Mayo study of inoperable advanced PCa... - Advanced Prostate...
Mayo study of inoperable advanced PCa now operable. from 2005 shows 79% alive at 15 yrs. stage 3 & 4 frequently overstated.
Interesting. Thanks for posting
Mayo is good care.IMO , we know there is a huge difference between 3-4..
We should remember this is a retrospective study with patients treated when the staging techniques and the radiotherapy techniques were very different from the ones use today. Having said that I do believe in getting rid of the mothership and avoid local complications if and when the cancer becomes untreatable.
I'm N of 1 but...I have T3 prostate cancer. Diagnosed in 2018. Doctors at Mayo gave me three months before I was in pain.
So far it has been just under 3 years and nothing to report. I didn't do conventional ADT, chemo, or radiation (my current MO talked me out of radiation).
RSH1, have read your Bio a couple of times over past 3 months. Thanks, appreciate your input. Yes, a very interesting alternative journey. Your Supra physiologic T in what I call mBAT, is becoming more and more in vogue. TA recently wrote that those of us wit a DNA Repair Gene (ATM for me), do much better on BAT than others. Bad part is ATM gene is busy repairing the many DNA strand breaks in PCa allowing it to grow faster, while BAT is good for extending the time for Hormone Sensitivity, delaying time to Hormone resistance, all while keeping your Manhood, strength, personality, less brain fog, and QOL in a happy place. The journey continues. Have to enjoy the journey. Best,
Mike
St Pete
Thanks Mike,
Last month my PSA finally rose. Two years of high testosterone came to an end.
I value the quality of life immensely so my new plan is BAT-like.
I'm taking Casodex to block the testosterone until cypionate leaves my system (approx 4 weeks after the last bi-weekly injection of 200 mg).
At the same time, I am taking a SARM. My testosterone has already dropped from 3000+ to about 300. Either the SARM is doing what I hope it will or something else is going on because I'm gaining muscle and getting stronger even as my T falls (I changed up my workout but I rather doubt that is the culprit).
For the first cycle, I am going to stay on the low T phase until my PSA and/or scans show cancer growth. At that time I plan on doing another cycle of high T. If my PSA still shows bad stuff I plan on radiation or what my MO suggests (within reason!). I think I'll also pursue the modified BAT in parallel. Yes, I want my cake but I want to eat it too. If I have a chance at QoL and keeping this beast at bay I need to take some chances.
This is my BAT plan:
Damn, so technical. I know insurance wont pay for this so you must self pay….or am I wrong? Im not afraid to pay for treatment. My children would urge me. What would you estimate the cost of this approach? Are you working with Sartor at Tulane?I just need to keep the account flush for my wife who will probably make 95. Mike
I hear you about the wife. My wife probably has another 40 or 50 years.
I'm not working with anyone. I talk to my MO but pretty much go with what I think might work. So far I've been lucky. At first my MO protested about my out of the box treatments but now she "seems" to trust me.
Test Cyp is about $60 a month when I'm using it. Casodex is $20. SARMs are maybe $30. I go through goodrx for most of it. Usually less expensive than my insurance.
Awesome. Thank you. You have great instinct for this. In the end, we are all a large Human Experiment. All of us trying for that meaningful extension of life. Appreciate your insight RSH1,
Mike
Good discussion Mike.
I wish you, and all of us, a good fight. We don't have a foolproof cure for APC. So we do what we can only do our best. But whether we have APC or not, that's the way to live.
SARM
Thanks. Which study? The phase 3 that I found had more adverse events in the placebo group than they had in the enobosarm group.
Does your bi-weekly injection of 200mg T mean twice a week or every two weeks ? I'd like to know.
Twice a week. There are some doctors practicing BAT and the opinion that I have seen is that T needs to be over 1500 in order to kill some cancer cells.
I'm going to try to dump the "bi-weekly" word. I looked up the definition. Once every two weeks and twice a week are the main definitions. Lame.
Are you aware that you're posting a Mayo Press Release from 2005? Even if it weren't outdated, It is not how good research is done - they quote a lower overall survival rate for radiation but fail to mention that the average age of men getting radiation there in 2005 was 70 yo vs about 60 yo for surgery.
Current numbers: 90% 5-yr disease-free survival for T3 with radiation and much lower toxicity:
prostatecancer.news/2021/08...
Men getting surgery for T3a (and say GS9, ½ cores positive) have a 5-yr progression-free probability of 29%
mskcc.org/nomograms/prostat...
