An Update On My Father's PCa - Test Results/Treatment Plan

[vforvendetta]

This is an update regarding my 79 year old father who was recently diagnosed with PCa (Gleason 9, PSA 14.1, 12 core biopsy, all of which contained cancer).

I originally posted about my father's PCa diagnosis here: healthunlocked.com/advanced...

The CT and Bone scans both came back as negative regarding the PCa having metastasized. With that being said, the urologist said he would not be surprised if it has microscopically spread (micro-metastasized) based on Gleason 9 and 12/12 of the cores coming back as positive for Adenocarcinoma PCa.

His recommended course of treatment is 8 weeks of IMRT (after 8 weeks of ADT) and 2 years of ADT and 3 month intervals for monitoring PSA levels. ADT would be Bicalutamide and Eligard.

I asked for a PET scan and he said there was no clinical reason to do so.

On Monday we will be travelling to University of Michigan's Rogel Cancer Center for a second opinion. We meet separately with a Radiologist Oncologist and a Surgical Oncologist, but both are part of a "multi-disciplinary team" for PCa.

These URLs are scans of his pathology report:

robosixlabs.com/pathology/1...

robosixlabs.com/pathology/2...

PSA HISTORY

14.100 ng/mL = Date: Apr, 2019

9.120 ng/mL = Date: Oct, 2018

5.470 ng/mL = Date: Aug, 2016

4.790 ng/mL = Date: Apr, 2016

3.520 ng/mL = Date: Sep, 2015

1.800 ng/mL = Date: Oct, 2014

1.520 ng/mL = Date: Jan, 2013

1.4 ng/mL = Date: Jan, 2012

I'm not sure what I am asking for here, other than any insight/comments regarding his original Uro's treatment plan, and anything specific that I should be asking the UofM docs on Monday. My father wants his prostate to be removed, but I'm inclined to see what each of his doctors say and come up with a pro/con list and go from there.

[Tall_Allen]

Brachy boost therapy has much better outcomes than IMRT radiation alone or surgery:

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

pcnrv.blogspot.com/2018/03/...

I recommend you speak to Daniel Spratt at the U of Mich. I think that a PET scan is a good idea, but it will be hard to get for a high risk patient (insurance probably won't cover it), unless they have a clinical trial going on. The reason why it's a good idea is to see if there are any detectable pelvic lymph nodes and to rule out distant metastases.

[vforvendetta in reply to Tall_Allen]

Thanks, Tall_Allen, we are meeting with Dr. Spratt.

[vforvendetta in reply to Tall_Allen]

A question for you Tall_Allen. Is standard protocol for "brachy boost" for the seeds to be implanted prior to EBRT or after EBRT? Does the standard 8 week EBRT still apply or is it shorter?

Finally, since I will be driving him to and fro NW Ohio to Ann Arbor (about an 1.5 hours each way), should I be "concerned" about radiation exposure from the brachy boost seeds?

[Tall_Allen in reply to vforvendetta]

The order does not matter - some brachy docs prefer one or the other. It's 25 treatments of EBRT over 5 weeks.

If you are coming from NW Ohio, you may want to meet with Alvaro Martinez in Detroit. He was a pioneer of HDR brachytherapy. You can have the EBRT done locally.

[vforvendetta in reply to Tall_Allen]

Thank you for the reply, I appreciate your knowledge and help!

[vforvendetta in reply to Tall_Allen]

In reading these articles, it appears that 3DCRT is better than IMRT. Am I interpreting that correctly? As a follow-up question, are all 3DCRTs/IMRTs created equal - i.e. would the success rate be the same with an IMRT treatment with a technician at Rogel vs. an IMRT treatment with a technician at a hospital in Toledo, OH.

[Tall_Allen in reply to vforvendetta]

The opposite - IMRT has supplanted 3DCRT for prostate radiation.

