Salvage radiation vs ADT and zytiga for stage t3b

[Concernedwife24]

Are there studies to show the outcome of having radiation after prostatectomy plus ADT vs ADT and zytiga with no radiation.

[Tall_Allen]

To my knowledge there has never been an RCT that compared SRT+ADT to ADT+Zytiga. It would be comparing a potentially curative therapy to a palliative therapy. I'm not sure it would be ethical.

[London441]

Hi, I am post RP t3b currently in a clinical trial of radiation, ADT, Zytiga and chemotherapy. May I ask why you are interested in a ADT/Zytiga combination?

[Concernedwife24 in reply to London441]

That is what the doctor is going to put my husband on. He had rp on 3/31. Gleason 9. T3b pathology. Post PSA is 4.88 and 4.80. The question is mostly about radiation. If the scans show still localized I think he should get radiation. Just want to know if it helps. One doctor said it's not worth the side effects. 100 guys get radiation to save 2 in his scenario. Other doctor said it would be good to do it. We will talk to radiation oncologist at UCLA next week.

[RonnyBaby in reply to Concernedwife24]

No two cases are identical, but I've been around this site for a few years now and I'd like to offer this up as food for thought.

I read of several T3b types (I'm one of them) who had different treatment plans.

So far, I'm one of the few who went the radiation + ADT route only. No RP or me - I was told I was too far gone for that. So, no need or call for chemo.

I was node positive, so the treatment plan included the pelvic bed / region for a few 'hot spots'.

In terms of side effects from radiation, mine were minimal - although I will say that the fatigue that followed surprised me. As best as I can tell, 2 years post-rad, I have no lingering side effects that are out of the ordinary.

I'm also on an ADT holiday (for now).

I chose the holiday because I was undetectable for about 1 year and I want(ed) to see what my real state of health is - off treatment will allow the numbers to go where they will - will I be stable, in remission or will I need to cycle (I will NOT stay on ADT unless it is a last resort) ?

I'd rather find out than keep guessing while avoiding taking drugs that I don't really need.

I note that you didn't provide a quick history or stats, so I am making an assumption or two ...

[Concernedwife24 in reply to RonnyBaby]

Before surgery the mri did not show seminal vesicle involvement. After surgery there it was and not clean margin. PSA was 19.8 now 4.8 after 7 weeks.

[RonnyBaby in reply to Concernedwife24]

Watching the PSA number will be key to the next decision that is made.

IF he stays @ 4.8. or drops further, he's looking good - if his number rises, under the right combo, he's having to decide what to do next because a problem still exists.

Radiation + ADT still offers a 'potential' cure for T3b's.

The 'b' in the equation = localized spread - typically, the way to get at it is thru radiation, unless some systemic treatment is used, which might be premature - although I'm no doctor - this is my opinion, based on what I've learned as a patient / survivor.

The ADT add on is to allow time to kill off the remaining cells that are circulating in the bloodstream or form part of the micro scale that can't be detected except thru various additional tests. Time is a factor in terms of ADT duration.

You're asking some good questions - hopefully, your medical 'team' are qualified to guide you forward.

You need to move past urologists ....

[Concernedwife24 in reply to RonnyBaby]

Yes we have moved to mo.

[Concernedwife24 in reply to London441]

What's the name of the trial.

[Horse12888]

Tall Allen is right. Radiation is potentially curative, and so should be pursued if indicated.

[pjoshea13 in reply to Horse12888]

One needs to distinguish between radiation as primary treatment - i.e. of the prostate & potentially curative - & salvage radiation after RP - i.e. of the prostate bed, & never offered as a "cure".

-Patrick

[DonUSNA73 in reply to pjoshea13]

Well...2 different med oncs recommended salvage radiation + Zytiga + firmagon post RP for me (T3c) and both independently used the word curative (as the goal).

[pjoshea13 in reply to DonUSNA73]

Don,

I was responding to "Radiation is potentially curative" & the context of "radiation after prostatectomy" i.e. salvage radiation [SR] (Concernedwife24).