Which would you choose?
is it "fair" to compare surgery without ADT to radiation with ADT???? also, haven't I read that Gleason is a greater predictor of progression than is pSA??? average Gleason of men in that small study? also, does MSK do extended LN dissection in all G 9 patients?
Yes. ADT with surgery has been proven in clinical trials to have no effect. ADT with radiation has a synergistic effect.
Gleason score, PSA group, and stage are all independent predictors of progression which is why they are all included in the nomogram.
What small study are you talking about? The Murthy study was large (n=224); in fact one of the largest I've ever seen in that patient population.
It's up to individual surgeons whether they do ePLND. Most in the US do not, with the notable exception of Karnes at Mayo. ePLND has not been found to detect more cancerous LNs than PLND and carries quite a bit more toxicity risk.
nature.com/articles/nrurol....
" uchesne and colleagues conducted the Timing Of Androgen Deprivation (TOAD) trial in 29 oncology centres in Australia, New Zealand and Canada to assess whether giving immediate ADT improves overall survival compared with delaying ADT until therapy is indicated. Participants were randomly assigned in a 1:1 ratio to receive either immediate or delayed therapy and in total, 293 men were recruited to this study.
Overall survival at 5, 6 and 7 years was 86.4%, 76.4% and 65.5%, respectively, for men who received delayed ADT, compared with 91.2%, 85.6% and 81.0%, respectively, for those who had immediate ADT. Of those men who were recruited as they had experienced a PSA level relapse, 19% in the delayed ADT group died compared with 11% in the immediate ADT group, and estimated 5-year overall survival was 78.2% and 84.3%, respectively. Times to local and distant progression were significantly longer in men who received immediate therapy.
Adverse events were experienced by 78% of men in the immediate therapy group compared with 47% of men in the delayed therapy group, with 41% and 32% of men in the immediate or delayed arm, respectively, having a grade 4 adverse event. Quality-of-life questionnaire scores decreased for men in both groups, by 6% in the immediate therapy (considered clinically important) arm and by 3% in the delayed therapy arm (considered clinically trivial). "
Interesting that adverse events (definition?) were so much higher in immediate ADT group ?
If your conclusion is true, perhaps this was a flawed study...eg men receiving immediate ADT were younger? guess a person needs to look at all details of a study when comparing one study to another.
Since studies I've seen have shown no dramatic difference in outcomes between surgery alone vs radiation + ADT ( with brachy boost superior to both) for high risk men, I guess it comes down to an individual's feelings about risk SEs/adverse events
from surgery alone compared to risk of SEs/adverse events of BOTH radiation and ADT, and even more to worry re brachy boost.
As you wrote recently, too bad we don't have radiation +/- ADT nomogram similar to MSK nomogram for surgery !!
PREDICT based on high ratio radiation:surgery patients I believe, but apparently still inadequate for a number of reasons for high risk.
You got that entirely wrong. TOAD was among men who had already had surgery. One of the things many patients, including yourself, have a hard time with is distinguishing treatments for one set of circumstances vs another.It is also not correct that all primary EBRT is the same, as POP-RT and AASUR has recently shown.
Yes TA, evidently I misinterpreted what had been written. My 1st read , seemed as though ADT had been given immediately after surgery, whereas evidently ADT was given to one groups with rising PSA immediately after PSA increase, and not immediately after surgery. Yes, many of us are just stupid TA. But even i understand that not all EBRT is the same......where did I say that?????
You are still getting it wrong. TOAD is about early salvage therapy not about therapy for high risk localized, which is what is being discussed by the OP. I didn't say you were stupid, just that you got it wrong.
You were comparing results of EBRT to surgery and said results were the same. "Since studies I've seen have shown no dramatic difference in outcomes between surgery alone vs radiation + ADT ( with brachy boost superior to both) for high risk men." The retrospective comparisons were started many years ago, before much of the learning we have now about how to adapt EBRT.
To clarify, my understanding, on 2nd read as I mentioned, is that ADT was given immediately to one group after PSA rise, and delayed 2 years after PSA rise for the 2nd group...both would be considered salvage as I understand that term.
Yes, I believe I was referring to a Kishan study published fairly recently re superiority of brachy boost. And recent reviews such as this......
mdpi.com/2075-4418/11/3/400...
Yes- TOAD was salvage, but the OP was NOT. Idk why you were trying to compare apples and oranges.
Kishan's retrospective review covered men who were treated between 2000 and 2013 at 12 tertiary cancer care institutions. It did not include AASUR or POP-RT, both of which were prospective clinical trials - better, more recent evidence.
