Update on My Lymph Node Metastatic Prostate Cancer

[dac500]

Initially, I was treated for low volume Gleason 3 + 3 cancer in 2011 with brachytherapy. In 2016, I an extra-capsular recurrence that was treated with ADT ( 3 months Firmagon and 6 months Lupron) and cyberknife. Then in 2018, my PSA started rising rapidly with less than 2 months PSADT from <0.1 in January to 4.48 in November. A PET/CT scan showed multiple lymph node involvement and a biopsy of peri-rectal lymph node confirmed metastatic cancer.

In November 2018, I started Lupron + Casodex treatment. My PSA went down rapidly: Nov 2018: 4.48, Mar 2019: 0.17, Jun 2019: 0.1, Sep 2019: 0.07, Nov 2019: 0.06.

It appears that my PSA has bottomed out. My MO recommended a break from ADT, which I decided to accept. I will go for another PSA and other blood works at the end of February.

So far my concern was becoming castrate resistant. I understand most men become castrate resistant in 1 to 3 years on ADT. I was on ADT in 2016/17 for 9 months and this time on it for 12 months. Does this mean that I should count 21 months on ADT for the castrate resistant clock? Or the clock started at the start of ADT in October, 2016?

I have wondered about the source of my lymph node metastasis. Did it come from the extra-capsular recurrent? Or, was it in the lymph nodes in microscopic form since initial diagnosis?

Did I make a good decision to take an ADT vacation? MO left the decision entirely to me but expressed his recommendation for it.

When my PSA starts rising again, what should be the threshold for restarting Lupron or other treatments? What role PSADT and imaging play?

[LearnAll]

You said: "most men become castrate resistant in 1 to 3 years"

NOT TRUE. Men can remain Castarate sensitive from 1 to 10 years...each case is different. There is no general rule. There is no castrate resistance clock.

IMO, staying on what is working well is good decision with regular careful monitoring of PSA, ALP etc.

Does not matter from where lymph node mets came from...they are there ,then treat it as metastatic stage 4 PCA.

[dac500 in reply to LearnAll]

I know that for some men ADT works even for 20 years. What I quoted is the average.

[dbrooks_h in reply to dac500]

Where did you hear 3 years was average.

[dac500 in reply to dbrooks_h]

I don't specifically remember the articles. There are quite a few of them. A Google search will find them.

[GP24 in reply to dac500]

Yes, many articles mention 2 to 3 years of ADT until men become castrate resistant. However, until now I have not been able to track down the source of this information. There is usually no source provided and if there is, this source again just states it without providing a source.

I did some research on the time until ADT will end up in castration resistance. There are many factors that determine this period and 2 to 3 years is so general that it is wrong.

[Tall_Allen]

Castration resistance occurs later when one has ADT. The cancer volume reduction overrides the selective pressure effect. Castration resistance occurs even without ADT. There is no point in anticipating it. It will happen when it happens.

Most studies have not reported failure-free survival for recurrent men with mets. (STAMPEDE/abiraterone had only 38 men in the "recurrent" placebo group.) The closest reported data to your situation is the STAMPEDE trial where men newly diagnosed with metastases had their prostates treated with radiation plus lifelong ADT. Failure-free survival was 26 months (36 mos for low met burden, 19 mos for high met burden)

Was intermittent a good decision? It depends on your quality of life. If it improved, it is a good decision. There is no set formula for when to end each vacation, but high PSA, rapid PSADT, scans, and length of time with adequate testosterone are all good measures.

You probably had some undetected higher grade PC originally, because ECE is unusual with a GS6. GS6 is also incapable of metastasizing while it is still GS6.

[dac500 in reply to Tall_Allen]

Thanks Tall Allen. Your answer is most informative.