SPPORT trial: whole pelvic salvage ra... - Advanced Prostate...

Advanced Prostate Cancer

16,121 members19,677 posts

SPPORT trial: whole pelvic salvage radiation + short-term ADT after failed surgery can be a curative option

Tall_Allen profile image

In contrast to a previous trial (RTOG 9601) that told us that ADT can be safely avoided if PSA<0.7, this trial suggests at least 4 months of ADT and whole pelvic treatment. The reason for the difference in recommendations is due to the choice of endpoint. SPPORT is telling us that if we are willing to put up with 4 months of ADT and some extra short-term toxicity from the wider field of radiation. a cure is likely. RTOG 9601 tells us that if your PSA<0.7, you aren't likely to die if you don't get the extra hormone therapy, but you may have to have lifelong ADT eventually.

Results may possibly be improved further with:

•Better patient selection using PET scans (PSMA, Axumin, or NaF)

•Extra radiation to the prostate bed

•Boost doses to cancer detected with a PSMA PET scan (if PSA> 0.5 - but do not wait!)

•Selection of patients who would benefit from treatment intensification using a Decipher test

•Hormone therapy intensification in select patients

prostatecancer.news/2022/05...

astro.org/News-and-Publicat...

57 Replies

I never made it to 0 after RALP. I was 0.1 after 3 months. I had radiation to just my prostate bed with 6 months of lupron and that did not finish it off either. A year after that ended I became detectable, and now 14 months later my latest psa is 0.74. A psma scan at 0.3 did not find the source.

I have been under the impression that they would not go for the nodes unless there was evidence the nodes were the source. Will they do whole pelvic radiation even if scans are inconclusive?

cesces profile image
cesces in reply to sszyszkiewicz

I'm a bit fuzzy on this, but my understanding is that when they irradiate specific lymph nodes, it does include bathing the entire pelvic region with radiation.

Can you get a NaF(18) PET scan?

In 2/16 I was diagnosed with prostate cancer. Da Vinci surgery 4/16, but persistent PSA after surgery. 8/16 flew out to UCSF for PSMA trial and scan found uptake in some pelvic lymph nodes and a little in prostate bed. ADT started 8/16 and stayed on for 2 years.12/16 completed whole pelvic radiation - Radiation oncologist at Cleveland Clinic, Florida, was able to use scan disc to tweak radiation.

PSA has been undetectable since. Only downside has been T-Level never recovered.

Tall Allen, at another site, had answered many questions for me and a great help.

Allen, thank you!

I'm glad it cured you. Would you consider testosterone replacement therapy?

I would do it if I were mostly sure, it wouldn't wake the sleeping cancer cells.

Would you be sure if PSA stays below 0.4 for 3 years?

My last ultra-sensitive PSA, in March, was <0.02So not sure?

TA, are you saying that PSA remaining below 0.4 for 3 years may be considered as BNED, and thus safe for ADT?

If so, can you perhaps suggest some work that underpins that suggestion?

I am coming up to two years undetectable post testosterone recovery and have been looking for some firm underpinning of when I might allow myself to believe I may have been cured. Any suggestion would be most welcome.

I've seen some using nadir 0.4. Here's one using 0.5:

prostatecancer.news/2017/01...

Anomalous profile image
Anomalous in reply to BobbyMac07

I am going to try clomid first-my T is 104 six months after my last 1 month Lupron shot. Which is a very slow rise. you might consider that prior to TRT. Since my estradiol is not high I doubt it will work but it may be worth a try

My husband had RP in 3/2020, Gleason 9 9/47 positive lymph nodes, PSA post surgery was 1.4 (2 weeks later 1.7) able to get PSMA scan that showed a para aortic lymph node. He started Lupron and Apalutamide in 6/2020 and they did whole pelvic radiation with a boost to that node 10/2020. He has been undetectable after 2months of starting lupron. We are now at the 2 year mark. We were told 2-3 years. MO initially told him last month he would come off both Apalutamide and lupron. But in our last conversation they have decided to extend lupron one more year. What are your thoughts? Other than the hot flashes he does seem to tolerate it. If it is a year of extra insurance with no down side I’m all for it but if we could be causing unnecessary damage without benefit I would like to see him stop taking it.

Tall_Allen profile image
Tall_Allen in reply to dkingsley

It's a judgment call. 2-3 years is standard-of-care. If it's tolerable, I don't see much downside.

dkingsley profile image
dkingsley in reply to Tall_Allen

Thank you!

Karmaji profile image
Karmaji in reply to Tall_Allen

After 3 years I am stopping ADT.PSA < 0.03 since 2 years..Oligo meta...RT in Nov 2019..Prostate in place..

My RO says that my PSA will go to 2 with time as my normal Prostate cells are there..

