Hi....I'm new. I think many newly diagnosed people may face my dilemma. I was diagnosed this January aged 77 with aggressive PC (Gleason 9) which has spread to two Pelvic lymph nodes but no further. I'm on Bicalutamide 150mg, soon to be augmented with Zoladex (LHRH). Although I have continuously had PSA tests over 25 years, mine is apparently one of those pesky uncommon cancers where the PSA grossly underreads the true situation so despite being always mindful of my health, I had no clue about the creeping menace until my peeing got slightly more difficult recently and even then my PSA reading was well below the average for my age. The Oncs were worried that the success of treatments for my type of cancer could never be reliably tested by PSA readings. Fortunately this proved not to be the case and the bicalutamide alone dropped my PSA from 4.8 to 0.4 within a couple of months. Anyway, after getting multiple opinions, there seems to be a radical difference of opinion as to whether recent trials pointed to early chemo, even for cases like mine - locally advanced with no metastises (the trials apparently established clear benefit of early chemo for more advanced cases). I'm not particularly looking forward to chemo (docetaxel) because, knowing my luck, I will probably be hit by all of the SEs but if its the best route for me, I'll tolerate it. On the other hand my extensive research leads me to believe (in line with many on this forum) that cancer cure could be just round the corner - probably via immunology therapy. Thus me, and others, are faced with the dilemma of going for early chemo (before the cancer becomes hormone resistant) and possibly ending up with permanent nasties from the chemo by taking a route which at least half of the experts believe will not, in my case, be in the least life extending and will probably have only very minor benefits if any. Whereas if optimists like myself are correct and a cure is just round the corner, I'm possibly far better off sticking to the orthodox route of ADT+LHRH+Radiotherapy and sitting it out until the big cure arrives??
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I wish I could be as sanguine as you at the prospect of a cure with immunotherapy. Provenge added 4 months, and every immunotherapy tested since has had disappointing results - the latest was ProstVac. Still, I am hopeful that some one or combination of immunotherapies will extend survival, at least in some well-chosen patients. I wouldn't put off any life-extending therapy in the hope that some great new cure will emerge in 5 years.
I agree with your concerns about early use of docetaxel. In STAMPEDE, it only increased survival among those with distant metastases, and not among those with only LN mets. In CHAARTED, it only increased survival among the subgroup with multiple distant metastases. In the latest STAMPEDE study of early Zytiga, it too was only proven effective for those with distant metastases BUT the hazard radiation for non-metastatic men was low (0.75) and it is very possible that with longer follow-up, it may reach statistical significance (there just haven't been enough deaths among those without mets to see the difference yet - a good thing!) Also, those with positive nodes did have significantly improved survival (HR was 0.61 - the same as for metastatic men).
I don't understand why you are not pursuing a cure with radiation first. In yet another arm of the STAMPEDE trial where those who were node positive (N1) were given radiation + ADT, 2yr failure free survival was 89% among those who'd had ADT + RT vs 64% among those who'd only received ADT. Toxicity was mild.
I did mention radiation at the end of my posting ("ADT+LHRH+Radiotherapy") and I will be having radiotherapy whatever happens. However, if they want to give early chemo, they seem to prefer to give it before radiation - probably because there is a window of opportunity in which early chemo must be given (whilst cells are 'hormone naive') and this window can be quite short with some folks. Orthodox first line approach of ADT (which I'm currently on) subsequently augmented by LHRH followed by radiology, might prove too long a string of procedures to then use chemo because the window may be missed and all advantages of early chemo (if any in my case) will then be lost.
Anyway, it would appear that overall, you agree that the questionable benefits of very early chemotherapy in my case is outweighed by its unquestionable toxicity and often permanent or very long lasting damage - especially if I am right about the elusive cure, (or at least the survival extension that you think possible) via immunotherapy being on the horizon. Incidentally, you probably know that they have already had dramatic success with Melanoma and Leukemia but you are right - not so far with PC.
There is one other consideration regarding early chemo of course. If I am to need chemo later anyway, perhaps its better to have it now whilst I'm still relatively fit enough to tolerate much of what it can throw at me!
On another subject, I know you cannot help me as an American so perhaps I could throw this question out to everyone:
can anyone recommend a competent and preferably forward looking prostate Cancer Oncologist in or near London please. I'm quite happy to go private.
With chemo, there seems to be a window of opportunity when it is effective. Before that time, it is ineffective, and after that time it is less effective. Based on the data we have, you have not reached that window yet. It is true that side effects are less if used while you are healthier, but there is no evidence for prophylactic use.
There is a small benefit of using docetaxel after radiation in high risk men (not N1), but it is small (increased 4-year overall survival from 89% to 93%) and probably not worth the toxicity.
My father has a very similar story and I believe that if he took the recommendation and did chemo initially he wouldn’t have become resistant. We were all afraid of “chemo” and i regret that we didn’t go with it initially because now he has developed NEPC, that is very difficult to treat. Best wishes and hugs to you!!
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