7.5 years post RP, never been on hormone treatment (ADT) and now Bio-Chemical Recurrent (BCR) (0.4 PSA). Had PSMA Scan end of December which revealed PCa in 1 pelvic lymph node. Done some research and am leaning toward Stereotactic Body Radiation Therapy (SBRT). My question is and would appreciate feedback on the choice of SBRT with or SBRT without ADT. The studies I have read suggest that SBRT without ADT will allow possible years without progression and high Quality of Life (QOL) while SBRT with ADT may be a better choice with possible curative outcome but would include the Side Effects (SE) of ADT. Your thoughts and suggestions are requested.
Oligometastatic Treatment - SBRT wit... - Advanced Prostate...
Oligometastatic Treatment - SBRT with or SBRT without ADT?
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Moespy
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I usually recommend ADT with SBRT directed to mets. This to avoid that new mets appear again six months after the treatment.
However, if it took you 7.5 years to reach a PSA level of 0.4 ng/ml. I think you do not have to worry to develop further mets quickly. So in your case I recommend no ADT.
When there is one LN met that you CAN see, there are probably many more that you CAN'T see. So SBRT is probably not optimal. Most ROs would recommend treating an expanded pelvic area and adding about 2-3 years of ADT.
pcnrv.blogspot.com/2017/01/...
pcnrv.blogspot.com/2017/12/...
Thanks Allen,
I will meet with my RadOnc in 2 weeks and report back what his thoughts and recommendations are on this subject or anything else he has in mind.
Appreciate your response,
Jim
I agree with Allen. All pelvic lymph nodes should be treated with low dose IMRT plus ADT of at least 18 months.
Hi Break60 and thanks for the response.
I continue to be on active surveillance (PSA every 6 weeks) and my medical team (MO+RO) at Johns Hopkins will start ADT once my PSA doubling time decreases. Right now I am at 15 months PSADT. We have discussed that my PSA may get as high as 20 before we begin ADT if PSA continues to increase at a slow rate. At the moment and the reason for this post is I am leaning toward SBRT without ADT with the goal of finding out if the SBRT will reduce PSA on its own and extend the time to when I will need to go on ADT. This seems logical to me since I am likely not going to be on ADT during this timeframe anyway. Thoughts?
I agree with your approach Moespy. You are very lucky with your DT. mine is about 7 months. I guess that is why my MO wanted to put me on ADT and never suggested any scans. But with yours at 15 months, I would not worry
Ahk1,
I am fortunate to have my current DT but it could of course change at any time now that it has escaped the immediate area. Living with it for 7+ years has greatly reduced my anxiety level but it is always there.
Thanks for the reponses,
Jim
Moespy
SBRT is high dose “targeted IMRT “ used when a few distant mets are imaged beyond the locale of the prostate. In other words distant mets.
The pelvic lymph nodes are very numerous and frequently the first place to which PCa travels through the lymphatic system after it has escaped the prostate. You’re very fortunate that it’s taken so long to do so after RP!
Once PCa is large enough to be imaged in one pelvic lymph node it’s assumed that microscopic PCa exists elsewhere in the pelvic lymph nodes so it’s SOC to treat all pelvic lymph nodes with IMRT and ADT.
The fact that your PSA doubling time is slow is a very good thing implying that your PCa is not aggressive. So your Gleason score and pathology post RP must have been favorable.
Your RO should know the feasibility of treating pelvic lymph nodes with low dose vs high dose RT in light of the risk of collateral damage to surrounding areas. And he should know if in your case ADT will make the RT more successful based on clinical trials for your stage of PCa.
All I can say is that back in 2015 I had IMRT of 75 grays in 50 fractions plus 13 months of ADT3 when my pelvic lymph nodes were treated. And I’ve had no recurrence there. But my pathology post RO is probably a lot worse than yours and ADT may not be helpful for you.
Good luck.
