PROSTATE CANCER PATIENTS NETWORK

Intensity-modulated radiation therapy (IMRT) takes the dose planning one step further than 3-D conformal radiotherapy. Studies have clearly shown that delivery of higher doses of radiation results in better outcomes.  However, if you remember from the anatomy lesson above, the prostate lies right next  to two rather important structures: the bladder and the rectum. Radiation damage to either of these organs can result in significant urinary and bowel problems that are not only unlikely to improve over time, but that have been shown to worsen over time as the effects of radiation accumulate. To avoid these problems, oncologists might be tempted to opt for delivering lower doses of radiation - at the expense of decreasing the chances for a cure.

IMRT does exactly as its name suggests - it allows oncologists to modulate, or change, the intensity of the doses  and radiation beams to better target the radiation delivered to the prostate, while at the same time delivering lower doses to the tumor cells that are immediately adjacent to the bladder and rectal tissue. With this approach, the local side effect rate is lowered further while keeping the cure rates as high as possible.  

Regardless of the form of external radiation therapy, treatment courses usually run five days/week for about seven or eight weeks, and are typically done on an outpatient basis. (Prostate Cancer Foundation - Pg. 25)  

Good news! The PSA tests in February and late April were .01 - undetectable, the sweetest words a person can hear! The follow up PSA test will be done in August. Testosterone has recovered nicely to 500.

James F. Girand

May 7, 2010

The most recent PSA test on July 26, 2010, revealed a slight uptick to .02, from the April reading of .01. The absolute level is still very low and is a little concerning but also could be attributed to equipment variations. Too early to draw any conclusions.

Going forward, there are several scenarios that could unfold, described as follows;

1. The combination of Lupron and radiation concluded January 14th can have two effects for the yearfollowing last treatment. First, Lupron whacks the last reading of PSA before treatment (.10) to zero immediately and if cancer is present it will gradually increase. Radiation on the other hand causes PSA to decline over time and in the absence of cancer will reach a nadir of .02 to .04, more or less about one year after the last treatment and remain in that range. During the next six months the effect of these two treatments will reach a confluence so my next PSA tests, October 26 and January 2011 will be important in determining whether cancer is still present beyond the pelvic areaand lymph nodes.
2. In the event the PSA readings continue to increase they might have a 'signature' and follow a similar trajectory as I experienced in 2008 and 2009. Specifically, from October 2008 to October 2009 my PSA increased from .02 to .10,suggesting I might reach .10 around July 2011. The absolute number and doubling rate are the key factors to interpret thenature of my cancer but not useful metrics until PSA approaches 0.2. At that point, if the doubling time is more than one year, it  probably calls for extended active surveillance.
3. Looking at possible scenarios, a continued increase in PSA to numbers of more than 1.0 could bring several options.First, when PSA approaches 4, I would consider a regimen of annual Lupron treatments, one year on and one off. Lupron administered in that manner has been shown to control cancer up to 10-15 years. The year 'on' would have similar effects as my 90 day regimen last winter, notably, whacking my testosterone and causing a 5+% deterioration in my cycling performance. I did not experience hot flashes or fatigue but who knows what would happen for a whole year? A second alternative would be to enter a Clinical Trial managed by Dr. Eric Small, depending on scope and availability at that time.

In summary, we have a reasonably well defined set of milestones, two important PSA tests in October and January, and, depending on the readings, more clarity as to the status of my prostate cancer. There is a broad range of possible treatments dependingon how the prostate cancer manifests itself, if at all. From a broader perspective, time is on our side as new treatments become availableover an extended period of time.

Stay tuned - the epic battle continues......!!

James F. Girand
August 2, 2010

Additional Treatment: In May ADT (Androgen Deprivation Therapy) four month depo Lupron  (anti testosterone) with only minor side effects of hot flashes.  ADT sort of holds the cancer steady or kills some cells by denying the fertilizer of testosterone. It is best to get the incontinence solved before the radiation. In September started 7 ½ weeks of adjuvant radiation even though the PSA was still 0.0.  Radiologist explained there are slightly better statistics by starting now before the PSA rises.  External Beam Radiation Therapy (EBRT) - Intensity-Modulated Radiation Therapy (IMRT) finished in November with no side effects except a week of loose stools handled with BART  (Bananas, Applesauce, Rice and Tea)  It is important to get a good team for planning and doing the radiation and of course good equipment. There have been major advances in radiation therapy and under certain circumstances it may be a good alternative to surgery. 

73 year old male
December 30, 2007

 I started IMRT on November 30, 2009 and concluded the 34 treatments on January 14th. The protocol is to deliver two Gy/session for a total of 68. Why 68? The answer was 'experience'. As delivery has become more efficient, the total number has been increased from 65 and will probably be higher in the future. Each session takes about 15 minutes and there is no discomfort. I did not have any discernible side effects the first week and Dr.  Gottschalk said, they are best compared on a weekly basis. At this time my testosterone has been whacked to less than 50 and PSA is undetectable, read, less than .01. On January 7th I had been taking Lupron for three months. Dr. Gottschalk reexamined whether I needed to take the last 30-day Lupron shot and concluded it was not necessary.

 As each week passed the 'grind' to drive to San Francisco wore on  me and I did experience a feeling of total dependence on the radiation equipment. The saving grace was the two men who administered the treatment each day, Michael Sanchie and Robert Chen are consummate professionals. Weekly meetings with Dr. Gottschalk were informative as he assessed my reaction to the combination of Lupron, Casadex and radiation. U.C.S.F processes 25 radiation patients or more/day and most are in far worse shape than me. Still, Mike and Robert were always positive, cheerful, upbeat and very efficient. I never felt hurried or part of a mass operation. With two weeks remaining I began to experience diarrhea and a strong burning sensation when I urinated. Also, I had to go more often. Minimizing fiber in my diet helped but I could not do anything about the stinging during urination.  After reviewing my blood status we agreed I would just 'tough it out'.

 At the conclusion of the 34 radiation treatments, Dr. Gottschalk is optimistic, the combination of my pathology coupled with early an aggressive treatment once my PSA started to rise, will give me a 90% chance of a cure. I have follow up PSA testing scheduled for February, April and then, three month intervals the first year. The overall goal is to have PSA remain undetectable - forever - and testosterone return to the normal range in six months or less, read, 200-700. If I do have a recurrence the treatment would consist of periodic Lupron shots to 'whack' the cancer because we have used the radiation 'bullet'. Look for updates after these periodic check ups.

James F. Girand
January 14, 2010