My URO says you have to watch doubling time during vacation

A bit confused....how to use PSA marker to know if I should go back ADT...wait till I cross 2

My ONCO is not sure if I should go on vacation as she is believer in RCT working with Kamel Fizazi of Ville Juif Paris

They say PSA every 3 months

then what to look ??

Thanks for commenting Sir TA

Tall_Allen profile image
Tall_Allen in reply to Karmaji

"My RO says that my PSA will go to 2 with time as my normal Prostate cells are there." I agree that it will go to 2, but not because of your prostate; it is because of your metastatic prostate cancer.

Your confusion over how to assess the duration of your vacation, or if you should have a vacation at all, is understandable. There are no standard guidelines. PSA, PSADT, testosterone, and time are all variables you can look at in making your decision. Also, you have to judge if you feel better when you are off ADT.

Hi, I had Prostatectomy in 2017 followed by salvage RT to prostate bed in 2018 followed by ADT for 12 months. PSA went to undetectable but then began to climb again in late 2020 once Testosterone started to return. Latest PSA was 5.9. Just this week I have completed 25 sessions of RT to lymph nodes in pelvic area after one node showed active in scan but no bone mets. Also commencing lifetime ADT. The latest RT wasnt given with curative intent but the sequence of RT/ADT sounds similar to what you describe. Is there a slight chance this could be curative for me? Not getting hopeful just asking. Cheers

Tall_Allen profile image
Tall_Allen in reply to NewMan57

Yes! That's exactly what the SPPORT trial showed. With just short-term ADT, there was no evidence of progression in 8 years of follow-up for many men.

In 2018, I had RP at University of Chicago and PSA did not go to zero. In 2019, I had 4-1/2 months ADT (Casodex + Lupron) and 38 sessions of PBRT at 68.4 Gy, 25 sessions of PLNRT at 50-60 Gy. PSA continues to be undetectable.

Is this the same as “sWPRT+STADT”?

6/6/19 Started 50 g Casodex,

6/19/19 1st Lupron 7.5 mg injection, following by three more monthly injections,

9/4/19 Started 38 radiation sessions,

10/25/19 Ended Casodex and radiation.

Tall_Allen profile image
Tall_Allen in reply to Polaris1

Yes, exactly the same.

Thanks for all you do.

I’ve come to think I might be a possible over treatment type of case, though the results have been good so far. With undetectable PSA post RP I had a year of ADT, early docetaxel, 3 months Zytiga followed by whole pelvic radiation.

I know you have points out there seems to be no benefit from early chemo with low disease burden, I accepted that long ago. And the rest of of the treatment was not onerous. One year plus past full return of testosterone and undetectable PSA throughout I am doing well.

Still I look back at the RP in 2019, which resulted in basically permanent ED and the other typical changes to the length and girth and total relentless incontinence necessitating a AUS and I wonder why I had surgery at all.

I know it’s a fairly typical situation, but at least I didn’t just have the RP and assume I was cured. Old school SOC for sure.

The (probably unanswerable) question is, is it possible I have better prospects from treating aggressively early despite having negative margins, a 4+3 (better than higher), 15 PSA at diagnosis, and being undetectable post RP despite a positive lymph node and SV invasion? So many seem to have waited too long for salvage. I know this may be an illusion!

Blackpatch profile image
Blackpatch in reply to London441

What was the basis for the chemo, given you were undetectable? The positive LN? I also had negative margins , SVI and the same Gleason and PSA as you, and undetectable for five months post RP -

… but when I raised the possibility of early/preventative chemo, it was just seen as a step too far. As it turns out, I have had a great result (so far) with eSRT + ADT + zytiga. - but I’m curious to know how you accessed the chemo.

London441 profile image
London441 in reply to Blackpatch

It was through a clinical trial at Johns Hopkins in USA. I think it was maybe a typical effort at the time (2019) to treat aggressively after RT with curative intent.

Yes the lymph node and SVI were the reason it was suggested. Tall Allen has pointed to trials that indicate no evidence of early chemo benefit in low levels of disease, few metastases etc. As I said, it may have been a mistake to include it. But I had no access to sensitive scans at the time and they were just trying to basically throw everything at it early. In my case, despite undetectable PSA.

Mostly when I look back, which I do very little of, I wonder why I got a RP at all. It doesn’t seem that there was any benefit.

This again is what I ponder: Was there any value at all in RP? It sure did come at a cost.

How long have you been doing well? Off ADT? Testosterone returned? For how long?

Blackpatch profile image
Blackpatch in reply to London441

I don’t really understand how a trial looking at intensive treatment post RT allowed you to access chemo when you had an RP… but anyway, I have seen the studies that show minimal benefit from chemo at low burden too, and haven’t regretted not being able to access it.