[Fairwind]

Gleason 9 and 12 of 12 positive means surgery would be a long shot at best..Your original treatment plans is pretty good.. Ask about adding a "Brachy Boost: where the IGRT radiation treatment is combined with brachytherapy which is more effective than either of the two alone...You may need to find an RO who actually performs brachytherapy and get HIS opinion if your present RO is shy about it...

[vforvendetta in reply to Fairwind]

Thank you, Fairwind. Thankfully we are meeting with an RO that does brachy boost.

[Hidden]

Here are two articles, there are more if you search:

researchgate.net/publicatio...

redjournal.org/article/S036...

[vforvendetta in reply to Hidden]

Thank you gregg57 for the links.

[tango65]

This is another article about the outcome of radiotherapy associated with brachy boost in comparison with radiotherapy alone or radical prostatectomy:

ncbi.nlm.nih.gov/pubmed/295...

[vforvendetta in reply to tango65]

Thank you tango65!

[immunity1]

Alternatively, a recent (2018) analysis indicates a better survival with radical prostatectomy with follow-up RT compared to Ext beam RT plus ADT, with high risk PC (eg. Gl sc 9-10).

[Comparative Effectiveness of Radical Prostatectomy With Adjuvant Radiotherapy Versus Radiotherapy Plus Androgen Deprivation Therapy for Men With Advanced Prostate Cancer].

One could follow that up with a PSMA scan to seek any mini metastases that might be nailed with Lu177 treatment.

This approach assumes a patient with no co-morbidities and some medical centers may say his age rules against surgery.

All the best. Rob.

[Rmurchu]

Husband has very similar dx, age 65 ,Gleason 10 , all cores contained cancer , no Mets on axumin pet scan. Treatment : casodex for 2 months , then Lupron was started 2 months prior to brachytherapy to shrink the prostate volume. It’s must be below 58 to get brachytherapy husband was 56 in volume but the Lupron shrank it by a 1/3 by the time he had the procedure done. He had the procedure June 4 and now is starting external beam radiation this week for 5 weeks (25 treatments) They are also radiating the pelvic bed even though there is no Mets found. Doc said because of his high Gleason score it’s better to radiate that as well . I did a lot of reading on this subject and the results were the same if not slightly better by 2% in favour of this treatment plan versus removal and all the higher risk of surgery. He is to continue ADT for 2 to 3 years but I just read that the new protocol says 18 months with the same outcome. Good luck to your father on his journey.

[vforvendetta in reply to Rmurchu]

Thank you, Rmurchu! This is really good information. I wish you and your husband luck as well through this.

[dadzone43]

PET usually cannot pick up mets smaller that 4 mm. Not going to add much to your data base and will cost him a pile. Aside from the emotional (false) reassurance of "taking it all out" the benefit of RP for your dad eludes me. Generally urologists are not eager to do RP on men you dad's age. Equal benefit from brachy or IMRT with delayed incontinence. "Standard of Care" calls for ADT but you might want to have him think twice about that not only in terms of benefits but also in terms of a _realistic_ review of the side effects. Osteopenia, muscle loss, ac- celerated cardiovascular disease, breasts, fatigue are not trivial in my view; oncologists in my experience tend to be dismissive of them in my limited experience. Oncologists are about survival-months. Quality of life is secondary.

Just my opinion/experience.

I am 75. My first urologist flatly declared "we do not operate on men over 70." The robotic surgeon thought otherwise.

[vforvendetta]

Hi Dadzone43, thank you for your insight. I'm leaning towards the EBRT with Boost for QLE benefits and I'm wondering how hard hit he would be from RP in terms of recovery.

I didn't know that about PETs (picking up METs smaller than 4mm - that is good to know).

I've sent him the links about the benefits/success of EBRT with BB in the hopes of educating him before we meet with the doctors on Monday.

I value your opinion/experience, so thank you for sharing it with me.

[j-o-h-n]

Surgery at 79 doesn't seem the way to go. Tell your Dad that rforradiation.

