I am 77 years old and was diagnosed with prostate cancer through a biopsy taken during a TURP in August 2016. After watchful waiting the PSA started rising to 10.3 by April 2018. A biopsy and PSMA PET showed that I had a Stage T3N0M0 tumor (with a Gleason 5+3). After a Zoladex 0.8 injection on 30 April 2018 I received 25 fractions of 65 Gy radiation in July and early August 2018 Since then I have received 3 further Zoladex injections at 3 monthly intervals. My PSA came down and was most recently <.008 in March 2019 and also in April 2019. Based on this and an MRI in March 2018 December and a physical examination rectum I have reportedly responded well and show “no evidence of disease”.
The rectum was "flat" and there was "no infiltration". Testosterone was 9.5
The Zoladex injections however have been causing me more and more discomfort: considerable weakness, weight gain around the abdomen, swelling in the ankles and lower legs etc. Being an outdoors person and otherwise quite fit I have continued daily hard swimming throughout but find it more and more difficult to do the same length. Even climbing a flight of stairs is an effort.
My next Zoladex injection is due but I would prefer not to continue with the hormone therapy as long as I am not taking an unacceptably high risk. Two doctors advise against whereas one agrees that I can. Would be grateful for any useful feedback.
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Jazzophile
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In high risk men like yourself, it has been found (DART 01/05) that 28 months of ADT is superior to 6 months when given with high dose radiation (like you got). There was also a randomized clinical trial (Nabid) that suggested that 18 months of adjuvant ADT was equivalent to 36 months, so it is possible that 18 months may be enough. However, there were important differences between the two studies. The Nabid study gave lower radiation dose and had significantly lower biochemical disease-free survival at 5 years. Was the difference because of the lower dose of radiation or because of the shorter duration of ADT - impossible to say. Given that you had predominant pattern 5, which is known to be relatively hormone and radiation resistant, you may want to consider erring on the side of caution.
Dear Tall_Allen, really nice of you to take the trouble to send such a reasoned reply. Looked up the Nabid article and the abstract of the Lancet article and learnt a lot in the process. However my reading of them is the biochemical disease free survival rates are about the same in both studies . In Nabid they are 88 versus 82 for long versus short term, going by the failure numbers in Fig 2C, and in Lancet they are 90 and 81. Wonder if I am misreading something. Good to be cautioned about the 5 in my Gleason, wasn't aware of that. Thanks again, very useful
You're right -( I was looking Figure 2D in Nabid - 69% at 5 years, but that also takes out men who died or had radiographic progression by 5 years). So, Nabid had 82% for 18 months of ADT, and 88% at 36 months of ADT. DART 01/05 for high risk men had 88% for 28 month, and 66% for 6 months for 5-yr bDFS.
I am not an expert on this and my opinion is that of a layman but, for whatever it's worth, here it is.
I think that in your shoes I would stop the Zoladex. Here's why:
1. When given in conjunction with radiation, the marginal value of ADT/Zoladex declines over time. The first few months of treatment significantly improves the odds of a cure. Each additional month continues to improve the odds up to about 3 years, but the improvement of odds gets smaller and smaller. By one year, which you've had, you've gotten most of the benefit and the risk of stopping Zoladex is a lot less than it would have been earlier.
2. At this point, the Zoladex is causing you significant and increasing health problems. Although the doctors know that, they often think that their main obligation to you is to keep the risk of death by prostate cancer down as low as possible. If they can improve your odds of a cure from (I'm making up numbers here) 60% to 63%, there are a lot of doctors who would advise you to accept the two more years of bad health and unhappiness to get that bump in the odds.
3. If you continue to get regular PSA tests, at least every 6 months and maybe every 3, you will find out if your cancer is recurring in time to resume treatment and prevent death by prostate cancer.
Your stage 3 Gleaon 8 cancer was serious. It may be that, if you get off Zoladex your PSA will rise steadily, indicating that you still have cancer, however that could happen even if you keep up the Zoladex for another year or two. There is a risk that the Zoladex is really curing the last of your cancer now and that if you stop it, the cure will be interrupted and the cancer will return. But I think that if the cancer returns, it is much more likely that it would have returned anyway, you just wouldn't have seen it for another year or two. If the cancer returns, there's no way to know whether staying on Zoladex would have prevented a recurrence but, in my inexpert opinion, the chances are that it wouldn't. The marginal value of continuing the treatment after one year is real, but fairly small.
There are some treatments that are weaker than Zoladex but also have less side effects. One is Avodart (generic = dutasteride), another is low dose Casodex (generic = bicalutamide.) They might allow you to continue some level of treatment but without the harsh side effects of the Zoladex. You might ask about whether one of those drugs is a possibility for you. You might feel much better on one of those drugs.
Dear Alan, thanks so much for the detailed and highly informative reply. Succintly summed up in comment that the marginal value of continuing treatment may be real but small. Thanks for drawing my attention to the alternatives to Zoladex. Cheers
Jazz, I understand that you have three doctors. From your posts, an Urologist, Radiation Oncologist, and a Medical Oncologist. All three have different disciplines of expertise. Hopefully your MO specializes in metastatic Prostate Cancer. If I am correct, you have to decide who is best suited to treat your cancer?
The brothers' advice reflects the state of knowledge. Population studies are GUIDES but may/may not reflect on your cancer's status. I think the question pivots around the balance between the assault on your quality of life from the ADT and the alleged benefits. We can tell you what the studies show. Only you can decide what risk you will tolerate. Happily, unlike the women with breast cancer , you have a marker to monitor the activity. A reversal in PSA would nudge me to reconsider and go back to ADT. CAN you tolerate the doubt? Can you tolerate the well-meant second guessing of friends and family and physicians?
My reading of your post is that you are having a hard time with the Zoladex. I once took a vacation from ADT, after a year of undetectable PSA. Less than a year later, I was back on ADT after proving to myself and my wife that my little man was dead to the world. Back on ADT (Trelstar this time) life is not close to great, but my PSA stays undetectable. If I had to do it again, I would insist on 30 day PSA tests. If there is a rise, you want to catch it early.
Dear Nalakrats, thanks for the very detailed reply and the note of caution and the stuff about intermittent vacations. I wish my doctors were as communicative! Really appreciate it
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