SBRT will almost certainly reduce your PSA, but your goal (I assume) is to live longer - not to reduce your PSA. ADT combined with RT contribute to the abscopal effect. By leaving out the ADT, you may be allowing more of your systemic micrometastases to prosper and grow.
Thanks Allen; definitely seeing the logic in combining ADT with RT. I appreciate your patience and persistence in communicating the facts.
Jim
I am in this same situation and STRUGGLING to make a decision at .51 psa although I have not done the 18F pet at NIH yet and sitting here debating if I should do the scan or not if I am gonna end up with ADT anyways, so I might as well start the ADT and forget about the scan because NIH is requiring me to do 3 CT scans(chest, abdomen and pelvis) in addition to a bone scan before they can get me in. Tough decision to make. Your thoughts would be greatly appreciated
Can you use radiation on the same area twice, Moespy adds this below in one of his replies. "1st Recurrence 06/2015 with 0.4 PSA 48 months after RP. IMRT Prostate Bed Radiation completed 09/2015. Post Radiation PSA <0.1."
2nd Recurrence with Rising PSA: 2/2018 - 0.2; 07/18 - 0.5; 11/18 - 0.7; 12/18 - 0.4, 0/25 - 0.4.
It wouldn't be on the same area twice. One can have salvage radiation of say, the pelvic lymph nodes if only the the prostate bed received salvage radiation the first time.
Much appreciated, thank you for everything you do here.
My 68Ga PSMA scan identified only 3 involved sacral LN's which I had robotically removed in addition to 5 more that the surgeon said "looked suspicious". Tall_Allen stated that most scans can not identify tumors smaller than 4 mm which I now believe is the case since my surgery only reduced my PSA by ~60%. Post-op PSA's continued to increase until I started my transdermal estradiol (tE2) gel regimen which so far has been extremely successful. The ONLY side effects are a bit of gynecomastia and tender nipples...couldn't be more thrilled with this form of ADT! I am convinced that the doctors and the pharmaceutical companies don't want to suggest this since there is little money to be made. My cost of the gel is less than $10 US/month and I haven't seen a doctor for a 1½ years. Thank you Dr. Richard Wassersug, PhD for your mentoring throughout this journey.
Thanks ronronHU! Will investigate and also discuss the transdermal estradiol (tE2) gel with docs. Sounds very promising and appreciate you sharing this valuable information.
Jim
• in reply toE2-Guy
Do you have a reference for this transdermal estradiol (tE2) gel regimen whereof you speak? I've only heard of transdermal estradiol as a treatment for hot flushes. TIA
Moespy• in reply to
Don't want to answer for ronronHU but this link may help answer your questions.
healthunlocked.com/advanced...
• in reply toMoespy
Thanks for link, I googled and only found information on a failed Phase II clinical trial. I'll see what this link says.
E2-Guy• in reply to
I have been Googling numerous articles on tE2 and DES for some time prior to starting my current regimen. DES was used for about 40 years with remarkable success. My father and his two brothers did quite well with only DES as adjuvant therapy after post-op BCF. They all were diagnosed with PCa around 60, had RP's and lived into their late 80s. I don't recall any of them ever complaining about side effects other than gynecomastia. I do remember that when my dad was taken off of DES and put on Lupron injections in the late 80s (because of the numerous DES lawsuits), he felt so shitty that he eventually opted for an orchiectomy. When I became a candidate for ADT, I asked an elderly oncologist at Loyola in Chicago for recommendations since Medicare pays for nothing outside of the US, and he suggested DES (if I could find it) along with an 80 mg aspirin. Recent research has indicated that the 5 mg oral dosage was more than what was necessary for adequate T suppression...2-3 mg appears to be equally effective with lower CV risks. The major advantage of the transdermal E2 gel (I prefer the gel over the patch since it is inexpensive, very easy to use and causes no skin irritation) is that it avoids the first pass hepatic metabolism (induced by oral estrogens) which was the primary cause of CV and thromboembolic events. Also, unlike most modern ADT's, it maintains bone density, and I myself have not experienced even one hot flash/flush. Following are some quotes from articles/abstracts regarding estrogen/estradiol useage: Hope this helps answer some of your questions...best regards, Ron
"Estradiol (E2) is the predominant estrogen both in terms of absolute serum levels as well as in terms of estrogenic activity."
