regularly treat N1 prostate cancer with XRT. However, a standard of care option for either nodal or distant mets is ADT without XRT.

Like I said, the guy wasn't all right, but he wasn't all wrong either.

 

[evilbooyaa]

2 nodes on each side were negative. Yes he saw an academic radonc at that same institution (a couple months after the medonc and after my rec for salvage RT), who said no salvage RT

Well of course the rad onc has to parrot the opinion of the referring med onc. Many rad oncs have zero spine and will frequently just agree with med-onc without assessing the case themselves or challenging somebodies opinion (especially when reliant on referrals). While I don't plan to ever be that person, I have seen that they certainly exist.

 

[scarbrtj]

Well of course the rad onc has to parrot the opinion of the referring med onc. Many rad oncs have zero spine and will frequently just agree with med-onc without assessing the case themselves or challenging somebodies opinion (especially when reliant on referrals). While I don't plan to ever be that person, I have seen that they certainly exist.

"The surest way to corrupt a youth is to instruct him to hold in higher esteem those who think alike than those who think differently."- Nietzsche

Many of our new rad oncs are somewhat corrupt

 

[medgator]

Well of course the rad onc has to parrot the opinion of the referring med onc. Many rad oncs have zero spine and will frequently just agree with med-onc without assessing the case themselves or challenging somebodies opinion (especially when reliant on referrals). While I don't plan to ever be that person, I have seen that they certainly exist.

Used to be more timid when I first got out.

Now it definitely goes both ways. Have a few mo referrals where I didn't radiate or did more wu before pulling the trigger

 

[evilbooyaa]

Used to be more timid when I first got out.

Now it definitely goes both ways. Have a few mo referrals where I didn't radiate or did more wu before pulling the trigger

Did those med-oncs refer to you again after that? I feel like its 50/50. Some will respect your opinion, others will internally shriek "Do as I say radiation therapist!!"

 

[medgator]

Did those med-oncs refer to you again after that? I feel like its 50/50. Some will respect your opinion, others will internally shriek "Do as I say radiation therapist!!"

Yes. I also get direct referrals from specialists, so that helps when they decide to not play ball. That helps.

I think the longer you are in a practice setting and the more "cred" you develop with the MOs as well as other referring physicians, the easier it is to be honest all around

 

[xrthopeful]

Only curative option left for him.

Many would take the gamble to avoid lifelong ADT/lupron (way more toxic long term than xrt imo)

I agree.

 

[scarbrtj]

I linked the risk calculator above which comes from the nomogram published in JCO. It's the best data we have to guide us.

His chance of salvage RT saving him from biochemical recurrence is low.

This shows somewhat the frivolity of nomograms and the malpractice-ish dithering they've been doing in the guy's case. When he first presented postop he had a PSA of 1. One month later, the PSA becomes 2, and yes the nomogram now says his chances have fallen off a cliff. And boom all of a sudden he's got M1 disease because of PSA 1->2. What a PSA.

 

[xrthopeful]

if his biology was such that his PSA went from 1 to 2 that quickly, then you're right, his chance of cure was never going to be 50% at 5 years if treated at PSA 1. nomograms can't capture that. thanks for making my point even more-so.

point is that this guy has all the bad features that make you think salvage is not going to work. every factor.

that said - again, salvage is reasonable to try - he's young, 'so you're saying there's a chance' etc etc etc

 

[scarbrtj]

if his biology was such that his PSA went from 1 to 2 that quickly, then you're right, his chance of cure was never going to be 50% at 5 years if treated at PSA 1. nomograms can't capture that. thanks for making my point even more-so.

point is that this guy has all the bad features that make you think salvage is not going to work. every factor.

that said - again, salvage is reasonable to try - he's young, 'so you're saying there's a chance' etc etc etc

To take that logic to its extreme conclusion, one should delay treatment on all postop PSA 1 patients as long as possible to see if their PSA can go to 2 so we can possibly exclude them from treatment. Or at least let the temperature of our smugmometer rise so we can offload some of the responsibility when the salvage RT doesn't work? "His biology" is as much due to poor clinical decision-making (obtaining repeat PSAs close together in time, not starting a tx, etc) as it is to... his biology maybe. If everyone is going to harumph harumph for RT at PSA 1, then start RT, and check a PSA one month later halfway into treatment and it's 2... what would people do? Cancel his RT???

