Saturday, January 25, 2014

Rising PSA After Radiation Therapy ? Don't Be Rushed Into "Salvage" Therapy!

Figure. Kent Wallner...
Kent Wallner, MD, has taken heat for his rational stance on PSA rise and 'bounces' after brachytherapy

After another increase in PSA, now to 2.8 (from 2.5) after only 3 months, yes I have begun to panic. In the ideal world it would have been going down, down, down and the 2.5 reading would have just been a "flare" as my radiation oncologist at UCSF put it.  But am I about to hit the 'chicken switch' and run for a urologist, or for 'salvage therapy'? HELL NO!  Not after pouring through dozens of technical papers  (mainly in the Journal of Radiation Oncology) since the test result came back.

To sum it all up: radiation, namely HDR brachytherapy, e.g. see my description of the treatment at UCSF in 2012 here: http://brane-space.blogspot.com/2012/09/thge-longest-dayand-then-some.html

takes much longer than surgery before a true PSA nadir is hit. Generally from 36-40 months, and in one article noted in the Oncology Times, a time of 5 years was assessed as proper before one could compare "apples to apples", i.e. with a typical prostatectomy nadir of 0.1 ng/ml. Five years is a long damned time!

Now enter a voice of reason in Kent Wallner, M.D., Associate Professor in the Radiation Oncology Dept, at the University of Washington Medical Center, who as early as 2001 reported three confirmed cases of men who had "temporary, self-limited PSA rises as well as post-implant biopsies showing "histological evidence of persistent  cancer" . All 3 declined to have salvage therapy (i.e. anti-androgen therapy, salvage prostatectomy or salvage radiation treatment). The hum dinger?Despite refusing further treatment all saw their PSAs fall.

In a subsequent interview, Wallner observed he was "met with skepticism" when describing the cases.  He said this was because:

"it defies common sense to have a rising PSA and a positive biopsy and not have cancer".

True, but again, mayhap the Medical Industrial complex doesn't know everything after all, and despite all their proclaimed 'insider' knowledge of what ought to happen after a radiation treatment, they are still on the short end of the learning curve.

As an aside, all of this pretty well confirms Medical author Shannon Brownlee's take, in her book 'Untreated: Why Too Much Medicine is Making Us Sicker and Poorer' (2007, p. 202):

"The evidence suggests that PSA testing is not saving any lives, and even it is the large numbers of men who are treated unnecessarily are paying a terrible price. They're the equivalent of civilian casualties in our war on cancer.".

Again, I reiterate, yes I did have treatment - under pressure from my wife, my urologist, my primary doc and others. BUT......as a fellow Intertel member emailed me (soon after I wrote about the experience in the Intertel Regional Newsletter 'Port of Call') I might also have lived with only minor problems (the cancer stage was T1c) and croaked eventually  of something else. This is because 97% of prostate cancers are slow growing. (Incredibly, 99% of males autopsied who are 79 years of age or older are found to have prostate cancer .....and most never knew about it!)

So now AFTER treatment (and many of the still lingering side effects like burning urination) I am to go back for more? Uh unh! Don't think so!

And I am validated by Dr. Wallner's research. Wallner has noted that since up to one third of men will have rising PSAs sometime after brachytherapy (possibly for a number of reasons including inflammation or enlargement because of the radiation effects - thus imitating BPH) " a fairly large percentage of them might have unnecessary biopsies and unnecessary surgeries."  (Oncology Times, Vol. 23, No. 10, 27-30)

Wallner acknowledges that his study lacks a denominator, because "not every man has a biopsy following brachytherapy" (with good reason, as the cells are in a 'mess' from the radiation, and the gland is still affected, so the histological skills to discern cancer are much much greater than for an ordinary biopsy). Most of the literature I've seen argues it would be foolish to even think of a biopsy before about 3 years AFTER treatment. There is simply too much room or error, and getting false positive or false negatives.

