When to introduce ADT after RP failure

[LakeT]

I'm progressing well on Triplet Therapy coming up 12 months after Chemo and comparing myself to my brothers situation. He doesn't belong on this advanced prostate group but I hope his cancer does not advance to the point that he does!

Diagnoses

Biochemical failure following radical prostatectomy in July 2019 for a pT2 N0 ISUP grade group 2, Gleason 3 + 4 = 7 adenocarcinoma of the prostate. iPSA 7.9.

Histology showing 10 mm dominant nodule, organ confined disease, positive margin at the right apex and distal anterior with no LVI, no ECE, seminal vesicle or bladder neck involvement. Initial PSA undetectable. First detectable PSA February 2022 at 0.11. Most recent PSA August 2023, PSA 0.28.

PSMA scan in 2023 showing no evidence of metastatic disease but some changes in the ribs suggestive of fibrous dysplasia and MRI prostate bed July 2023 showing no evidence of local recurrence.

Outcome: For postoperative radiotherapy to the prostate bed alone with 52.5 to 55 Gy in 20 fractions.

There has been discussion around ADT but no recommendation to do so. Is this a case of seeing if the RT produces undetectable PSA and, if so, doing nothing further until another reoccurrence at which time ADT will commence? Is this consistant with standard of care?

[Tall_Allen]

Recent evidence is that at least some short-term ADT (4-6 months) may be necessary for a cure:

prostatecancer.news/2023/02...

[LakeT in reply to Tall_Allen]

Thanks for your assistance Tall Allen. I found the SPPORT trial quite relevant to his situation.

[Daddysgirl83 in reply to Tall_Allen]

May I ask, with ADT you mean lupron or firmagon right? Here in Sweden its standard to give Bithaclutamide/Casodex first. Why is it so different from US?

[Tall_Allen in reply to Daddysgirl83]

In the US, Casodex (50 mg) is often given for a couple of weeks before Lupron starts. Lupron initially causes testosterone (T) to skyrocket before negative feedback shuts testosterone production off completely. Casodex prevents the T surge from activating the cancer's androgen receptors.

Casodex is unnecessary before Firmagon, because Firmagon doesn't cause a T surge. In fact, Firmagon is sometimes used to prevent the T surge of Lupron.

Casodex (150 mg) used to be the standard ADT before Lupron became prevalent. It is seldom used that way now. Sometimes, non-metastatic recurrent men take it.

[Daddysgirl83 in reply to Tall_Allen]

Thank you for explaining. Here in Sweden Casodex 150 mg usullay gives to men with biochemical recurrence but not any metastatic spread that can be shown on scans. And to younger men with only small spread. I understand it has less side effects but I am wondering if its preventing spread/ mortality in the future / long run.

[RoseDoc]

The standard is to begin ADT before the radiation and continue after for a total of 6 months

[LakeT in reply to RoseDoc]

Thanks RoseDoc. I will encourage him to question the treatment plan.

[j-o-h-n]

OMG You're down under, under down under.................

Good Luck, Good Health and Good Humor.

j-o-h-n Wednesday 09/13/2023 6:35 PM DST

[LakeT in reply to j-o-h-n]

Your still on Wednesday?

[j-o-h-n in reply to LakeT]

I think I am...... let me check........... yep still Hump Day....

Good Luck, Good Health and Good Humor.

j-o-h-n Wednesday 09/13/2023 8:07 PM DST