Surgery+radiation+ADT orRadiation + ADT

[mysticmini]

Gleason 9, low PSA, already had TURP, spread to local lymph nodes in left side of pelvis. Have been given 2 treatment options: Surgery+radiation+ADT or Radiation + ADT. Brachytherapy possibly not an option due to previous TURP. Questions are: What are benefits of surgery? Would Surgery+radiation+ADT possibly lead to a cure, or at least a shorter amount of time on ADT or longer time to recurrence? Is nerve sparing surgery even an option if it has already "broken the capsule?"

[DMohr011]

Not a medical expert at all, only a patient like you that they practice on. Seems we both share a ductal form with high Gleason and low PSA.

My RO at Mayo said a couple of times, that surgery plus radiation would be the preferred option. But since my bitch tumor was attached to the rectum, surgery was not an option. They did explore the surgery option fully.

Did they do any genetic testing on you? Since I have some broken genes from my mom's side, Lynch Syndrome, I qualified for Keytruda. So Keytruda plus proton beam radiation was my direction. So far, so good!

Best to you and your decision. Doing right by getting all options and opinions in front of you.

Dave

[DMohr011 in reply to DMohr011]

Would like to add, my ADT failed after 6 months. Aggressive is my cancer, as it spread to a muscle and made for a summer to not want to remember. But were all different. Good Luck!

[maley2711 in reply to DMohr011]

confused.....you earlier said " so far so good" but now " ADT failed" ????

[DMohr011 in reply to maley2711]

6 months on Zytiga and cancer spread. Doc said ADT failed at that time and removed me from Zytiga. Today, 6 months after radiation and on continued Keytruda it is, 'so far, so good'.

[Tall_Allen]

Radiation after surgery has much worse side effects than either alone. It should be avoided if you can.

You are right that you can't have low dose rate brachytherapy (seeds) after a TURP, but you can have high dose rate (HDR) brachytherapy (temporary implants). HDR brachytherapy is not widely available. Where are you located? Another option is an SBRT boost to the prostate. Some kind of dose intensification to the prostate is warranted with IDC-P. It may also be warranted to intensify the hormone therapy.

The following clinical trial seems ideal for you. I think they are restarting it very soon and may be changing the hormone therapy to darolutamide. Check with them:

clinicaltrials.gov/ct2/show...

[mysticmini in reply to Tall_Allen]

Thank you. I am located in CT and current care team is at Yale New Haven. Travel to NYC and Boston are both possible.

[Tall_Allen in reply to mysticmini]

I know MSK offers HDR BT - I don't know if Yale does. I know James Yu at Yale offers SBRT but I don't know if he gives it to high risk cases like yours. MSK does. Michael Zelefsky might be hard to see, but Sean McBride is also very good.

[TylexGP in reply to mysticmini]

Hi Mystic, I am also from CT and I have a similiar DX. G9, IDC-P with a suspect pelvic node and epe with a PSA 10.1. Also recently found to be BRCA 2 positive. I would encourage you to get genomic testing. I went to MSK no disrespect to Yale just my personal choice. After multiple consults I ended up with HDR Brachytherapy followed in 4 weeks later with EBRT 25 tx and am on Lupron plus Zytiga. I started the ADT aprox 10 weeks before my HDR Brachy. I am scheduled to be on ADT for a total 24-30 months. I have had minimal side effects from the radiation (so far), but the ADT has been a grind for the last 1.5 months. So far I have responded well with current PSA 0.11.

[Max225 in reply to mysticmini]

Sorry I did not see your post earlier. I had HDR BT in 2020 at Dana Farber. Excellent experience; virtually no side effects (except for the catheter coming out, a bit painful for two days).

Dr. King performed the procedure:

dana-farber.org/find-a-doct...

I had IMRT prior, last Lupron shot this month. Undetectable to date.

[Scout4answers in reply to Tall_Allen]

T_A

I think Nelson Stone has already figured a lot of this out, his conclusion : ADT for more than 6mos. is detrimental.

youtube.com/watch?v=0CnbyiR...(Not working as expected?)

[Tall_Allen in reply to Scout4answers]

That's not true. Peer reviewed trial? ( I don't rely on youtube videos for info- you shouldn't either)

[maley2711 in reply to Tall_Allen]

If it is the Stone Grand Rounds talk on this topic, not sure why it should be totally disregarded. It seems he repeatedly refers to overall survival as the preferred endpoint of studies he discussses> I don't know whether or not his mention of reduced overall survival with more ADT is applicable to all risk groups, or whether the numbers he mentions are a fair comparison...but certainly food for thought and reason to look in more depth at that endpoint for men in various studies. We know the definite disadvantages of ADT...especially long-term.....we need to feel confident in its benefit for overall survival. Are there sufficient randomized studies.....Stone and other Docs repeatedly mention the need for additional randomized studies.

Salavage radiation magnifies adverse side effects, but can't the same be said for salvage treatments after failed radiation ? Some fortunate surgical patients escape ADT forever. IMHO, there are no good options.....I'd gladly sacrifice 1 or 2 fingers if that were an equally effective treatment!!

I will attempt to dig up the MD video...one RO researcher showed data that going from 6 mo to 12 mo ADT decreased PCa mortal ity by some thing like 12%, but from 12 mot to 18 mo by only 4%.......which was good news, as many men bale before making it to 18-24 mo !!!

another factor....seems clear that the older the man, the more the ADT risk.