 

[deleted1002574]

The smugmometer is the device of choice of rad oncs, especially here - where everyone who doesn’t practice exactly the same as you is a ***** or a money grubbing dirt bag.

#WeTheMorons

 

[scarbrtj]

The smugmometer is the device of choice of rad oncs, especially here - where everyone who doesn’t practice exactly the same as you is a ***** or a money grubbing dirt bag.

#WeTheMorons

Heh. "Smugmometers" (my neologism, you're welcome) and calling others *****s etc. is a psychological defense mechanism for the ego when it feels the tension of a cognitive dissonance. Especially prevalent in religion and politics; unfortunately present in medicine and radiation oncology. Hopefully this guy will get offered some form of treatment because with a PSA DT of 1 month, in a year and a half or two his PSA is going to be over one billionmillion! If he still has no objective and documented evidence of metastatic disease at that time and is still healthy and asymptomatic, I would still offer pelvic RT even if his PSA were a million. I don't think PSA = 10E6 fits in any nomogram, but is admittedly and probably a more specific test of metastatic M1 (not N1!) disease than PSA = 2.

 

[xrthopeful]

I didn’t say anything smug. I even said it was reasonable to treat.

But make no mistake - a PSA going from 1 to 2 in ONE MONTH is bad biology.


This is literally not controversial.

 

[medgator]

I didn’t say anything smug. I even said it was reasonable to treat.

But make no mistake - a PSA going from 1 to 2 in ONE MONTH is bad biology.


This is literally not controversial.

Until you repeat it a month later and it's 1.5

 

[scarbrtj]

I didn’t say anything smug. I even said it was reasonable to treat.

But make no mistake - a PSA going from 1 to 2 in ONE MONTH is bad biology.


This is literally not controversial.

Well then I'm just makin' mistakes all over. To take what is an early-stage prostate cancer patient and attach the moniker of bad biology based on a single PSA data point seems controversial. In fact it's so controversial everyone here in this forum has said treat the guy (and we are the treaters of these types guys), but when same said guy goes to someone who's a never-treater of these guys that guy says don't treat! (What if the PSA had been repeated 5 days after the PSA of 1 and it returned as 2? That must mean a patient is about to die.) Ideally one might want several months of data points; kinetics/DT obviously helpful but I just can't find any data re: 1-month slices in time. I doubt we will find any data that a PSA rise of 1 to 2 in the immediate <3 month postop setting for pT2N0 Gl3+4 PSA=1 is more or less indicative of bad biology, metastatic disease, or localized disease once all staging (pathologic and radiologic) has been done to equal M0. IMHO, the Gleason score, and primary Gleason grade especially (his was 3), are far more salient predictors of biology when PSAs in a patient have been <10. One may wind up vacillating a patient's prostate cancer all over the place if we do monthly PSAs on patients. What if next month his PSA is 2. And the month after that also 2. And the month after that it's 1.5. Could happen, and then his biology would've went from good-->bad-->good? Like Twain said, "It ain't what you don't know that gets you into trouble, it's what you know for sure that just ain't so." Someone knows for sure that this guy has bad biology/metastatic disease, and I think it's going to get the poor guy in trouble.

 

[xrthopeful]

Until you repeat it a month later and it's 1.5

How often have you seen a PSA go from 1.0 to 2.0 in one month in the post-op setting that wasn't a real PSA?

you guys are being intellectually dishonest for fun. cool.

but don't pretend to be serious.

you guys are oncologists.

the rest of the thread has their senses.

 

[medgator]

.

you guys are oncologists.

the rest of the thread has their senses.