I was undetectable for five months post RP but then it came back with only 4 months DT…. When it hit 0.12 I did eSRT plus 12 months ADT, with zytiga for the first 8 months. It has been undetectable ever since - so 12 months ADT + six months zero T + 3 months for T to fully recover + about 21 months at full T.

As you say, once the recurrence fear recedes, I too have focussed a bit more on the ED, although it feels pretty trivial vs. what most have to endure. I had nerve graft surgery that they’re experimenting with down here but, 15 months on, the impact has been minor - I take a VEGF suppressor for unrelated lung fibrosis and gather this may impact nerve growth - they have had some late successes at even 24 months, so I haven’t given up yet.

London441 profile image
London441 in reply to Blackpatch

I didn’t ‘access chemo’, it was part of my clinical trial. At the large centers of excellence they do all sorts of things as you know. For example where I was treated (Johns Hopkins) Sam Denmeade pioneered BAT (or at least was part of the vanguard). Popular but still somewhat experimental.

Definitely do not give up at 24 months!

I went through that procedure. 9 months of ADT with full pelvic SR. The procedure bought me about 22 months of undetectable PSA. According to my nomogram, I should have had an average of 6 years.

Justfor_ profile image
Justfor_ in reply to Murph256

Your post gave me the idea for a validation poll. Thanks.

healthunlocked.com/prostate...

London441 profile image
London441 in reply to Murph256

Interesting. Sorry to hear you didn’t approach the 6 years. Surprising and disappointing you had persistent PSA after surgery with only a 3+4 and no spread. Are you back on ADT?

Murph256 profile image
Murph256 in reply to London441

Thank you. Yes, I was hoping for better success from surgery and SR +ADT.

Yes back on ADT. My MO is already talking about an ADT holiday, which I find very tempting, if not prudent.

London441 profile image
London441 in reply to Murph256

I’d take that holiday, based on nothing substantial whatsoever. Except maybe if there’s any growing in you at least maybe you’ll actually find it.

Again not a medical opinion!😀

These ate all very interesting stories. What about someone with distant mets, still has their prostate, and is still responding to ADT,Zytiga, Prednisone, when that finally stops being effective, what's next? Or, with widespread mets, am I not a good candidate for any of these treatments? I read so much about stopping ADT, I'd love to be able to take a break and build muscle again

Tall_Allen profile image
Tall_Allen in reply to

SPPORT trial screened out men with distant metastases, so it has no relevance to you.

in reply to Tall_Allen

Thank you, that's kind of what I suspected. What is there for guys like me, once the Eligard / Zytiga+ Prednisone stops working? I've heard chemo, ( but only extends life by a few months). Is there anything?

Tall_Allen profile image
Tall_Allen in reply to

There are half a dozen medicines that you might qualify for at that point, and we are still learning the best way to sequence them and combine them, and the best biomarkers to indicate their use. By that time there will be more, and we will know more.

in reply to Tall_Allen

If I have any say in it, I plan on this current therapy to keep working for years to come👍

Interesting data. I had surgery in 8/16, reoccurrence in 11/17, started at 0.18 then to 0.29 in 2 months. Sloan Kettering decided radiation + 7 months of ADT (starting 2 months prior to radiation).

So far undetectable with no other treatment.

There was a debate on whether ADT was needed or not, but we decided to go with it.

London441 profile image
London441 in reply to Emak1

What was your PSA at diagnosis? Gleason score? Any spread?

Emak1 profile image
Emak1 in reply to London441

Initially PSA was 7 at 41, had a biopsy detected GL 6, continued PSA increase. PSA right before surgery was 20, 43 y.o., GL7. Post surgery it dropped to undetectable but 16 months later BCR at 0.18.

Candidate for SRT, nothing visible on the scans, but something was there. The debate was do we do ADT along with the radiation, I opted for ADT. So far undetectable without any treatment, going on 4 yrs.

London441 profile image
London441 in reply to Emak1

Excellent!

MSPCF2021 profile image
MSPCF2021 in reply to Emak1

Can you tell me more about the “debate” about whether was ADT needed with your radiation? My doc acts like ADT is always needed unless PSA is undetectable, no matter what. Since ADT is so devastating and since it seems eventually inevitable for all of us with advanced PCa I would be interested in delaying it as long as I can. I am a couple weeks out from my post surgery PSA draw but the post surgical pathology suggests I’ll need salvage treatment. Thanks and best wishes.

Tall_Allen profile image
Tall_Allen in reply to MSPCF2021

Is the certainty of 4 months of ADT now to prevent lifelong ADT a reasonable trade-off to you?

MSPCF2021 profile image
MSPCF2021 in reply to Tall_Allen

Damn right it is. But no one is saying it’ll be limited to 4 months. They talk like it is forever or indefinitely.