"Estrogens (female hormones) were once the main alternative to orchiectomy for men with advanced prostate cancer. Because of their possible side effects (including blood clots and breast enlargement), estrogens have been replaced by other types of hormone therapy. Still, estrogens may be tried if other hormone treatments are no longer working."
"Estrogens. Some synthetic versions of female hormones are used for prostate cancer. In fact, they were one of the early treatments used for the disease. However, because of their serious cardiovascular side effects, they're not used as often anymore. J. Brantley Thrasher, MD, a spokesman for the American Urological Association and chairman of urology at the University of Kansas Medical Center, says they're usually used only after initial hormone treatments have failed. Examples of estrogens are DES (diethylstilbestrol), Premarin, and Estradiol."
A few related links:
researchgate.net/publicatio...
stampedetrial.org/media/187...
Talk to your oncologist about 10 mg/day tamoxifen to counter the breast effects. There are clinical trials in the UK which may change the standard of care.
Thank you Allen. I have been considering trying tamoxifen based on your previous recommendations; however, I'm still wondering if it could be counterproductive to the efficacy of the tE2? My doctors don't seem to be all that knowledgeable on estrogen usage for PCa since most of them weren't practicing back when DES was being administered. I think that the numerous DES lawsuits have discouraged them from even considering using estrogens for men even though we know that transdermal/parenteral delivery is far safer than oral. I guess I can give it a try for a few months and see if any of my numbers go in the wrong direction. Do you think that tamoxifen can reduce some of the existing fatty tissue?
Ron Ron
I find your journey fascinating. My profile is worse than yours and I’ve taken a different route to treatment relying on triple blockade ADT and radiation to treat mets after failed RP. My BCR was rapid having only been on the journey since 2013.
Anything which can be found to replace LHRHa is seriously worthwhile. It’s a man killer. I use estradiol patches for hot flushes but never dreamed that E2 might be a replacement for LHRH. I hope it turns out to effective and really appreciate you being a guinea pig along with guys in the PATCH CT. Ironically I already have man boobs from bicalutamide and wish I had been given tamoxifen for mitigation.
Please keep us posted on your progress!
Bob
Moespy,
I think you are the fist person I have encountered who is in a position similar to mine. Like you, I have seen the studies suggesting that SBRT to mets without ADT can be beneficial to survival . Indeed, I spoke with an oncologist at a major cancer center who said as much but who also pointed out the theory has not been thoroughly studied enough to influence standard of care (which only takes into account longevity and not QOL).
Like you, l have never had castration in any form. All offer it but I have refused it. I have failed radiation with mets to sternum and two lymph nodes.
It has been difficult but I have found oncologists who will treat me even though the treatment I seek is at the fringes of standard of care. One said it was "highly experimental". Were I to accept castration along with focal salvage treatment finding them would have been much easier. All these specialists are affiliated with highly respected cancer centers. All are researchers. All work at competing institutions in different states and one is in Europe.
The radiologist only considered it after conferring with the med onc from Houston. He required that i have treatment to the prostate as well gut I cannot be radiated there again. For that, I am going to Europe for a new type of HIFU, again at a research teaching hospital.
Will it work? I am after QOL as much as longer life. My goal is to delay castration, knowing full well the risks I take. It might all be an expensive failure and every doctor has pointed this out and made sure I understood that castration was a much more sure thing.
My radiation begins next week. After that I will go to Europe for that part.