Wallner (ibid.) documents his following 6 men (beyond the original three) who had PSA bumps and also positive biopsies but "whose PSA levels have since fallen and are consistent with long term cancer control".

He added:

"This is a real problem because common sense would tell us we've got to operate on these people. But because there's no clear answer we should think long and hard before recommending a salvage prostatectomy ."

Indeed. And while we're at it, let us bear in mind that often in science the failure of a simple common sense signifies massive ignorance in an area. In physics, for example, it is "common sense" that a dart fired at a board with two apertures or holes can only transit one or the other, not both. Yet at the quantum level the electron violates this script all the time in the classic two-slit diffraction experiment. Hence, the danger in using common sense as a guide, including in the medical arena.

Dr. Wallner hypothesizes that a repeat biopsy might be positive because of residual tumor in the prostate.  As he describes it (ibid.):

"We know it takes a couple of years to clear cancer after high dose radiation, so for the first two years or so you can see residual cancer in the prostate.  But you don't know if it is viable or not."

This again makes eminent sense, because the effects of radiation occur over time, not all at once as in the case of radical surgery. Hence, the medical industrial complex ought to be sensible enough to realize that and hold back - but that's not in their nature. Like gunslingers of the old West they want to 'kill' any sign of the 'bandit' - even though he's basically moribund and on his last legs.

Wallner is backed up by Bradley R. Prestidge, M.D.,  a radiation oncologist at the Cancer Therapy and Research Center in San Antonio. He points out (ibid.):

"The older literature is fraught with misreadings of biopsies done too soon. within 12 to 18 months post radiation treatment. Cancer cells take a while to die off and even though some may look like cancer architecturally, they are not dividing."

Dr. Prestidge went on to point out that especially after brachytherapy, y prostate cells labeled 'indeterminate' on biopsy "may look cancerous because of background radiation effect."

His recommendation: Patients, urologists and oncologists "should not rush into this".

Indeed.

Dr. Wallner's main take away: he would personally wait three years for the PSA to decline after brachytherapy.

He concedes this is a "tough option" because "some men will indeed have recurrent cancer".

But he adds:

"If I had done a salvage prostatectomy on these men (in his original study) I would have done them a great disservice."


Footnote:

In a study of 779 men following Dr. Wallner's , Frank Critz, MD, and colleagues, found that the median PSA rise was 0.4 ng/ml above the median pre-bump PSA of 0.7 ng/ml. For 10 to 20 percent of these men, the rise was 2.0 ng/ml during the bump. In one case the PSA level reached 15.8 ng/ml before dropping.
 
The median time to the rise was 18 months from the time of implant, and in 92 percent of men it was observed within 36 months.

Dr. Critz defined a bump (which he called a “bounce” in his report) as a PSA rise above 0.5 ng/ml with a subsequent fall to less than 0.5 ng/ml, for men who had a post-treatment PSA nadir of 0.5 ng/ml or less. For men with a pre-bump PSA of greater than 0.5 ng/ml, a bump was a rise of 0.1 ng/dl or more with a subsequent fall below the pre-bump PSA level. He noted, however, that one percent of men have a bump with the very first PSA assay taken after treatment.

The mechanism of PSA bounce after radiotherapy and its relevance to long-term survival were unknown, Dr. Critz said, in an interview for the OT. But he noted that curative surgery for prostate cancer differs from curative radiotherapy, in that time must be allowed after successful irradiation for malignant and benign prostate epithelium to disintegrate.

It may be this process that causes a clinical or sub-clinical prostatitis and leads to the temporary PSA rise.

Perhaps it's time  (before making generalizations about treatments) the medical community do much more study and research on the effects of radiation - at different doses - on living tissues, including cancerous tissues!

Addendum: 1/ 26:

An email received this morning from my radiation oncologist, Dr. Hsu, acknowledged my research and that he agrees what we're seeing is a PSA "bounce".  He also said that the original PSA reading of 2.0 ng/ml was not the nadir. So, this may well be a 2-3 year wait!



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