first apologies in advance for the long post - my wife keeps telling me to edit before I bombard everyone including medics!
I am trying to gather information to aid my decision when I meet my oncologist in a few weeks to discuss the way forward. I finished Moderately hypofactionated Radiotherapy just before Christmas/ 20 sessions of 3Gy each (60Gy total) for locally contained Gleason 9 (4+5) T2cN0M0 with a negative PSMA scan in august 2022.
Given my other conditions of polio muscle loss (I only have 12% lean muscle on a DEXA) and my age - 72 - it was decided to treat with only RT to prostate and not lymph nodes. They are also suggesting maybe only 6 months ADT if all goes well. I had Gleason 7 (3+4) in January 2020 with PSA never above 5.1 until sudden jump to 8 by October 2021 and opted to try HIFU which failed to reduce PSA and a subsequent biopsy showed a Gleason 9 in a different previously biopsied negative cores area. So I guess I am technically salvage RT but still with a ‘ curative intent’ as they optimistically phrase it - but as a Heath professional I know this is PCa so it’s always uncertain.
The question of immediate concern is the length of ADT given they are thinking only 6 months - as I was in Bicalutimide 150mg the day they got the biopsy back in august and on it for 10 weeks and then Zoladex from mid October as some delay in decision whether to use complete testosterone deprivation given my muscle issues.
Does the 2 months bicalutimide count as part of the 6 months protocol or is it 6 months on the Zoladex complete deprivation? Maybe it’s just a matter of degree or marginal advantage for recurrence. What’s peoples view of the science behind how I weigh up the decision when to stop.
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SimMartin
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Well, the best data says that 26 months of ADT are necessary with external beam radiation for high risk PCa. And the AASUR trial proved that intensifying the treatment with 6 months of abiraterone+apalutamide+ADT may provide equivalent results:
So you are getting a light treatment already, which we know is sub-optimal in terms of cure, but accommodates your particular circumstances. It comes down to you - what are you comfortable doing, recognizing that it is less curative but more sparing of your muscle tissue?
Thanks for these reports. Interesting information, but still a bit confusing. So if SBRT (whole pelvic) is the treatment for high risk but localized disease, not sure what is recommended for ADT duration. Also if Nubeqa is added, is the duration shortened (or is the Nubeqa discontinued after a short duration to avoid breading out some nasty strains like neuroendocrine PC)? Sure do appreciate your take on this.
ADT duration depends on the kind of radiation you're having. SBRT is a lot like HDR-brachytherapy, so I would expect a shorter duration is needed. Kishan is using 9 months in his trial. AASUR only used 6 months, and got great results, but boosted it with abiraterone and apalutamide.
I have not seen any trials of SBRT for high risk that used Nubeqa. But treatment-emergent neuroendocrine PCa is definitely not a concern with any adjuvant hormone therapy.
I guess that part of it is coming to terms with what risk I am comfortable with - there are two parts of me - the psychologist I trained to be that has always tried to balance the research with the reality that my patients have to live with. The other part is dealing with what we all deal with here and that is managing my anxiety and fear around the l likelihood that the PCa is just sitting there waiting to come back and maybe this treatment or that extra ADT or diet or whatever will substantially reduce that risk …. I think the word there is ‘significantly’ reduce the risk !? My oncologist pointed out early in meeting me that research (albeit of course past years cohorts) showed maybe 5% difference over 10 years of OS … of course that IS the issue OS. We know that many men succumb to heart issues maybe because of the long term use of ADT. I am just struggling a bit with:
1 what’s the best for a similar cohort as me
2 what’s best for me given my comorbidities
3 what’s the relative difference
Admittedly only I can answer the last question, but equally from years as a polio patient and a clinician I know that medical opinion and individual medics are often not exactly unbiased or unfettered in what they offer. As they say knowledge is power.
ADT (Lupron)was started 5 months before salvage EBRT following RP. Casodex was added to the mix 4 months after start of Lupron and continued for a year until my PSA was below detection. Lupron only was continued for another year after that. That's a total of 2 1/4 years on Lupron. PSA remains below detection 1 year after my last shot of Lupron. I'm keeping fingers crossed.
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