Lupron and High Dose Brachytherapy

[Trying-Times]

I had a biopsy that shows recurrent cancer in both seminal vesicles. The recommended treatment from MSKCC is 4-6months on Lupron and High Dose Brachytherapy. I had Brachytherapy in 2012 and I’m concerned with more radiation to the area. The doctor who will do the procedure is Michael Zelefsky. I’m inclined to accept the recommended treatment but I thought I still should research other alternative treatments. Also I am reluctant to take hormones can anyone point me to info on procedure with and without hormone treatment? Any information would be greatly appreciated.

[Tall_Allen]

Zelefsky is RO royalty. He is expert at brachytherapy and SBRT. Will he treat just the seminal vesicles (which were not treated previously) ? I'd do whatever he recommends. With your PSA that high, you certainly need adjuvant ADT. 4-6 months is pretty minimal - why are you reluctant?

[Trying-Times in reply to Tall_Allen]

I sought out Zelefsky in 2012 and he did my Brachytherapy then. He is R0 royalty. To be honest though when I asked him about the downsides and failures of the therapy he said not really any downsides he could think of and there were at the time very low rate of failures. I’m not suggesting my recurrence was a result of my treatment choice but there was a significant downside by limiting treatment options for recurrences. I wouldn’t hesitate taking his advice or his treating me for this new problem but I just want to be more vigilant this time. Hormone reluctance is just me being foolish because my wife and I are very active.

[Tall_Allen in reply to Trying-Times]

Zelefsky's background was in LDR brachytherapy, of which he was one of the few masters. He was slow to get on board with SBRT, but is now a true believer. LDR brachy doesn't treat the seminal vesicles, so you did not have a failure in the treated areas of the prostate. There were possibly a few undetected cells sitting there for a long time, and they are just now getting around to growing. They don't routinely treat the seminal vesicles of intermediate risk patients because of possible adverse effects (urinary and sexual). HDR-brachy can treat the seminal vesicles- they can aim the catheters anywhere. Hopefully, that will cure you.

[Trying-Times in reply to Tall_Allen]

Thanks I am glad I found this site

[timotur]

I would do HDR-BT again as Zelefsky is probably mainly targeting the SV area plus some margin. I was t3bN1M0 + left SV, and Dr Chang/UCLA treated both left & right SV’s, and IMO, BT is the best option for SV involvement. I did 18 months of ADT, not real bad, but cumulative effects over the last six months led to some joint pain and osteopenia, even though I was very active. It’s a package deal, need to do both at t3b.

[Trying-Times in reply to timotur]

Thanks for sharing that with me it was very helpful. Did you do 6 months hormones before treatment then take a break and another 12 months?

[timotur in reply to Trying-Times]

I started Lupron and Zytiga together in March ‘19, three months before HDR-BT in June, staying on both until August, when I had some arrhythmia with Zytiga, and dropped it, continuing Lupron only for a full 18 months total, no breaks. There’s lots of posts on this site about dealing with ADT, main thing is being active as possible.

[Trying-Times in reply to timotur]

Thanks for sharing the sting of everything is fading after hearing others have faced the same or similar challenges.

[timotur in reply to Trying-Times]

Yes, there was a lot of trepidation choosing a doctor/treatment and then going through with it all the way up to the morning of the procedure. Looking back it was not as bad as the perception going in. Wish you all the best.

[EdinBmore]

External beam, brachy and ADT for 9 mos here. Re: ADT. You'll read everything from, "ADT was no big deal; a few hot flashes. Done," to "Oh, my god, this was awful; worse time of my life." Hopefully, you'll be in the former group not the latter, as I was. My only caution to you is to be aware of the numerous potential side effects (e.g., hot flashes, fatigue, genital shrinkage, joint pain, weight gain, loss of muscle mass, etc.) so that, if they occur, you can address with your docs. And, I suggest reading, "Androgen Deprivation Therapy: An Essential Guide for Prostate Cancer Patients and Their Loved Ones." You said that you're "active," so be prepared for ZERO interest in all things sexual. ADT was a bummer for me; hope you're luckier than I.

