IMRT only without radical prostatectomy

[Gary_T]

Born Jul 1961 in Hawaii of Japanese descent. No PSA screening. Made appointment with PCP because of problems urinating. After abnormal DRE, she ordered PSA test and referred me to urologist. PCa was diagnosed Feb 2014 (PSA 56, Gleason 4+4 in 4/4 left cores PNI, 3+3 in 3/4 right cores, stage T2c with negative bone and CT scans). Started neoadjuvant ADT Mar 2014 (bicalutamide 50mg + leuprorelin 30mg at four month intervals), IMRT (80Gy in 40 fractions including seminal vesicles and lymph nodes May 2014 - Jul 2014) with continued hormone suppression for one year (last injection Nov 2014) reduced PSA (63ng/ml Mar 2014, 0.15 May 2014, <0.01 every two months until 0.02 Aug 2015) and total T (2.5ng/ml Mar 2014, 0.10 May 2014, similar every two months until 0.62 Aug 2015). Then another one year on ADT (first injection Aug 2015) reduced PSA to <0.01ng/ml and total T to 0.20ng/ml). Last injection for this second round of androgen deprivation therapy is next month.

Other: tamulosin 0.4mg for urinary retention, oxybutynin 5mg for urge incontinence after IMRT, CPAP to treat obstructive sleep apnea, bupropion XL 450mg for depression (possible side effect of the ADT?), BMI 47, cholesterol 210, triglycerides 169, fasting glucose 112, hypertension (amlodipine 5mg + losartan 100mg + hydrochlorothiazide 12.5mg).

My urologist at Kaiser and the second opinion at Johns Hopkins both recommended IMRT alone since the probability was low that prostate cancer was confined to my prostate (I also calculated probabilities with pretreatment Kattan and Partin nomograms) and the significant toxicity associated with prostatectomy followed by external beam radiation. I know there is disagreement, but the majority opinion appeared to advise avoiding such toxicity if there was a high probability of positive surgical margins. Of greater relevance to how I handle stress and my reaction to local anesthesia than PCa treatment, I did not suffer any adverse reaction after transrectal ultrasound-guided needle biopsy (TRUS) but I passed out after fiducial markers were placed in my prostate by the radiation oncologist. I assume this was orthostatic hypotension caused by anxiety since I had a similar incident during blood donation 30 years ago. I was evaluated in the emergency room and released after a few hours.

Questions after reading clinical literature:

1. Why is radiotherapy described as "definitive" or "with curative intent" when the treatment is unlikely to eliminate the cancerous cells or to cure disease?

2. When high risk patients are likely to have micrometastasis and extracapsular extension already, why is their prostate cancer described as "locally confined"?

3. What are the differences between "locally confined" and "locally advanced" since both appear to be applicable (perhaps an incorrect assumption) for high risk patients staged at N0 M0?

4. Is there consensus on when to begin salvage treatment with respect to increased PSA values from nadir and PSA velocity over several tests?

Although I know good, clinical studies of high risk patients treated with escalated dose IMRT have not yet been done, my admittedly selfish interests are in cases like mine: effectiveness of intermittent ADT, prognosis after biochemical or clinical relapse, what to do after progression to hormone resistance and metastasis, and disease specific survival.