Not sure if I answered any questions but as for myself, it makes sense that reducing tumor burden should have a positive effect with or without castration. Yes, there will still remain circulating cancer cell in my system, I get that.
I guess it all boils down to your comfort level in the QOL / longevity debate.. In the end they all fail in either case.
All the best
In the end they all fail; great quote and I agree with it. I had 2 chances to get this thing with RP and later IMRT and neither succeeded. Now I am on the road to progression and want to stay around long enough for a 3rd "curative" option to be found. I would however like to have the best QOL while I hang on. I think I have a choice right now (to be confirmed by RO at next meeting) of Active Surveillance (1), SBRT without ADT (2) and SBRT with ADT (3). Active Surveillance would last until PSADT gets down to an unacceptable velocity and then choice 3 would be logical. But right now with a wide PSADT I think I can safely hit all LN's in the pelvic area with SBRT without ADT (2) and see if it further delays progression. I believe that micrometastasis are in circulation but not a huge believer that in my current stage that ADT will kill them nor extend my life by slowing them down. NIH believes that the F18-DCFPyL PSMA CT Scan will be available to the GP within a year which I would use to monitor the results of the SBRT. In the end I am in good hands at JHU and will go with my RO's recommendation. Receiving the valuable thoughts, opinions, anecdotal and real experiences here at HU greatly helps me to have an intelligent conversation with my doctors.
Thank you!
JIm
407ca,
I am also in same situation and am nervous as hell from making the wrong decision. It’s extremely frustrating. I am afraid not to start ADT now and delay it and make the cancer tumor burden goes high. I always think what is the effectiveness of SBRT while we know there are cancer cells somewhere else growing but we can’t see. Why delay ADT then. I am not even worried about the side effects of adt ( some guys think it’s not that bad) but worried about it stopped working. Very confused and don’t know what to do. My psa now at .51 increasing with DT about 7 months.
Your initial post didn’t highlight that you have already had one episode of salvage radiation...
SBRT may not be possible if the lymph node that is showing up now is in an area that has already been irradiated - there is a limit to how much radiation any given area can be subjected to. I’m sure your RO will have your full history, but that’s what I would be focusing on in the discussion, rather than just the ADT aspect. Frankly, since you are actually failing SRT now, I would have thought ADT was the logical next step, either with or without some additional radiation to the lymph node.
I had previous radiation to lymph nodes as well but the radiologist is going to retreat the area very carefully.
407ca,
I would be very interested in the results of the re-treat radiation. I think in skilled hands this could be effective. I am now following you and look forward to seeing a post on your result.
Best wishes,
Jim
I too wasn’t aware that you had SRT after failed RP. You didn’t indicate that. However assuming it was only to the prostate bed, then IMRT to lymph nodes is not a problem. Your RO will look at the SRT Radiation plan to ensure that no area is hit twice.
Hi Blackpatch, Here is my profile.
60 years old. Diagnosed at 53 years old with Initial PSA 7.9. Davinci RP 6/2011, Gleason 4+3, Stage pT2c, Localized, Margins Not Involved, No Seminal Vesicle Invasion Identified, Tumor 1.5 x 1.3 cm. Post Surgery PSA <0.1.
1st Recurrence 06/2015 with 0.4 PSA 48 months after RP. IMRT Prostate Bed Radiation completed 09/2015. Post Radiation PSA <0.1.
2nd Recurrence with Rising PSA: 2/2018 - 0.2; 07/18 - 0.5; 11/18 - 0.7; 12/18 - 0.4, 0/25 - 0.4.
"Color" Genome Test taken in 11/2018 with no genetic abnormalities found.
PSMA Scan at NIH 12/18 found PCa in 1 pelvic iliac node. Biopsy scheduled 01/19.
Thanks for your logical input. I am a square peg in a round hole personality but in the end will normally follow the logical path.
Appreciate it,
Jim
Would this not be treating the same area 2 times with radiation.
