Is ADT and radiation enough?

[davebliz]

Hi. I was diagnosed in Apr/18, PSA 38, Gleason 4+4. Started on Firmagon in June and PSA has dropped to 0.7. After several CT scans, MRIs, bone scans, they say my lymph nodes in pelvis have cancer but does not appear to be in any bones or organs. They plan to start external beam radiation for 4 weeks (20 doses). My Medical Oncologist said that ADT typically works for 1 - 1.5 years then I'll start on drugs. Anyone have comments on this approach? Thanks.

[Dayatatime]

Unfortunately nobody really knows for certain the answer to that question. The way this disease falls is it may be enough for some but maybe not for others. It is of my opinion an aggressive multimodal attack will offer you the best chance for a possible cure or durable remission.

My case was similar due to scans not picking up bone mets however I had extensive pelvic and some abdominal disease in lymph nodes. The course of my treatment happened due to the change of doctors and hospitals and not actually planned. I started on HT and then chemotherapy 4 months afterward. At that time my local team would not offer me a localized therapy. Through much research I found localized treatment might help with advanced disease. I sought several opinions and landed at The Mayo Clinic and offered surgery and have no regrets. There will be publications found for both therapies and studies showing one is possibly better than the other and vice versa. I'm telling you what worked for me.

I talked to Deborah Kuban (Professor of Radiation Oncology MD Anderson) and Jeffrey Karnes (Professor of Urology Mayo Clinic) and it was of both their opinions surgery was the better option in my case. Dr. Kuban did say she thought the surgeons there may have a mixed review at her hospital. They both said radiation will leave scarring and can only be done once and make any follow up treatment more difficult. They both told me I should save the radiation for a later date and not put all my eggs in one basket. Dr. Kuban also stated radiation doesn't usually show after effects up front and it is down the road they generally occur. She said at my age of 46 that could affect me. She also said getting your PSA at a very low point before any local treatment will up the odds for success greatly.

I went with Dr. Karnes and he did an open prostatectomy with an extended lymphadenectomy only to debulk the disease. He said it was his goal to extend my life 10 years. To his surprise all nodes except 1 showing in scans were actually scar tissue from where cancer was. The docetaxel treatments wiped out almost all of it outside of prostate. There was much scarring around prostate also making the surgery challenging but thankfully successful. Since surgery I have had an undetectable PSA and scans are clean.

My case is not the norm but so far seems to be working for me. Surgery was offered because of my age and healthy condition. Chemo works and so does debulking depending on the individual. Had I stuck it out with the standard of care treatment all my doctors agree I would not have achieved the results I did. Check out my complete treatment in my profile if you would like.

Ron

[HopingForTheBest1 in reply to Dayatatime]

Glad to hear your surgery went well. About 2 months ago I started on Eligard 3 mo shot with daily Zytiga/Prednisone. PSa now down to 0.32 from a high of 20, and Alkaline Phosphatase down to 90 from 248. Have several bone lesions in pelvis. Will also be starting Xytega next week to strengthen bones. I am 63.

I am also participating in a trial at CINJ, for newly diagnosed metastatic PC patients, where I am having robotic surgery on Nov 14. This study is looking to determine effectiveness of HT standard of care with surgery, as this is not the norm for metastatic PC. Hoping for similar results as you. Wishing you continued success.

[Dayatatime in reply to HopingForTheBest1]

My initial PSA at time of diagnosis was 286 with Gleason 9 (5+4). Believe it or not the first jackass of a Urologist I went to started me on Lupron the same time as the Casodex and I definitely had a testosterone flare. Felt like I was 18 again. My PSA did drop to 1.5 and hovered in that area through chemo. During chemo I was placed on only Lupron and after I requested back on Casodex after consulting with Dr. Kuban. It did bring it down to .51 preoperative. All my treatments were done within an 11 month period. I didn't intend for things to fall in the manor they did, it all just sort of happened that way in a whirlwind at that. Thank you and wishing you and all the guys on here success in their treatments as well.

[Joes-dad]

Hey Dave. My condition is similar to yours but with a higher initial PSA. I'm doing ADT plus Zytiga and Prednisone all at the same time. I had 9-weeks of IGRT that ended a month ago. I'll have additional scans in a few months and then I'll be just watching my PSA for now.

If adding in Zytiga & Prednisone is not part of your current plan, I would suggest reading up on it. In trials, it showed a large increase in life expectancy if taken along with ADT vs waiting for the initial ADT to fail and then starting to take something like Z&P. You will find a lot of information and links on this site.

To answer your question, is it enough? Unless my PSA starts going up (it's actually still going down) or the scans show something new, there's nothing else for me to do right now. Well, I do plan to keep reading about new trials and treatments so I'm prepared...just incase.

