Thoughts on Treatment to Date

[Gatodd]

I was diagnosed in October 2021, Gleason 8 in 4 cores of 13 of which were 15%-75% involved. PSA at diagnosis was 4.3. Initial biopsy read by Wellstar (GA) and re-read by Dr Epstein at JH. JH detected cribriform morphology and PNI. Based on the biopsy readings, I was borderline cT2 or T3a. Decifer score was .79. CT scan and Bone scan was clean, but did not perform PET ( I asked for it, but urologist said that insurance wouldn't cover. I should have pushed harder at the time - it was all so new to me).

After numerous consultations and insurance battles, I decided on triple play treatment. Began Firmagon and Zytiga in Dec 2021 Dr. Alvaro Martinez in Troy, Michigan, performed HDR Brachy in Feb 2022. Started IMRT (28 treatments) shortly therafter, but it was performed closer to home in Georgia. Completed April 2022.

T is now <3, PSA <.1. Tolerating treatment effects ok, although fatigue is tough even with regular exercise, but managable.

Met with MO yesterday. He indicated that I would likely stay on Zytiga for 2 years, firmagon for 3 years. I wanted to get thoughts on this duration, as I was thinking the ADT would be in the 24-26 month range (or perhaps 24 months following radiation completion). Also, and there any other medications or treatments I should be considering in addition those outlined above?

Given Gleason score, cribriform, PNI and high Decifer - I want to be as aggressive as I can tolerate.

I have learned so much from this forum and appreciate your input.

[Tall_Allen]

According to this analysis, 18 months of ADT should be enough with brachy boost therapy:

prostatecancer.news/2022/01...

And with the Zytiga, you are probably doing more than what is necessary. But if you are tolerating it well, and you want to be aggressive, it is your decision.

[Gatodd in reply to Tall_Allen]

Thanks. I had read that article before, but thanks for the link. It was a good refresher.

The article seems to say that, for Ebrt only, 28 months is better than 4 months, best estimate is at least 26.3 months. And for bbt only, 18 months is better than 6 months, best estimate is at least 12 months.

I had both Ebrt and bbt, so I can deduce that my best estimate should be the lesser of the 2, or at least 12 months. I am guessing the “at least 12 month” duration should start at the time bbt and/or Ebrt were finished (since by adt started 2 months before bbt and 4 months before completing ebrt).

I still have a long way to go before reaching any adt completion date, so for now it’s a bit mute. But 3 years seems long to me as well (although it is at least 12 months).

Thanks for your help.

[Gatodd in reply to Tall_Allen]

I am meeting with MO tomorrow for our quarterly check in. In our last meeting, he indicated that he will likely want me to take Abiterone + prednisone for 2 years, adt for 3 years.

I am somewhat confused regarding some of the literature. I had brachy and Ebrt earlier this year. Some studies seem to suggest a 12 month treatment period. But I recently read this study that seems to support the 2 year Abiterone and 3 year adt.

ncbi.nlm.nih.gov/pmc/articl...

I am tolerating treatments well, except the brain fog is clearly real.

Any perspective on treatment duration you have would be extremely appreciated.

[Tall_Allen in reply to Gatodd]

You were high risk and received curative therapy. With your high Decipher score, you may want to copy the intensive therapy in this clinical trial:

clinicaltrials.gov/ct2/show...

[Gatodd in reply to Tall_Allen]

Thanks.

So, consider adding Erleada based on decifer score (.79 is close enough to .85). I assume that this would be additive to AA and prednisone, correct.

[Tall_Allen in reply to Gatodd]

No - either Erleada or abiraterone for 2 years.

[Gatodd]

thanks. The MO recommends Abiterone for 2 years and adt (firmagon) for 3 years-so I think the treatment plan is consistent with these studies.