Video: Radiation for Relapsed Prostate Cancer (Indigo Stage)

The Staging Guide Video Series | Transcription

Hi, I’m Dr. Scholz. Let’s talk about prostate cancer.

In this video we’re going to talk about five different types of radiation for men with relapsed prostate cancer after previous surgery or previous radiation.

It’s always irresistible for me to at least talk about this myth that you have to do surgery first to protect against the possibility of relapse so you can do radiation as salvage. In this video we’re going to talk about how radiation can be used as salvage for people who’ve had previous radiation. So there was a time—when radiation was really, really lame, and dangerous, and problematic—when you couldn’t do radiation after radiation. But that has changed and we want to get the word out about that because the myth that you can’t do radiation after radiation has been spread and repeated many times and honestly it’s one of the last arguments used by surgeons to do surgery because all their other arguments (like it cures you better or it has less side effects) have disappeared because radiation has improved so much.

So the five types of radiation after surgery or radiation...

Let’s take the way we subdivide prostate cancer into the five stages, this being Indigo: The relapse type of prostate cancer. If you don’t know if you are Indigo, you should go to the PCRI website, take the quiz, and make sure that you really are Indigo stage. Once you have confirmed that, then the determination as to whether you are in the Low, Basic, or High Indigo status needs to be made. (And we’re not going through how to do that in this video, but you can, again, look at the PCRI guide and determine whether you’re in the Low, Basic, or High category.)

So let’s take men in the Low category first. This is where the cancer has come back, but we believe that it is still in the area of the prostate (in men that have had previous surgery they call it the “[prostate] fossa”) or inside the prostate itself in men that have had previous radiation, and the conclusion is that there is very low possibility that the cancer spread to the lymph nodes or around to the rest of the body. So it’s logical that treatment to the prostate are alone will be sufficient.

So there’s basically three approaches—three different types of radiation—that could be considered to treat someone that has locally relapsed or locally persistent prostate cancer.

The simple and obvious one of course is to give intensity modulated radiation called IMRT to the prostate fossa in someone who had previous surgery, but the surgeon didn’t get it all out. This type of treatment is usually administered over 7-9 weeks. It is in some cases as little as five weeks, but the protocol involves daily visits to the radiation therapy facility (Monday through Friday) for a brief treatment. The side effects while you’re going through the treatment tend to be very mild. You might have a little bit of discomfort with urination, a little soreness in the rectum that should dissipate within 4-6 weeks. The main concern, of course, is that if after surgery a man is still getting erections, the administration of radiation increases the chance of getting erectile dysfunction. The chances are not entirely clear—the studies are not very clear—because people have variable function after surgery to begin with, but I think one has to consider that there’s about a 25% chance that—if you are functioning after surgery and getting erections—that the addition of radiation will cause erectile dysfunction. And in the prostate cancer world that means the use of Viagra and Cialis are not going to save the situation; you’re going to have to move onto something like injection therapy or possibly even a surgically placed prosthesis. So radiation after surgery, the sort of classical type of salvage treatment—that most people are familiar would be the first type of radiation that we’re going to cover for the Low-Indigo category.

Now, what about men that have had previous IMRT and it appears that there’s still cancer in the prostate and not anywhere else? This is also a Low-Indigo, but in a person that’s had previous radiation. These situations more and more are being successfully treated with salvage seed implantation. There are two types of seed implants: Permanent and temporary, and both are on the table for consideration. If your situation calls for a salvage seed implant such as this it is very important to get to a center that has a lot of experience doing this sort of thing. It’s a skill procedure and there are greater risks in someone who has had previous radiation.

The third type of salvage radiation for people for people that have had—in this case previous surgery—would be very accelerated beam radiation called stereotactic body radiation or CyberKnife, and preliminary studies recently published suggest that this is feasible without excessive danger. We don’t have super long follow-up, but the convenience of not having to take a radiation salvage treatment over a 5-9 week period, and instead undergo the treatment in a relatively short period such as less than a week or two is very attractive. So stereotactic body radiation would be another consideration for someone with Low-Indigo that’s had previous surgery. This has not been done for people who’ve had previous radiation that I’m aware of.

Now let’s move on to talk about Basic and High-Indigo relapse. This is a situation where men are presumed or actually is known to have spread into the pelvic lymph nodes (the small nodes that surround the prostate area. This is a type of metastatic disease—early metastatic disease—and now radiation is able to treat this safely.

So when we’re talking about the two types of radiation for Basic-Indigo and for High-Indigo, this can occur in people that have had original surgery and people that have had original radiation. So radiating the lymph nodes—assuming the radiation to lymph nodes wasn’t administered at initial treatment—is feasible with either approach, but as we talking about for Low-Indigo (in other words treatment of the prostate area) men that have had previous surgery would need IMRT whereas men that have had previous IMRT to the prostate, their salvage situation would require a salvage seed implant. So you could see how it could be a consideration for someone that is relapsing after radiation and has Basic or High-Indigo that they could need a salvage seed implant to the prostate area, and then salvage IMRT to the surrounding pelvic lymph nodes.

Are hormone treatments necessary when you’re doing salvage radiation?

My opinion for Low-Indigo: Hormone treatments may be unnecessary. But for men that are undergoing IMRT on a salvage situation with Basic or High-Indigo (that is to the pelvic lymph nodes) two studies now have shown that better cure rates can be achieved by adding hormone treatment. In one study Casodex alone 50mg a day was used, and in another a Lupron type drug was administered. In these two studies the treatment was continued for an average of 6-12 months. Better cure rates were achieved. There are of course a variety of side effects from hormone therapy which we’ve covered in another video and precautions always need to be implemented when taking hormone blockade.

As you can see radiation is an essential component of managing Indigo. There are different types of radiation and they can be used in different combinations with or without hormone treatment. All of this is based on accurate staging ensuring that you know whether you’re in the Low, Basic, or High subgroup.