Seeking advice regarding hormone therapy and radiotherapy duration

[fangjoell]

Dear members,

This is Joell and I'm from Malaysia. My father was diagnosed with Gleason 9 early-stage (clinical stage T1c from a doctor and T2c from another doctor) on July 22, 2020 via transperineal MRI fusion biopsy. 32 samples were taken and 4 cores are Gleason 5+4, 2 cores are Gleason 4+5, 3 cores are Gleason 4+4, and 1 core is Gleason 3+3. (13 cores out of 32 cores are positive). No perineural invasion or seminal vesicles invasion according to the biopsy and MRI.

His PSA was 8.31ng/dl (tested on May 27, 2020) and DRE was 35g.

He has only done a bone scan and the result came back negative. He hasn't done any whole body PSMA scan or pelvic CT/PET scan.

The doctor suggested a) surgery or a) hormone therapy + radiotherapy and we chose the latter due to my dad's age (69 this year) and other health conditions. So the doctor gave my dad the first Lucrin (lupron) 11.25mg injection on July 28, 2020, and prescribed him bicalutamide 50mg daily and scheduled him to have radiotherapy after 6 weeks of the injection.

Of course we wanted to seek second opinion so we went for several other doctors. Some suggested that we should do at least 3 months of hormone therapy before my dad starts his radiotherapy. And other even suggested doing hormone therapy for 3 months or 6 months. I'm super confused now. So my first question is:

1) Shall we wait for 6 weeks, 3 months or 6 months of hormone therapy before carrying out the radiotherapy?

Also, different durations and types of radiotherapy were suggested by the doctors:

a. 6 weeks neoadjuvant hormone therapy + tomotherapy for 8 weeks on prostate and pelvic lymph nodes

b. 3-6 months neoadjuvant hormone therapy + VMAT for 4 weeks on prostate (maybe pelvid lymph nodes as well)

c. 6 weeks neoadjuvant hormone therapy + tomotherapy for 28 days on prostate only

So my second question is:

2) which of the above radiotherapies is optimal for my dad's case?

And my other questions:

3) what is the cure rate for my dad's condition?

4) what is the recurrence rate, say, in 5 years' time?

5) what is the percentage of my dad's 10-year life expentancy?

Sorry for bombarding you guys with so many questions. I'd really appreciate if anyone can help me out on this as I don't wish any delayed treatment or wrong treatment for my dad - the person I care about the most. Thank you so, so much!

[Tall_Allen]

Good questions.

1) What matters is not the time so much as the undetectable PSA achieved. There was a randomized trial of 6 months vs 2 months neoadjuvant ADT, and it made no difference in outcomes. As long as the cancer is "preconditioned" by the ADT, he is ready.

2) None of those is optimal. Your father has high risk (GS 9) PC. The kind of radiation found to be optimal is a combination of external beam radiation to the whole pelvic lymph node area plus a brachytherapy boost to the prostate plus 18 months in total of ADT. The superiority of this approach was proven in a large randomized clinical trial, which you can read about here:

prostatecancer.news/2017/03...

While the ASCENDE-RT trial (above) used 12 months of ADT in everyone, a recent trial (TROG RADAR) randomized high-risk men receiving brachy boost therapy to 18 months or 6 months of ADT. Results were optimized by the 18 month course of ADT:

prostatecancer.news/2020/04...

The whole pelvic lymph node area should be treated because the risk of lymph node involvement is quite high (over 30%, by the Roach formula). They have expanded the lymph node area to include the common iliac lymph nodes.

3-5) See the TROG RADAR and ASCENDE-RT results, above

[fangjoell in reply to Tall_Allen]

Thank you very much, Tall_Allen. Your reply is extremely helpful

Since you mentioned that it makes no difference in outcomes for either 2- or 6-month neoadjuvant ADT, would it be right for me to say that if we prolong the neoadjuvant ADT duration, say, up to a year, and then only do the radiation/brachytherapy, it can actually delay the recurrence?

I talked to another doctor yesterday and he suggested 2-month neoadjuvant ADT + 8 weeks tomo radiation + 18 months of adjuvant ADT (both Lupron injection and third-generation oral ADT) - What is a third-generation oral ADT?

None of the doctors we have spoken to mentioned of brachytherapy. I asked and they said it wasn't a common treatment option in my country. I wonder why if it is so effective according to so much research?

Hope you can help, Allen. Thank you so much!

[Tall_Allen in reply to fangjoell]

"would it be right for me to say that if we prolong the neoadjuvant ADT duration, say, up to a year, and then only do the radiation/brachytherapy, it can actually delay the recurrence?" No, that would not be right. I said it makes no difference.

Unfortunately, brachytherapy is underutilized in the US as well In the US, radiation oncologists are reimbursed by insurance based on the number of treatments. So there is an incentive to give more external beam radiation treatments. I hope you are able to find a provider.

[fangjoell in reply to Tall_Allen]

Thank you, Tall_Allen. Appreciate you for taking the time to share these very useful information.

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

Greetings fangjoell,

Of course God will bless you for being such a worthy caregiver for your dear Father. Keep it up and keep posting here for valuable information.

Good Luck, Good Health and Good Humor.

j-o-h-n Wednesday 09/09/2020 5:48 PM DST

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

Hi John,

Thank you for your well wishes, John. I will post any updates here and hoping it will be helpful to someone.

"Good Luck, Good Health and Good Humor" - Love it!