This was a good week for prostate cancer.  First there was a front-page article in the Sunday New York Times which reported that the drug finasteride (Proscar) may, if taken regularly, lower one’s risk of developing prostate cancer by 30%.  Then there was a study by Dr. Ornish of UC San Francisco, (excellent hospital), which showed that “lifestyle changes” trumped bad genes in men with early PC!  “Genetic nihilism” is a thing of the past!  So they say.  But I would like to trumpet the news that hit closest to home.  Dear husb had salvage radiotherapy just about a year ago for recurrent prostate cancer.  So when I saw this, I was thrilled:

A research study performed at Johns Hopkins hospital whose results were reported in the Journal of the American Medical Association found that radiation therapy for prostate cancer that has recurred, also called “salvage radiotherapy”, has been shown to prolong life – if performed within 2 years — even in aggressive cases. 

This story took center stage in the medical news and I urge you to read it in its entirety:

http://uk.reuters.com/article/healthNewsMolt/idUKN1738226020080617

http://www.washingtonpost.com/wp-dyn/content/article/2008/06/17/AR2008061701645.html

http://www.sciencedaily.com/releases/2008/06/080617160804.htm

The implications of the Hopkins study are huge, if only because the findings are counter to what was believed by many PC researchers.  First, we now know that there is an effective treatment for recurrent PC.  It was reported that 86% of men who received salvage radiotherapy (SRT) were alive after 10 years.   Deaths were reduced by two-thirds.  More exciting, salvage rad appeared to be working on aggressive tumors, i.e., high-grade (e.g. high Gleason score) and fast-growing (high PSA velocity) ones.  The researchers are not sure why and how this works, but the important thing is that it does.   From Reuters:

While past studies have found radiation therapy helps keep tumors from growing, the latest study is the first to show a survival benefit from radiation therapy in aggressive prostate cancer that has returned. . .

You may not think it a big deal if a treatment prolongs survival.  Isn’t that what it’s supposed to do?

Not necessarily.  Let me give you the inside story as the wife of a man who recently underwent SRT.  Believe me, I leanrned something about the subject.  I think that sharing some of it might help you better understand the issues underlying the Hopkins story and the importance of their findings.  And I also cannot urge patients enough to check out — on their own — the possibility of adding radiation therapy to surgery if they have intermediate- or high-risk cancer.  It’s much better than having a relapse.

My husband began salvage RT just about a year ago for a recurrence of PC.  (Had RP 10 ’05, PSA of .12 Jan. ’07).   He had about 40 individual treatments.  The good news is that it was painless (potential side effects are often exaggerated by surgeons) and that at 6 months his PSA was undetectable. 

Originally, when dear husb got the news about his recurrence, (as a dutiful wife) I did a whole lot of research on salvage radiation.  Of course, I was most interested in treatment outcomes.   Unfortunately, after researching outcomes for salvage rad extensively, I found the results confusing and demoralizing.  That’s because there was not a lot of reliable information out there.  Mostly guesswork.  T’s doctor said his chances of a “cure” with salvage rad was about 70%.  That was consistent with what I read in the medical papers.  Let me just explain that his odds would have been 50% if not for the fact that he had the rad done so early.  Tacked on another 20 points, it did.

HOWEVER, I noticed after reading some medical papers that, after touting the effectiveness of salvage radiation, there would be a disclaimer at the end of the article stating, “SRT has not been shown to prolong life in any patient”.  So what does it do?  Halt the progression of the disease?  Possibly.  But it’s easy for statisticians to “cook the books” to get whatever result they want.  I think in the case of the SRT studies I read the projections were based on the 5-year life expectancy of a man with PC who had been given salvage rad.  So, spouse, age 55, would almost certainly be around in half a decade.  Satisfying, but I would have preferred a longer-term outlook.

That’s why I’m one of those contrarians who recommends doing PC research sparingly.  One reason is that, unfortunately, not much is known about many areas of prostate cancer.    And statistics can confuse rather than enlighten.  I’ve heard it said that most doctors don’t even understand them.

But I did find out some important things about SRT (and adjuvant RT, which is RT given immediately after surgery before there has been any rise in PSA) that I felt were not known to the online PC community and so I tried to spread the word.  Some of the papers I read said that adjuvant and salvage RT are effective and lifesaving treatments — but that they’re “UNDERUTILIZED”.  It’s unfortunate that the newest and best treatments are often not put into practice by doctors. Sometimes you, the patient, have to take the lead.

One point that was made repeatedly is that radiation after surgery is more effective the sooner it is done.  Therefore, adjuvant radiation (done before any recorded rise in PSA) is better than salvage radiation.  What this means in practice is that if a man is at medium- or high risk for a recurrence, he should consider having RT immediately after surgery.  With salvage RT, men with a post-RP positive PSA are traditionally advised to wait 6 months in order to observe 3 successive rises in PSA to confirm that there is indeed a problem before undergoing treatment.  In our case, based on advice from some “elders” in the newsgroups, we decided to consult some radiation oncologists right away.  I have no doubt that that was the right thing to do.  And the rad oncs didn’t think we came a moment too soon.  DH had the salvage rad done when his PSA was (only) .17. 

One thing to understand about SRT is that it will only work if a recurrence of prostate cancer is localized.  The doctors have to aim the radiation at a specific part of the body, in this case, the prostate bed (where the removed prostate had lain).  The hope is that there is some residual cancer there that is giving rise to the PSA that is circulating in the body.  The other possibility is that the cancer has moved beyond the prostate area to other parts of the body, or metastasized.  In that case, the SRT would not be expected to work.

Initially it was thought that only about 16% of recurrent PC was local.  That would not bode well for salvage radiation.  But doctors were getting positive results with a (much) higher percentage of patients, so there were several possibilities to consider.  One was that more PC recurrences than had been previously thought to be distant were indeed local.  The other observation made by researchers was that even some aggressive, high velocity cancers seemed to be responding to salvage radiation (again, confirmed by the new studies).  So the assumption could be made that an aggressive, fast-growing cancer was not necessarily a metastatic one.  Or — more boldly — could the radiation of the prostate bed help in some way we don’t understand even with distant metastases?  That’s what many doctors believe.

The new research study answers some important questions.  The finding should encourage patients with aggressive cancer who might not have other avenues for treatment, and also let patients who’ve had RP know that if their primary treatment should fail there are good alternatives available.