SRT with hormonal therapy, I need your help!

[Ralph1966]

The MO (Jasek Pinski, MD) at USC Noris Cancer Centre, told me that he will put me on monthly injections of Degarelix (Firmagon) for 6 months and the RO will start the SRT 6-7 weeks after the first injection, he said that this will shutdown T level quickly and help the effectiveness of Raiation therapy.

I have G 9 (4+5) PCa, RRP surgey 09/2017. Localized with no extracapsular extension.

BCR started January 2019 PSA 0.020 0.030 0.05 and lastly 0.09 April, will repeat the PSA May 20th before starting injections!

1) Why not Lupron injections?

2) RO not sure if I will need + pelvic radiation, although she may decide that in my next visit on June. I asked her for combination Prostate bed and Pelvic LNS radiation. She said this may increase the side effects mostly worried for Lymphadema since the surgeon removed 63 local LNs to slow down recurrence (all were clear from cancer), and she think that prostate bed radiation will be enough!

I am 53 year old and have 2 young kids, and of course I want to keep the metastasis at bay as long as possible although I know it is an unevitable and there is no cure for this disease...

3) RO said at USC Noris cancer center they have 70% ten years non-recurrence after radiation therapy, and for high risk PCA it may go down a little bit to 60-65%,

I need your advice for questikns 1 &2 and your expeience for q 3.

Thanks!

[GP24]

Degarelix will reduce the T level more quickly than Lupron and without flare. It can be a bit more effective than Lupron.

After 63 removed lymph nodes I would also hesitate to radiate the pelvis. Not much left there which could be treated with this radiation. If there is no cure you do not need side effects for the rest of your life. Prostate bed can be done with little side effects. Of cause there are many patients who suffer from side effects.

I do not have better statistics than USC Noris.

[Ralph1966 in reply to GP24]

Thanks GP24

[tango65]

Some information from the SPPORT trial about RT, ADT and PLNRT:

ascopost.com/issues/novembe...

astro.org/ASTRO/media/ASTRO...

IMO, you should get a second opinion about the extension of the radiation. UCLA has good radiation oncologists:

uclahealth.org/Albert-Chang

uclahealth.org/Christopher-...

UCSF also good radiation oncologists:

radonc.ucsf.edu/mack-roach

[Ralph1966 in reply to tango65]

Thank you tango65,

The clinical trial link was so helpful!

PLNRT + PBRT + SADT is slightly better 89% in the survival chance from PBRT + SADT 83%, but the cost is higher possibility of grade 2&3 blood/Bone Marrow adverse events (both acute and late) are huge 2.0 % (no PLNRT) vs 7.7 % (with additional PLNRT) (acute AE) and 1.8 % (no PLNRT) vs 5.2% (with additional PLNRT) (late AE).

Thank you again!

[tango65 in reply to Ralph1966]

Best of luck in your journey. Consider a second opinion of Drs with clinical experience.

[Tall_Allen]

1) Firmagon must be given monthly and stops testosterone production more quickly, while Lupron is available as a multi-month injection and takes longer to kick in. By starting with Firmagon, and switching to Lupron, you avoid the initial testosterone surge you get with Lupron.

But the bigger question is - is ADT of any benefit? The answer is that there is no known benefit at your low PSA.

2) Salvage treatment of pelvic lymph nodes is also of no benefit at low PSAs like yours. Your RO is right that your ePLND was extensive and there is a danger of lymphocele and lymphedema, but the bigger risk is enteric inflammation.

3) You are wrong when you say "there is no cure for this disease." Many men are cured with salvage radiation. Here's a nomogram that gives a rough idea of your odds that salvage radiation will be successful:

riskcalc.org/ProstateCancer...

[Ralph1966 in reply to Tall_Allen]

Thanks TA,

Now I feel that your heart is with me...

You are awesome!

[AlanMeyer in reply to Tall_Allen]

Allen,

I have read that ADT improves the odds of a cure from radiation in cases of aggressive prostate cancer. Wouldn't Ralph's high Gleason score and rapid PSA doubling time indicate that he has pretty aggressive cancer and would therefore benefit from ADT even though his current PSA is very low?

Thanks.