And I am sure plenty would offer a young healthy pt the chance of cure with salvage xrt after a discussion regarding the nuances of that situation

 

[xrthopeful]

And I am sure plenty would offer a young healthy pt the chance of cure with salvage xrt after a discussion regarding the nuances of that situation

That’s literally what I have said as well, multiple times. In this thread.

With the caveat (re-posting my own words here) that I would get advanced imaging first, and then when treating would include pelvis and adt.

 

[SneakyBooger]

 

[medgator]

View attachment 282499

View attachment 282500

View attachment 282501

Wonder if the academic "med" onc knew that paper....

the academic center med onc said post-op RT would be “highly toxic” and said no benefit with negative margins

Not even sure of the point of a med onc seeing a post-RP pt except if the rad onc doesn't give ADT/hormones. Even then the RO should know the hormone data better than the med onc.

 

[Mandelin Rain]

I think you should treat without ADT just so we know who is right.

If you treated pelvis to 45Gy and bed to 68Gy without ADT and Vegas set the over/under for the first post-xrt psa at 2.0, I’d hammer the over all day.

FWIW, I recently saw a guy with Gleason 9 disease and a *gasp* negative bone scan and ct have his psa go from 90 preop to 166 postop. Nodes were negative and margin was positive. Despite the lack of clear evidence of Mets, I did not offer him salvage radiation. I’m sure some flowchart or nomogram or calculator would tell me there’s like a 15% chance of salvage or some nonsense, but I know it’s zero.

The other guy... it’s better, but not much. Certainly not 50/50.

 

[Palex80]

Yes and it was negative

Based on what evidence did they give him a combo of ADT and Xtandi?

Non–metastatic (all imaging studies negative), hormone–sensitive (never had ADT before) disease

 

[medgator]

Based on what evidence did they give him a combo of ADT and Xtandi?

Non–metastatic (all imaging studies negative), hormone–sensitive (never had ADT before) disease

Stampede? Tried xtandi instead of zytiga?

https://www.nejm.org/doi/full/10.1056/NEJMoa1702900

 

[Palex80]

Stampede? Tried xtandi instead of zytiga?

https://www.nejm.org/doi/full/10.1056/NEJMoa1702900

For metastatic patients data exist for Zytiga, Xtandi and Docetaxel. But this fellow here only has a rising PSA without any detected metastasis.
These patients were not included in the trials.

Active surveillance or ADT alone are standard of care for this scenario.

 

[medgator]

For metastatic patients data exist for Zytiga, Xtandi and Docetaxel. But this fellow here only has a rising PSA without any detected metastasis.
These patients were not included in the trials.

Active surveillance or ADT alone are standard of care for this scenario.

Stampede included high risk non metastatic pts

 

[scarbrtj]

I think you should treat without ADT just so we know who is right.

If you treated pelvis to 45Gy and bed to 68Gy without ADT and Vegas set the over/under for the first post-xrt psa at 2.0, I’d hammer the over all day.

FWIW, I recently saw a guy with Gleason 9 disease and a *gasp* negative bone scan and ct have his psa go from 90 preop to 166 postop. Nodes were negative and margin was positive. Despite the lack of clear evidence of Mets, I did not offer him salvage radiation. I’m sure some flowchart or nomogram or calculator would tell me there’s like a 15% chance of salvage or some nonsense, but I know it’s zero.

The other guy... it’s better, but not much. Certainly not 50/50.

A PSA of 166 has a higher specificity for M1 disease in the postop setting than a bone scan (or a PSA of 2). So likely a more accurate treatment withholding decision than the med onc made.

For metastatic patients data exist for Zytiga, Xtandi and Docetaxel. But this fellow here only has a rising PSA without any detected metastasis.
These patients were not included in the trials.

Active surveillance or ADT alone are standard of care for this scenario.

Well, see, he had a PSA rise of 1 point, from 1 to 2. That means he has metastatic disease. It’s really unfortunate. If only his docs had “believed” the initial PSA of 1 and not repeated it a month later. Reminds me of those people whose birthdays are Dec 31st and who say “If I’d been born one day later I’d be a whole year younger.”