This recent published study surprisingly? portrays that a higher PSA following RP and early pre salvage radiation theray (pre-SRT) has a better outcome using ADT than a lower PSA - anyone have thoughts on this ?
Conclusion from the study:
The investigators concluded, “These results suggest that pre-SRT PSA level may be a prognostic biomarker for outcomes of antiandrogen treatment with SRT. In patients receiving late SRT (PSA > 0.6 ng/mL), hormone therapy was associated with improved outcomes. In men receiving early SRT (PSA ≤ 0.6 ng/mL), long-term antiandrogen treatment was not associated with improved overall survival.
Allen I see that these men were given Casodex. Also that the study took place 20 years ago. With today’s use of more advanced radiation and LHRH agonists in place of (or in addition to) the nonsteroidal antiandrogens, do you think this conclusion would still apply?
Yes, it still applies. They were given 150 mg/day Casodex, which is still the monotherapy dose. The radiation dose was low by today's standards (65 Gy vs 70 Gy). Arguably, the optimal cutoff for adjuvant ADT might be a bit higher with the stronger radiation. But some ROs use a lower PSA limit. King and Zelefsky, for example, give adjuvant ADT at anything above 0.2. Sandler uses a cutoff of 0.5. It has to be decided case by case.
Thank you. As a adjuvant therapy after RP patient with negative margins and undetectable PSA after surgery but with 1 of 12 lymph nodes positive and seminal vesicle invasion I am in a aggressive trial at Hopkins that has included Lupron, Zytiga, taxotere and IMRT both to the prostate bed and nodes. Lupron was to last 2 years, I’m a year in. They’ve told me it may be shortened to 18 months instead based on changes in ‘guidelines’.
I’m not miserable on the ADT but like anyone else I’d be happier stopping, especially if the difference between 18 mo and 2 years is nonexistent or minimal. Thoughts?
With a positive lymph node, none of that applies to you. You would normally require 2-3 years of adjuvant ADT. But maybe less because of the added Zytiga and taxotere. It's a judgement call if you want to shorten it to 18 months. That 18 month guideline is not based on patients with positive lymph nodes.
I had positive lymph node involvement and the PSMA scan showed some remaining in the prostate bed. My 18 months of Lupron and 12 months of Zytiga end September 30th. We are hoping for a positive outcome.
This is a great example of the kind of "science" backing the majority of medical studies. There is an axiom that reads: To every medical study concluding X, there is another one concluding the exact opposite. This is such a widespread and implicitly acknowledged truth, that most researchers very meticulusly try to cover their nether parts by including final line reservations of the sort: "... more study is merited" or "known weaknesses of this study are ... bla-bla-bla".
The study that you quoted has taken said axiom to unattainable heights: A study can conclude to A, but the SAME study can partially conclude to the opposite.
Long story short, last September in Barcelona three (3) recent studies from all around the world concluded that if the PSA at the begining of SRT is low enough, concurrent ADT is almost useless. Almost, in the sense that not only it won't extend the life of the patient, but may posibly become harmful by inducing other, not related, risks (read cardiovascular causes of death).
This has shaken, more properly phrased: "will shake" -because many drs take many years to digest the newer trends- their existing concrete belief that concurrent ADT with SRT is the right combo.
The dr that authored your quoted paper, took the data of the old study and stratified patients according to the PSA they had at the initiation of SRT.
And by this newer analysis the world of past "scientific knowledge" tumbled down.
That is, until newer studies emerge...we have got a new king. Long live the king!
Science sets down timeless rules, empiricism evolves with time.
I can see how the wording is confusing, but what they are saying is that antiandrogens with SRT offered a survival advantage in men with higher PSA compared to placebo in the same cohort (the placebo group also had high PSA).
Antiandrogens with SRT did not offer a survival advantage in men with low PSA (PSA ≤ 0.6 ng/mL) compared to men in the same cohort on placebo (the placebo group also had low PSA).
So the study was NOT saying that men with high PSA had better survival than men with low PSA when given hormones with SRT as it wasn't comparing these groups directly to eachother, rather it was comparing survival to placebo within each cohort. The results were what we would expect and indicated that antiandrogens do not need to be used along with SRT in men with low PSA.
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