[Tall_Allen]

You should not be talking to a medical oncologist (MO) about this, only a radiation oncologist (RO). MOs have no specific knowledge of such treatments and do not keep up with the latest developments. Your MO doesn't seem to understand that you are pursuing curative treatment.

You should also talk to an RO who specializes in brachytherapy. Now that your PSA is under control, you have time to meet with other specialists. The ASCENDE-RT clinical trial showed that external beam with a brachytherapy boost to the prostate affords significantly higher cure rates than external beam alone:

pcnrv.blogspot.com/2017/03/...

Granted, that trial did not include men like yourself with known pelvic LN mets. However other studies suggest that radiation may still be curative:

pcnrv.blogspot.com/2016/08/...

The remaining variables in your treatment plan include the dose to the whole pelvis and the prostate, the size of the pelvic radiation field, and the duration of hormone therapy.

[davebliz in reply to Tall_Allen]

Thanks for the comments. My RO actually specializes in brachytherapy and doesn't feel I can do brachytherapy due to my current urinary condition. I don't have information on the actual radiation plan, I'll be talking with the RO in early Oct on this. One of my questions is should I also be taking Casodex and / or Avodart now rather than waiting until the current ADT stops working? PS: My testosterone is now stable at 0.5.

[Tall_Allen in reply to davebliz]

There is no conventional radiation plan that lasts only for 4 weeks (20 treatments), so they must be planning a hypofractionated radiation plan:

pcnrv.blogspot.com/2017/06/...

If you have urinary problems that continue while you are taking Lupron, that would rule out a brachy boost. In the ASCENDE-RT trial, all men were given ADT for 8 months before brachytherapy began. This shrank their prostates so that brachytherapy would not be problematic. Still, late term urinary problems were serious for 19% of the men getting that treatment.

You have the wrong idea about ADT stopping working from your MO. As I said, he doesn't seem to understand the radiation therapy you will be getting, which will hopefully be curative. You will not need ADT for more than 18 months. IF the therapy doesn't work, you will go on lifelong ADT. With testosterone that low there is no need for Casodex or Avodart.

[davebliz in reply to Tall_Allen]

I'll let you know the radiation plan once I find out. I thought that once the cancer was out of the prostate then you can't cure it just control it? Thanks.

[Tall_Allen in reply to davebliz]

There is still an opportunity when it is only in the pelvic lymph nodes. Unlike blood, spread through lymphatics is very slow. The nodes are like filters that can stop further spread downstream. However, once the cancer has escaped the pelvic area, it is systemic (everywhere) and cannot be eliminated. Pelvic radiation can eliminate even micrometastases there in some cases. this article examines the evidence so far:

pcnrv.blogspot.com/2016/08/...

[Hidden]

I did 8 weeks RT and continue on adt with no Psa or visable signs for the past 2&1/2 out of 3&1/2 yrs of treatment. So it is possible to do well in the first round and extend your chances to be here for upcoming breakthroughs. A prostate cancer specialist can make the right call for you.

[Hidden]

That is an impressive turnaround in such a short time you have already responded well to the treatment. I had a very similar diagnosis in April 16 and have been on Zoladex and had the same RT treatment and have maintained a 0.04 PSA for about a year. Tumours in both Prostate and lymph node have both shrunk, the lymph node tumour to no more than a small scar tissue. I am told that this is an excellent result and the best outcome that one can expect. I am 63 years young. Apparently for me, prostatectomy and surgical removal of the lymph node is Not an option. I cannot determine whether the the result was due to one or the other treatments or a combination of both. My Gleason was 4+5 ; 9, which I am told is an indication of the aggressiveness of the Cancer. I was advised that it is incurable but treatable, so basically it is being held at back. The Oncologist is suggesting ceasing the Zoladex in March 19 and see what happens.

I hope the above helps.

Good luck

Grahame

[SUPERHEAT12]

Dear Dave,

In December 2003 I was diagnosed with PC, Gleason 9 (5+4). Immediately started Lupron and in January did 43 IMRT radiation treatments. After the local MO told me basically what yours told you, I searched for an alternative and found Dr. Myers. He added Casodex, Avodart and a mix of other ADT therapies and supplements. For ten years I was in what he called long term remission with PSA near 0. After I stupidly stopped taking my maintenance Avodart, my PSA started doubling and I now have bone mets. I thought I was cured, Dr. Myers had warned me not to. However, it does show that ADT and radiation can hold the disease in check, at least in my case.

[ARIES29]

I received external beam radiation they call it here in 2012 & it stopped the rising psa untill 2016 when started ADT which knocked it down again.Stopped ADT for over a month now & psa on the rise again so now try the Lutetium 177 treatment.

Unfortunately it all just holds things in check & it will never be a cure i am told.