It was made quite clear to me 15+ years ago that SR by itself was never offerred with curative intent. There was no Zytiga then, of course, & Lupron wasn't offered me until SR failure (I declined).

My question at the time was whether the cancer was confined to the bed, i.e. what were the odds?. I did have a scan & having no known mets was a precondition for SR, but imaging tools were lousy then. Essentially, I was told that I had chosen an aggressive treatment [RP], so why stop now, even if the cancer was only slowed for a while? Even if the cancer was already distant? What did I have to lose? LOL

I was told not to look for a dramatic drop in PSA. "Success" would be measured by doubling time going forward. I agreed to the SR, but without enthusiasm.

I had L5 radiated 5 years ago. My radio-oncologist said that there were probably cancer cells there from the start. My RP had been clean according to the surgeon & pathologist. Perhaps I could have skipped the SR?

Anyway, what percentage success rate should there be before we describe a therapy as being curative? Some men with purely local (prostate bed) PCa have presumably experienced very long-term remission without futher treatment.

In March we had "A Post-Hoc Analysis of RTOG 9601 Trial Data" [1]:

"Patients with biochemical persistence after RP are approximately 2.5 times more likely to experience local/metastatic failure and death, compared to patients with biochemical recurrence after RP, despite equivalent sRT with/without antiandrogen therapy use."

So that adds a wrinkle. I had "biochemical persistence" - not "recurrence". & that was always how I thought of SR at that time. Something that was done after RP once the bed had healed. Perhaps with biochemical persistence, diagnosis & treatment had come too late to think in terms of cure?

Anyway, here's to both of us (as I raise a glass of decent red on this rainy lockdown day.)

-Patrick

[1] pubmed.ncbi.nlm.nih.gov/322...

[DonUSNA73 in reply to pjoshea13]

Thanks for the response Patrick...cheers!

[Concernedwife24 in reply to DonUSNA73]

Our MO and radiation oncologist both said curative if he does the radiation because he had the psma pet scan and it's not in bones or organs.

[London441]

Not a name that I know of. It's a small one, through Johns Hopkins. IMRT, Zytiga, docetazel and ADT for 2 years. I was 1 node positive, seminal vesicle involvement, pt3b. PSA undetectable 6 weeks post RP, which was June of last year, and remains that way so far. Basically an aggressive move post RP as recommended. This even though undetectable with negative margins. As opposed to waiting for possible recurrence down the road. No one knows its efficacy yet, though there are large trials such as STAMPEDE and others that show benefit in some.

Basically it's between throwing everything at it early vs wait and see. Much like RP itself, it's easy to buy into being that aggressive, but the results are mixed. RP recovery remains slow, but I've had very few side effects from any of the treatments overall.

All I can say for sure is-obvious though it may be- we are ALL different when it comes to what we can handle, intensity and duration of side effects etc. Many men would never do a trial similar to mine even if they thought it would work bc all the potential sides. Co- morbidities are potentially a BIG problem with any treatments as you know.

Again, re side effects: So much fear around them, understandable but often misleading. For instance, plenty of guys flat out refuse ADT, which is their business. Based on my pathology I'm convinced it's important for me. I've found the sides easily tolerable. This is likely due to specific reasons that are well known, centered around diet and exercise. Unfortunately, the folklore that ADT is definitively a horrible nightmare is easy to understand-like all other treatments, those who suffer the most are all over these boards. Those who don't experience them, or tolerate them easily aren't heard from much.

All I'm saying is I don't make treatment decisions based on the reporting of others-the info is easily skewed.

[Concernedwife24]

Thanks. Hope it all goes well

[j-o-h-n]

Don't know about any studies, but I got the "bed frying routine". 39 sessions with absolutely no side effects then, but a couple of years later there was a stricture in my left urinary tract that they "think" was caused by the frying. Caution is the key word...

Good luck, Good Health and Good Humor.

j-o-h-n Thursday 05/21/2020 5:56 PM DST