Most men can hold off on radiation after prostate cancer surgery

Decisions about follow-up care after prostate cancer surgery sometimes involve a basic choice. If the cancer had features that predict it could return, doctors will likely recommend radiation therapy. But when should a man get that treatment? Should he get the radiation right away, even if there’s no evidence of cancer in the body (this is called adjuvant radiation)? Or should he opt for “salvage” radiation, which is given only if his blood levels of prostate-specific antigen (PSA) begin to climb? Since prostate cancer cells release PSA, the levels should be nondetectable after surgery. If they increase, that means the cancer has begun to metastasize, or spread.

Now preliminary findings from a European clinical trial show that for many men, waiting can be a safe bet.

Called the RADICALS-RT trial, this is the largest study yet of adjuvant versus salvage radiation for prostate cancer. In all, nearly 4,000 men have been enrolled, all of them with features that predict an intermediate or high risk of recurrence, such as aggressive cancer cells in the tumor, pre-operative PSA levels in excess of 10 nanograms per deciliter, or positive surgical margins (residual cancer cells in the tissues surrounding the area where the prostate used to be). One group of men received adjuvant radiation while their PSA was undetectable, and the other group got salvage radiation if PSA levels spiked by at least 0.1 ng/dL during two consecutive measurements.

Similar outcomes

Five-year data are now available for a subset of 1,396 men, and they show no significant difference between the groups in terms of the cancer spreading, PSA levels rising over 0.4 ng/dL (a threshold that prompts other drug treatments), or death from prostate cancer. Furthermore, 75% of the men who were initially assigned to the adjuvant group had yet to go on salvage radiation, since their PSA values had not increased. Importantly, the RADICALS-RT data were also combined with those from two other ongoing studies in this area for a broader review (called a meta-analysis) that reached a similar conclusion.

Prostate cancer tends to grow slowly, and it will be years before final results show if either strategy is associated with better survival in the long run. But in the meantime, the new evidence “apparently shows that that you can wait on radiation,” said Dr. Marc Garnick, Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org.

An important question, Dr. Garnick said, is how high the PSA should go before salvage radiation gets underway. Expert guidelines previously recommended 0.2 ng/dL. But Dr. Garnick said he would start radiation as soon as he detects any increase in PSA that’s revealed by ultra-sensitive measurement tools. And he continues to recommend adjuvant radiation for the highest-risk patients, including those with positive surgical margins and cancer that was spreading into nearby tissues prior to surgery.

Dr. Garnick cautioned that any form of radiation can exacerbate urinary incontinence and erectile dysfunction after surgery, and he recommended waiting at least six months after the operation before initiating it. “The encouraging aspect of this new analysis is that many men can avoid radiation and its side effects by intervening only when the PSA becomes detectable,” he said.

The post Most men can hold off on radiation after prostate cancer surgery appeared first on Harvard Health Blog.

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How to talk to children about the serious illness of a loved one

It’s an inescapable truth: sometimes hard, bad things happen in life — including that sometimes parents, or other important people in a child’s life, get very sick.

It’s natural to want to shield a child from news like this, but that’s not a good idea. Children pick up on more than people realize — and can sometimes imagine things to be even worse than they are. Also, it’s important to help children gain the understanding and skills they need to weather a loved one’s illness, as well as to weather the inevitable difficult times in their future.

Talking to a child about serious illness: the first steps

Every child and every situation are different. But here are some suggestions as you think about what to say — and how to say it.

Think about your child’s developmental stage. This is really important. Younger children aren’t going to be able to understand or handle very much, whereas an adolescent can understand much more and will want and need to know much more. Younger children can be very concrete, and might worry not only that they can catch the illness, but also that it’s their fault. Older children can understand more nuance and complexity and will have very different worries. If you aren’t sure exactly where your child is in the developmental spectrum, talk to your pediatrician.

Talk first with your parenting partner. The two of you should be on the same page about what you are going to say and how you are going to say it. It’s also important that the two of you think together about the context of your child’s life, and how the news — and the illness — will affect them, so that you can be ready to manage the logistical and emotional fallout.

Find a time when you can sit for a long time and give your child undivided attention. You may not need a long time, but better to have it than not. At the same time, know that this is just the first of many conversations; you don’t have to relay every bit of information. It’s fine to do an overview, and then revisit and talk through more in other conversations.

Keep it simple and straightforward. Even older children can get overwhelmed by lots of details. For young children, that may be as simple as, “Daddy is sick. He will be in the hospital for a while. The doctors are working to help him.” For older children, that might be, “Daddy has cancer. It’s in his lungs. He is in the hospital for tests while the doctors figure out the best way to treat the cancer.” Use simple terms and simple sentences.

Be truthful. That doesn’t mean going into every gory detail. That’s rarely helpful. But it does mean that if the illness is serious, you should say so. Let them know what may happen next, such as if the person might lose their hair from chemotherapy.

Don’t hide your own feelings. If you are sad or worried, say so. You want your child to know that it’s okay for them to feel that way. As you move through the situation, you will need to find healthy ways to deal with your sadness and worry, as your child will be watching you for cues. Sometimes a mental health professional can be very helpful when it comes to helping both you and your child.

Talk about the helpers. Fred Rogers always used to talk about the importance of pointing out to children the “helpers” such as firefighters in a scary situation. Talk about the doctors and nurses and other people who are helping the person get better.

Talking about serious illness: Answer questions and make room for feelings

Talk about how this will affect their daily lives. Children of all ages worry about this. Let them know that you are thinking about this and planning for it. You might do some brainstorming together about how to manage any necessary changes. Reassure them that they will be taken care of during the illness.

Encourage them to ask any question they have. Answer those questions truthfully.

Be prepared for any reaction. Children may be upset — but they also may be angry, or not seem to react at all. Reactions can play out in all sorts of ways, like behavior changes or trouble at school. Also, children may need time to take in the information, so their reactions may be delayed — or vary from day to day. Build check-in times into your daily life so that you can have more conversations, give updates, see how your child is doing, and see if new questions have arisen.

Ask for help. Talk to your pediatrician. Get a referral to a social worker or mental health provider. Reach out to your faith community or any other available supports. It takes a village to raise a child, and this is especially true when someone that child loves is sick.

Follow me on Twitter @DrClaire

The post How to talk to children about the serious illness of a loved one appeared first on Harvard Health Blog.

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