EdinBaltimore

[Teacherdude72 in reply to EdinBmore]

My suggestion relates to attitude before starting treatments. If you focus on getting side effects you will get those side effects. If you focus on not having bad side effects then the likelihood of having few issues is high. I just had a few significant hot flashes a week and frequent urination the first few years.

[EdinBmore in reply to Teacherdude72]

Apparently you were one of the lucky ones whose response to ADT was more positive than the response that others have. Lucky man. For whatever it's worth, I seriously doubt that my awareness of potential side effects resulted in those side effects occurring. But, who knows?

[Teacherdude72 in reply to EdinBmore]

True that.However remember the Placebo effect:

noun

a beneficial effect produced by a placebo drug or treatment, which cannot be attributed to the properties of the placebo itself, and must therefore be due to the patient's belief in that treatment.

[EdinBmore in reply to Teacherdude72]

I am familiar with the concept; however, it's generally used to refer to treatments - that is, if I take a pill and believe it's "real" or curative, and it's nothing more than a sugar pill, and it "cures" me of whatever it is I'm complaining about, then, that's a placebo effect. Having screwed up blood work, fatigue, wt gain, joint pain...not sure these fall into the same category. But, thanks, for taking time to respond and share your perspective.

[MateoBeach]

Seminal vesicles invasion is a marker for high risk of early further spread, regional or distant. So while I would agree to the plan for HDR-BC. I would have careful discussion about also having external beam IGRT to the entire pelvic lymph node fields. Preemptively rather than waiting.

[London441]

6 months of ADT is almost always well tolerated if you exercise enough, especially weight bearing. ADT side effects are cumulative but it takes a course longer than 6 months for most.

Have you expressed your reluctance? I trust Zelefsky will make it clear you have serious recurrence that needs the best treatment possible, if he hasn’t already. The ADT is proven to improve the efficacy of the radiation.

Yes it will almost certainly kill your libido, but it comes back.

[Trying-Times in reply to London441]

Great info

[gsun]

I would say ditto as to what London said. The libido will come back so don't sweat it. Just keep up with some penile "exercises" to keep from causing damage. If it's only six months, boner pills should be sufficient.

[London441 in reply to gsun]

Yes. The pills help, but they help much more if you stimulate manually.

I started taking Viagra and Cialis years ago. Although I had no ED per se I found they basically gave me back the same function I had at 18.

However, this was only true if I actually engaged in sex, masturbation etc. Like so many, if I took it and just went to work for instance, I was not at risk of getting spontaneous erections on the job.

In the bedroom it was a pleasingly different story. I used to joke that the slogan for those drugs should be ‘It works as hard as you do’.

Unfortunately for me, ADT made working on penile rehab so unappealing I ignored it. Function returned somewhat when I got off and T came back, but as most men who’ve had RP will tell you, it’s not the same.

Would I have held on to more of my size and/or regained better function had I done the rehab? Possibly. Again, the issue was I simply had zero interest-strange for a man who had been very sexually active with great function since puberty.

My point is that I was given the standard prescription 5 mg daily Cialis with no mention made of rehab. For me 5 mg daily Cialis alone post RP to restore/maintain blood flow, despite ‘nerve sparing’, was like throwing popcorn at a tank.

[Teacherdude72 in reply to London441]

I agree on no mention of rehab. And age often enters the doctor's mind. Older gentleman not caring about sex. My female urologist was surprised when she asked if I was interested in sex and I told her Yes!

[EdinBmore]

And, you might want to consider a penis pump to help keep the blood flowing, as it were. I was in a 2 yr study conducted by U of MN that dealt with maintaining sexual function for men who had been treated for PCa. They provided sildenafil and recommended a dose of 60mg three times/wk. Additionally, they also provided a pump. Took awhile to get use to it but my partner and I had fun with it. Yes, your interest in sex will return after stopping ADT but it can be slow going for some; it took more than 16mos for T to return to pre-treatment levels. And, yes, to exercise while on ADT; it's one of the few things that seemed to help at all (given the accompanying fatigue, it was often difficult to motivate myself but I made a point of 5times/wk.) Good luck to you.

EdinBaltimore