[maley2711 in reply to Scout4answers]

At least on my computer , the video doesn't seem to be working.

Could you provide the exact title of video, and I'll try to access using youtube.com search engine. Thanks!!!

[Scout4answers in reply to maley2711]

Long-term Morbidity of ADT and Radiation Therapy

Posted by Nelson N. Stone, MD | Jun 2019

Nelson N. Stone, MD, presented “Long-term Morbidity of ADT and Radiation Therapy” during the 24th Annual Southwest Prostate Cancer Symposium on April 14, 2019 in Scottsdale, Arizona.

[Scout4answers in reply to maley2711]

Not going to start a fire fight over this but this info looks actionable to me.It is going to take 15-20 years for us to see the results of the clinical study that T_A posted. Much longer than many of us have to make decisions about our own course of action. A lot of what we are doing here is reading tea leaves and trying to make decisions that make sense to us. Right now SOC does not offer us a cure.

[maley2711 in reply to Scout4answers]

You're referring to the results for 6 mo ADT vs longer-term ADT....... not inferior re overall survival ?

[maley2711 in reply to Scout4answers]

Thanks! Here are the slides he presented. As with most studies, questions on details.

[tango65]

I would considered radiation to the prostate plus whole pelvis radiation ( they have to treat mets they do not see) plus SBRT boost to the prostate and the positive nodes plus 2 years of ADT and abiraterone

urotoday.com/conference-hig...

pubmed.ncbi.nlm.nih.gov/333...

astro.org/ASTRO/media/ASTRO...

[Tally111]

Similar case with low PSA and mets to lymph nodes, and went through Surgery, whole pelvic radiation and am on ADT for a little over two years. Every Urologist recommended Surgery and every Rad Onco was against it. Currently undetectable so don't regret it but like TA says side effects can be worse...having issues with incontinence and proctitis apart from fatigue and low immunity. In hindsight, I suggest avoid Surgery as it doesn't appear to give any major advantage.

[mysticmini in reply to Tally111]

Thank you for sharing your experience.

[Lieto55 in reply to Tally111]

I'm tending to your conclusion as well. Gleason 3+4, PSA 4.98 at the time of RARP in 2019, we declared BCR in August 2021. GA68 PSMA indicated a small uptake on the T10 lamina and a 5 mm perirectal/presacral lymph node. CyberKnife for what turned out to be the T11 Lamina, and 25 fractions of IMRT with SIB for the specific offending lymph nodes. Just prior to all that I was 30D on Bicalutamide, then the 90D Eligard ADT with Zytiga/Prednisone being added tomorrow.

In retrospect, it seems the surgery gained me very little but it had/has life-altering side effects that I wish I'd considered more thoroughly. We dramatically underestimated the consequences of continency and ED. I don't know about the radiation post-surgery increased side effects, but I had been told there was no such thing as surgery AFTER radiation.

So far on ADT, my Testosterone went from 580 to 20, and PSA went from .29 to <.01, no fatigue, muscle loss/definition seems to be not occurring yet, keeping the weight off with HIIT and diet. The only bugger on ADT is the standard hot flashes. My views might modify on Zytiga. Bottom line, I'll be watching this post closely. I can't wheel back time. But I believe the surgery option has a bit more smoke and mirrors around it than I thought at the time.

[vjjensen in reply to Tally111]

How was metastasis verified prior surgery, our bone scan and CT negative, Gleason 9 with 4 benign, 6 Gleason 9, 4 Gleason 6, perineurial invasion noted on 2 cores.. PSA 5.3..

[john_in_pa]

Same DX here, G9 with 1 hot pelvic lymph node and low PSA. No genetic mutations identified. After 6 second opinions I went with IMRT+HDR Brachy Boost+Eligard+Zytiga. Treated at Fox Chase in Philly. So far so good.

[ChristopherH]

I have same but higher PSA, tumor out on both sides. Surgery w 50% nerve sparing both sides, Radiation + ADT. Going for 4th Eligard this morning, trying the ice pack trick I read about. PSA is low .04. ADT side effects not fun but…1 yr in Good luck on whatever choice..

[MGBman]

My Gleason was 4+3, PSA 35. All 8 biopsy cores with cancer. Cancer had escaped the prostate capsule. Seminal vesicles involved. Resulted in having what I call the ‘Big Three’ somewhat concurrently:Radical prostatectomy - Jan 2015

Started ADT - Apr 2015 (8 injections over 2 yrs)

31 External beam radiation treatments- June/July 2015. Had side effects from all three.

PSA nadir 0.01 ended Oct 2017

PSMA PET/CT May 2020 discovered tumour in location where right seminal vesicle used to be and right beside bladder and rectal wall. Can’t remove it surgically and can’t target it with radiation. PSA has slowly climbed to recent 6.9. Literally 4 hrs away from my second PSMA PET/CTscan. I can’t speculate what might have happened if I had not had the Big Three. I await in anticipation what my scan will reveal.

[mysticmini in reply to MGBman]

Good luck with the scan. Must be very nerve wracking.

[j-o-h-n]

Hate to be a fly in the ointment but a "lead to a cure" is not gonna happen with the big C.Remission, Remission Remission...

*** click on Watch on youtube" ***

youtube.com/watch?v=HUEF-Nz...(Not working as expected?)

(Chonia Pola Gianni)

Good Luck, Good Health and Good Humor.

j-o-h-n Friday 01/07/2022 6:27 PM EST - Greek Orthodox name day for JOHN.