I think I have seen a study that reviewed "optimal" RP and "optimal" eBRT.....optimal RP may have included ADT for high risk, while pointing out that something like 40% never developed metastases, so ADT was overtreatment for many of these men?
Also BTW, per that Star-Cap nomogram you posted, my data put me at the 6th stage(highest intermediate I guess) of 9 stages. With treatment, approx 10% PCM at 10 years.......Hopkins shows 1-2% ???? Statistically significant?
I’m not interested in explaining all this to you. I’m here to answer the OPs questions not yours. Suggest you talk to a doctor.
With the results from brachy boost, and favorable studies for whole pelvic and the AASUR protocol, perhaps the kitchen sink approach of combining all those modalities would be a future "gold standard" for high risk ? AASUR protocol would seem to be more desirable re toxicity, when compared to brachy boost or even IMRT + 18 mo. ADT. Unfortunately , Kaiser RO seemed little interested in anything other than the same same old 28 days IMRT + 18 mo. ADT. No brachy boost offered, no SBRT, etc.
It doesn't seem surprising that adding other modalities for high risk non-metastatic would enhance at least middle-term results, as many non-metastatic men are metastatic but simply undetected with conventional scanning, and those other modalities have proven useful for castrate-sensitive metastatic men.
Were AASUR an approved SOC, would that be your choice compared to brachy boost, etc? And I guess including whole pelvic with either?
I learned that OHSU has a GA PSMA PET trial ...will inquire about that. They also offer Axumin....I guess both of those are out-of-pocket unless a patient has recurrence.
POP-RT screened men out with detectable LN or distant metastases using PSMA PET scans. Ga68-PSMA-11 has been approved by Medicare at UCLA and UCSF - insurance usually follows suit. Unlike Axumin, it is approved for high risk as well as recurrent men.
You can see how much treatment intensification improved results in the updated table in the following article:
prostatecancer.news/2021/06...
You may wish to transfer out of Kaiser during open enrollment to take advantage of therapies Kaiser does not offer.
Thank you TA. Yes 90% superior to 29%. Yes, I included that this was from 2005 (16 years is a long time ago). And as Scott says above, big difference between Stage 3 & 4. Mayos stat of 79% progression free at 15 years caught my attention. But for me, being told that I am inoperable, and 2 Radiologists saying that I am not a good candidate as Space Oar would not work with me, it just seems that doing less (just ADT+ABI/p) with the prostate intact is not a good direction. I understand that once castration resistant, there is Provenge and Docetaxel, and Human Trials, but I have seen to many cases where more is better for Stage 4. So many guys here get there after a Surgery or Radiation didnt get it all, but in the process, the Mothership, and Primary tumor were removed, which seems to equate to a longer life.
The old medical adage of doing less for stage 4, and more for stage 1 & 2 because they will live longer just seems archaic.
Im heading up to MSK in 3 weeks to see if there is anything that can be done pre-emptive vs reactive, maybe including the Nano Knife. I am now 11 mos since Dx, and finally have PSA below 1 @.67. Time for new scans as it has been 6 mos.. Will keep the group posted. There must be many of us, here, in the inoperable category.
Best,
Mike
Who you going to see at MSKcc?
Good Luck, Good Health and Good Humor.
j-o-h-n Sunday 09/26/2021 4:10 PM DST
John, Deaglan McHugh medical oncologist specializing in advanced prostate Cancer. Then Jonathon Colemman.
I see Dr McHugh
SpeedyX, are you happy w Mchugh? This will be my first visit. Thanks,
Mike
Yes he has done right by me...when my previous MO was ready to change my treatment he left MSK and McHugh step in kept me on same med and said let's give it more time and in 4 months my PSA started to come down and 15 months later still working...he is calm and knowledgable and works with the best Dr Morris...J-o-h-n MO
Good info... thanks Spyder54
It has always confused me how I skipped Stage 3 and ended up Stage 4. My pathology report was GL9, T2N1M0, with clear Seminal Vesicles (stage 3) and microscopic evidence of PC in 1 adjacent Lymph node (Stage 4). I have done RT - 8/2019, ADT - 10/2020, and 38 sessions of Salvage RT - 4/2020, as instructed. I feel well except for the low T effects (hot flashes, lethargy, etc.) and always wonder if maybe my Stage 4 is a bit overstated? I reach my 1 year ADT anniversary in 3 weeks and would love to consider a vacation and get my muscle strength back. Not sure what to make of information like this.
Looks like a remarkably better success rate for surgery compared to radiation !!!!!
Correction...as TA has already pointed out, there was a 10 years age gap between RP and RT patients.