Hi dbrooks_h,
407ca will be able to answer for his specific treatment. In my case the IMRT sessions were directed only to the Prostate Bed. Since the pelvic area was not previously radiated I "should" be a safe candidate for SBRT or IMRT to the Pelvic Lymph Nodes. There are radiologists that will entertain re-treating a previously radiated area but I certainly would like that RO to be very experienced and able to explain to me how this will likely be safe.
Jim
Moespy
You just have to realize that radiation is not systemic treatment whereas ADT is. Your stage is intermediate risk so I guess you're on the bubble in terms of the need for systemic treatment and I don't blame you for wanting to delay ADT because it's life changing.
What I find interesting is the thought of using high dose radiation to the pelvic lymph nodes since they cover a large area of your abdomen. Is he planning on treating only the lesions(s) he can see with imaging or treating all pelvic lymph nodes? It certainly would be much less tedious than vanilla IMRT of 1.5 to 1.8 gray per fraction. Can your RO point to a clinical trial which proved the efficacy/safety of SBRT to pelvic lymph nodes?
Bob
Hi Bob,
Since I received the result of the PSMA scan I have not yet met with my RO. I initiated this discussion to gather information for that appointment. Once I learned from my recent PSMA scan last month that I had just the one pelvic lymph node expressing PSMA I started researching and asking questions. SBRT for oligometastatic disease was suggested by some heavy hitters here and several studies I read online. The people with the most experience are suggesting 2 months of ADT followed by radiation (5 rounds of SBRT) to all the pelvic lymph nodes then 2 years of ADT. The desired result would be an attempt at cure.
Couple of studies are here:
pcnrv.blogspot.com/search?q...
ncbi.nlm.nih.gov/pmc/articl...
healthunlocked.com/advanced...
Thank you,
Jim
Jim
These are excellent resources! Thanks much. I’m happy to see so many trials in process for treatment of oligomets. TA as usual has done an excellent job of bringing us up to date on this issue with his blogs.
I’ve undergone my own trial having treated oligomets three times now in 2015, 17 and 18 . I wish I could find a way to get off ADT for longer than six months at a time.
Bob
I took a viagra about an hour ago and my face and head are on fire! Can't wait to see how ADT feels (😒). Just ordered a fan bike to try and lose weight and get in shape to help with the SE's. I'll be in the boat with you soon and we can commiserate.
Best wishes and hit 'em good,
Jim
That is always my fear break60, introducing toxicity with radiation on the hope it buys you a year or so for the psa to stop rising while we ALL know it’s gonna rise anyways soon after. My IMRT gave me 6 months free psa progression
I'm dealing with the same problem. My findings till now are this:
Salvage radiotherapy alone is standard of care for men with PSA <=0.5 ng/ml.
Salvage radiotherapy with hormonal treatment is standard of care for men with PSA >= 0.7 ng/ml.
Men with high risk features and pre-SRT PSAs of <0.7 should still be considered for ADT.
So I'm decided not to accept ADT till my PSA is under 0.7 (now it's 0.5).
This statements are based on two trials: RTOG 9601 and GETUG-16 (viz links bellow)
urotoday.com/conference-hig...
tau.amegroups.com/article/v...
utswmed.org/medblog/prostat...
My psa now is at .51
What is the difference between.5 & .7?
They are the same 
My is 0.62. The difference between .5 & .7 is 0.2
Update: I decided to go with ADT and full Pelvic Radiation. I started Casodex 3 weeks ago and had the 6 month shot of Eligard last week. Side effects to start in 3-4 weeks from the injection I am told by RO nurse. Radiation to begin in mid-March for 8 weeks.
PSA is down to 0.1 from 0.4 two weeks after starting Casodex which my MO thinks is an excellent response.
I plan on staying on the Eligard for 24 months if it continues to keep me at an acceptable PSA level. I will then stop ADT and see if it holds.
Thanks very much for the comments and opinions!
Jim
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