Tall_Allen profile image
Tall_Allen in reply to MSPCF2021

Patients either got 4 or 6 months in the SPPORT trial. If they detected cancerous lymph nodes during the surgery, it can be 2 years.

Emak1 profile image
Emak1 in reply to MSPCF2021

My 'debate' was part of salvage radiation. At the time there were no distant mets or indication that it was outside of the prostate bed (of course there was nothing on imaging so who knows)

Urologist, who I was with the the BCR said, do radiation, no ADT.

Oncologist at Sloane Kettering said, she would recommend, radiation with ADT for 7 months.

Figured we are doing a one-time shot for a long term fix mind as well throw everything at it.

Now if this comes back, that is a different story for ADT timelines, but for not it is undetectable.

Now you tell me, lol. Got the adjuvant radiation, but skipped the ADT. I’m now fighting gross hematuria.

Had Da Vinci surgery in 2006 by Dr Tewari. PSA started rising ,Sept. 2021 it was 0.6. Had a 1 month shot of Firmagon followed by a 3 month shot of Lupron in Oct. 2021. Followed this up with 27 pelvic radiation treatments in December 2021. As of May 2022 my PSA is undetectable with my testosterone is at 413. I started out with a testosterone level of 607. I’m 76 years old. I had the radiation done by Dr Marshal at MUSC

I had prostate bed and LN around the prostate bed, is this concerned whole pelvic radiation?

Here are the dimensions that current guidelines recommend:

prostatecancer.news/2021/05...

You can ask your RO if that is what you had.

Thank you

Very interesting study. Do you know if BCR is taken as 0.2 and/or 3 consecutive rises in this study? Is it AND or OR? I have had up to 4 consecutive rises in the past, with 3 monthly testing, but highest reading is 0.084 (and last was down to 0.078). So perhaps my rises are due more to the 3rd decimal result. Or perhaps PSADT is more of a key factor. There is much to consider if I have SRT at some point re. ADT and dose / field, and would certainly plan to get a second opinion - am in UK and the support is good but the oncologist is probably quite a generalist.

Tall_Allen profile image
Tall_Allen in reply to julianc

Do you mean the BCR for getting into the trial or the BCR for failing the salvage therapy? To get into the trial, PSA had to be >0.1 and >2.0 and no known lymph node metastases. They used nadir+2 as the definition of BCR after receiving any of the 3 salvage therapies.

julianc profile image
julianc in reply to Tall_Allen

Many thanks TA, I did mean BCR to enter the trial, and importantly from my perspective what would constitute a BCR. I will continue to monitor and see if I get to 0.1 and then consider options. Although I am told NHS in UK will prefer to wait until 0.2. The trial is very useful to help consideration of ADT. I think an individual choice would depend on PSADT too. Thanks again for posting such useful info :)

I had adjuvant RT six months post surgery. PSA had only moved from .01 to . 03 at that point but because of a positive margin and high decipher we proceeded with RT to include LN. Because of my low PSA, I had no ADT after seeking the advice of 2 RO’s, my urologist and several on this site including TA, mostly based on RTIG 9601 as well as my + margin. Finished RT in June 2020 and am still at PSA .00 as of 3 weeks ago(2 years post radiation). Alan, are you now advising pts with very low PSA post surgery who are high DECIPHER to have ADT perv this more recent trial?

Tall_Allen profile image
Tall_Allen in reply to Jmr11820

I think adjuvant ADT is prudent with a high Decipher score - but that is just my opinion (SPPORT didn't use Decipher). SPPORT found that 4 months of ADT improved recurrence-free survival for all patients undergoing SRT. But when they tried to look at the subgroups who had less than average PSA and more than average PSA, they didn't have enough sample size to detect a statistically significant effect in either subgroup. So SPPORT tells us that 4 months of ADT may be able to prevent some cases of recurrence. RTOG 9601 tells us that, if your PSA is low and you don't use ADT, you probably won't die of prostate cancer.

Jmr11820 profile image
Jmr11820 in reply to Tall_Allen

Thanks Allen. You go with what you know at the time. Doing well so far almost 3 years out from surgery and 2 years from RT. Fingers crossed. Appreciate what you do, both here and Twitter.

11 years since prostatectomy with no ADT after surgery. After my first BCR 3 years after RALP I had 38 radiation sessions to the prostate bed with no ADT afterward. 3 years later after my second BCR I had a PSMA Scan through a clinical trial at NIH which found a hot spot in a Pelvic Lymph node. I had the PLN biopsied and verified PCa. I then had 38 radiation sessions to the whole pelvic area with higher concentration to the affected PLN. I started ADT 30 days prior to the radiation and continued for another 23 months. PSA blood tests every 3 months since radiation and have been undetectable for 3 years since the radiation. Hoping for the best!

You may also like...