Alan

[Tall_Allen]

He doesn't have a PSADT - doubling time is not valid for PSAs under 0.1. He does have a pattern of rising PSA, which is a good indicator that SRT is a good idea. Other than his Gleason score, he had no adverse pathology. RTOG 9601 (one of our best RCTs) showed there was no benefit to adjuvant ADT in men with PSA< 0.7 (although some ROs I know still recommend it with PSA as low as 0.1). Here's what I know:

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

(RTOG 9601 used bicalutamide rather than a GnRH agonist)

All of the studies so far used doses of radiation on the low side. With escalated dosing available with today's linacs, the need for ADT as a radiosensitizing agent is reduced.

That said, those are just population statistics and individual results vary. One man in my support group (with GS 8 and no adverse pathology) decided that he wanted short term ADT when his PSA reached 0.2 because it gave him peace of mind to do so. Every man must decide for himself, and should discuss all this with his RO before deciding.

[Blackpatch in reply to Tall_Allen]

On uPSA measurements and associated ePSADT estimates - some of the people responsible for one of the better studies looking for ePSADT correlations with PSADT and not finding any, seem to have shifted their ground recently...

doi.org/10.1016/j.juro.2017...

and these guys have a neat plot that marries up the first derivative of uPSA v T and subsequent PSA v T curves (ie effectively ePSADT and PSADT)...

nature.com/articles/srep36161

I think you're right that a doubling time estimated with uPSA measurements can't be plugged straight into nomograms and other analyses undertaken with earlier-era PSA measurements (i.e. at higher absolute PSA values), but uPSA seems increasingly well accepted as a diagnostic tool.

Stuart

[GeorgesCalvez]

Nomograms do not say much about an individual patient.

What they do say is that if a doctor has a hundred or better a thousand cases then so many per cent will relapse and so many per cent will die in ten years.

They are akin to an actuarial calculation, if an assurance firm is selling annuities to 65 year olds they factor into the payments that so many per cent will be dead after 10 years, etc.

If you look at a sample of clients you will find some that are in fine health and some that are a bit closer to looking at the daisies from the wrong side.

Looking at your case I would say that you have a good chance of SRT working and even if it does not you will hold the demon at bay for a long time so don't splurge your pension pot!

[j-o-h-n in reply to GeorgesCalvez]

Just a FYI

If my memory serves me well.... which I must admit it hasn't lately, our esteem member "Patrick" is a retired actuary.

Good Luck, Good Health and Good Humor.

j-o-h-n Friday 05/10/2019 6:32 PM DST

[GP24]

Nomograms provide a prognosis how long you would live if you were treated 10 years ago. They are based on statistical data which is that old. However, new drugs and treatments became available recently which will extend your overall survival significantly.

[Ralph1966 in reply to GP24]

GP24,

You are right, I noticed that the new clinical trials showing much better outcomes with new treatments.

We need to do whatever we have to do, get treatments / life modifications and try to tolerate the side effects, and move on.

Even a healthy person does not have the guaranty that he/she will not die tomorrow or next year!

[RonnyBaby]

I can't help but recall how many patients mentioned something was 'missed' when they performed surgery. Those poor souls typically went on to develop 'advanced' scenarios.

I started out as G9 with node involvement (N1) and a high PSA (300+). (I'm 67 yrs ld)

I had EBRT with an ADT combo (Lupron), starting about 2 years ago.

Today, I'm doing well (getting stronger, slowly but surely) and remain optimistic.

Of course nothing is guaranteed, but you can always hope and pray for the best outcome !

[Ralph1966 in reply to RonnyBaby]

Thanks Ronny,

Your words are really helpful.

[GreenStreet]

A really difficult decision and one that I faced in 2018 but I did have a positive margin unfortunately. I pushed for 6 months hormone therapy because I read some European studies that seemed to suggest some synergistic advantages with SRT. My PSA was 0.06 before I started HT and was undetectable when commenced SRT in Feb 2018. Now at 0.02 in March 19 unfortunately. On RO advice I did not have RT to lymph nodes. They advised against. Good luck with your decision and treatment.

[Ralph1966 in reply to GreenStreet]

Thanks for your feed back, really appreciate it.