Good Luck, Good Health and Good Humor.

j-o-h-n Saturday 06/15/2019 12:21 PM DST

[Don_1213]

A few comments on studies. The studies preferred to above appear to be retrospective studies - meaning the study is based on data from various databases from a time prior to the study. I can't recall any of these being true 2 arm comparitive studies.

One thing to consider is the changes in technology that have taken place over time. It's somewhat of a quandary trying to determine which treatment option to choose based on data from treatments done 10 years ago.

In the general field of RT - basically treatments being given today bear little resemblence to the treatments of 10 or more years ago (some of the studies were based on treatments from 2003.. 16 years ago.) Precision of delivery and the amount of the RT dose have both changed considerably from what was available 10 or 15 years ago.

The other flaw in the retrospective studies is inadequate information in the databases being used for the data. I understand some of the most commonly used databases have no information on comorbidities of the patient population being studied. It's not being hidden - it just wasn't considered of value when the data was recorded. In general, this means that people with the worst comorbidities were usually directed to the least stressful or invasive treatments. As people here have been told (including me) men over 70 are frequently directed away from RP - since recovery from it becomes more difficult as one gets older. And due to their comorbidities - they are likely to pass away sooner than people with less or no comorbidities. That effect isn't addressed in these studies that I could see.

EBRT with BB sounds good from the studies and there are a number of "fans" of it. I suspect a lot of the results on BB were based on very expert treatment with the brachytherapy.. something that apparently is harder to find now since there are less radiation oncologists doing brachy. The reason they may not be doing brachy could be as simple as they are seeing equal (or better) results with modern high-dose (80GY or more) radiation therapy combined with ADT.

Most of the studies above that I looked at were showing data from people who frequently received radiation doses of 71-75GY. That isn't the current standard of care for high-risk patients. Current standard is 79-81GY - coming closer to the total for RT & BB along with concurrent ADT. ADT isn't really mentioned in these studies. ADT has been found to make the cancer cells more sensitive to radiation damage, ie - make the treatment work better. Again - what the studies are based on is not the current standard of care.

The other point is - the 81GY treatment done today, with almost-real-time or real-time image guiding, multi-directional, conformal treatment is capable of delivering a more intense dose of radiation to the actual cancer and sparing adjoining tissue damage. At this point in time, I think it can't be definatively said that RT&BB is "superior" to other option treatments. It may have been at one time - but the radiation oncologists I spoke to felt with modern equipment there was no overwhelming reason to choose that route. It was available if I desired it, but not recommended by any of the 4 MD's that I consulted with.

Your dad is 79 years old. MSK has nomographs showing how many men survive 5 or 10 years based on Gleason score - with no treatment or with RP (the nomographs unfortunately don't seem to cover any radiation treatment options - at least last time I looked.) For mine, a 72 (73 in a week) G9 with no metastisis, if I had no treatment, the difference in the chances I'd be dead in 5 years from PCa when compared with men who received other treatments was small. At 10 years - ~30% of the men would still be alive (ie - 83 years old), but ~90% of the ones who passed away passed from something other than PCa.

It might be enlightening to go to the MSK page and plug in your dad's numbers - then consider the side-effects of something like RP or even BB and decide if the gain in mortality is worth the risk of poor quality of life for the remainder of his life.

I'd suggest looking for a newer cancer center, with an under 45 year old head radiation oncologist and ask about what treatments they offer and what their results are and what the possible side effects of each treatment are. You want someone young enough that they are still on top of current treatments and studies and trials, and you want a cancer center with the newest treatment equipment. And you want a center that won't look at your dad as simply a number.

Good luck!

PS: A study worth reading - ncbi.nlm.nih.gov/pmc/articl... - there are others with very similar results.

[vforvendetta in reply to Don_1213]

I love this response and this web site, crowd sourcing at its finest. I'll be printing this out and taking it with me. I believe Dr. Spratt at UofM (medicine.umich.edu/dept/rad... will be a man that we can rely on. He is young, seems to be near the top of his field, and has excellent street creds.