Long-term adjuvant ADT improves results of brachy boost therapy in unfavorable-risk prostate cancer patients

[Tall_Allen]

For most unfavorable risk prostate cancer patients, brachy boost therapy is the preferred option.

This RCT proves that 18 months of adjuvant ADT gives better outcomes than 6 months.

pcnrv.blogspot.com/2020/04/...

[Don1157]

ADT Lupron bad for me the latest was in 2017: cataracts and Type 2 Diabetes began. Went off after 8 months out from Brachytherapy. But PSA went up gradually over 5-7 months from .444 to 5.2. PET Axumin showed nothing for sure outside the prostate, PSA down to 3.43. Hopefully this was a spike after Brachytherapy. Holding my breath with a new MO. By the way , if you live around Rochester NY, my former MO is heading there for director of research and teaching. But if he sees patients, he is great! Patient and listens to all! Peter J. VanVeldhuizen, MD

[rust]

Thanks for posting this and it is very relevant and timely to my case being 9 months in to 24 months ADT course concurrent with 6 cycles of Taxotere followed by radiation to paraaortic lymph nodes. I especially found the link to the Nature Communications article at the bottom of your blog article helpful regarding IADT. Most interesting was that an induction period of 36 weeks seemed to be favorable to allow hormone resistant cells to thrive over castrate resistant cells prior to IADT. Keep on truckin' friend

[timotur]

Those are great results for HDR-BT with HR's around 0.70 and below versus EBRT for all outcomes, and reaffirms the need to do ADT for 18+ months depending on risk factors. I'm 12 months into ADT after HDR-BT/IMRT reaching nadir of <0.01 and have thought about stopping ADT, but think I will finish out 18 months, and maybe longer. Excellent post, thanks!

[Don_1213 in reply to timotur]

The comparison of HDR-BT and EBRT isn't based on current RT practices. They state the same "The external-beam radiation (EBRT) doses they explored (66 Gy, 70 Gy and 74 Gy) were below today's standard of care (78 Gy-82 Gy), so have become irrelevant to current practice. "

I haven't seen a study comparing current practice IG/IMRT/ARC radiation to HDR-BT - possibly because that RT standard wasn't being done 10 years ago. If you know of one - please pass the link along.

[timotur in reply to Don_1213]

Don, good point, the SoC for EBRT dose appears to have increased from an average of about 70Gy to about 80 Gy since this study was initiated in 2003-07, which would be about five more sessions at 2Gy per session. It would be interesting to know if the HDR Brachy dose changed over that time as well. I’m pretty sure the isotope used changed over that time from Cobalt 60 to Cesium 131, which has a higher dose rate.

Here’s a study comparing HDR-BT + IMRT to IMRT alone, showing no difference in outcomes at 5 years, but as the study mentions, longer term follow up is needed.

prostatecancerinfolink.net/...

[Tall_Allen in reply to Don_1213]

It's not HDR, but ASCENDE-RT compared LDR-BT to escalated-dose EBRT.

[jkm100]

Thanks for this. Just curious, when we consider 18 months, does that include the last 3 month shot at 18 months? I started last May and will be having my 5th shot next month. And obviously 6th shot in August. This 3 month shot will get me to 18 months.

I did HDR brachy in August, EBRT in September. PSA last month was 0.012.

Originally G8, PSA 54, no signs of node involvement or metastasis.

[Tall_Allen in reply to jkm100]

It includes the 3-month shot at 15 months, which would be the 6th shot (in August 2020 for you) if they were all 3-month shots. You may want to get a 6-month shot in May to avoid an extra visit to the doctor.

[jkm100]

Thank you. Good point on the six month shot.

Too further the discussion a bit, my T was up around 1200 upon diagnosis. Being relatively young (47), I can assume/hope the T will come back a good percentage in time. Is there any evidence that attaining an above average T after ADT and undetectable PSA, can lead to early reoccurrence? With that, are there any studies concerning controlling T at a said acceptable level? Is there a way to accurately control it to a parameter based on the individual’s T characteristics?

[Tall_Allen]

No - I haven't seen anything like that, and can't imagine why it would be true. Testosterone doesn't cause prostate cancer. It doesn't fuel prostate cancer more when it is higher than normal - it has to be at castration levels to stop fueling prostate cancer. Enjoy your high levels!

[jkm100]

I guess we are all searching for the how and why after getting this shitty deal.

Looking at my past, I can assume I’ve always had an exceptionally high T. Well built without trying, crazy libido, competitiveness, etc.

If I didn’t have sex with other or myself at least twice a day, it was a bad day!

Maybe testosterone doesn’t directly cause prostate cancer, but is it possible that the physical response from such levels can?

I don’t know much, and is why I read this group everyday. However, I wonder in comparison of an alcoholic that begins at a young age and develops chronic liver disease by 50 years old.... did I abuse my prostate in a similar way?

[Tall_Allen in reply to jkm100]

Men who have low testosterone (hypogonadal) are more likely to get aggressive prostate cancer. Testosterone is protective for most men. You were just unlucky. It's pointless trying to blame yourself.

[A0007720]

Another wonderful literature review from Allen. Allen, will you please tell us, what is something that WE citizenry can do FOR YOU? Buy a copy of your book, a donation to a certain cause? What can WE do FOR YOU?

[Tall_Allen in reply to A0007720]

Thank you so much - how very kind! Read my novels only if that is the sort of thing you like. Thaw's Hammer is about a virus that kills millions. If coronavirus, an RNA virus, is daunting, it could be a lot worse if the unleashed virus were an RNA-retrovirus that can cripple all immune response (like HIV) and spread through direct contact.

[Don_1213]

Allen, interesting paper.

What's interesting is that ADT duration seems to be becoming standardized on 18 months of ADT (total - including any given before radiation treatment).

Even my somewhat reluctant urologist (who started out pushing for 36 months) has come around to a 18 month course of ADT as being adequate, even for a high-risk (G9/10).

Dr. Mark Sholtz in response to a question I posed on the duration of ADT (during an on-line discussion) - where I asked if he felt 18 months was adequate, stated the study/trial by Nabid et al was definitive, and he asked why anyone would subject themselves to more ADT torture than was necessary.

Had my last (6th 3 month) shot at the beginning of the month.

[Tall_Allen in reply to Don_1213]

They only tested 18 months vs 6 months; 24 months may be better, 12 months may be adequate - who's to say? Unlike Scholz, I know the Nabid trial only referred to that group of patients. There may be good reasons to use more or less, as I explained in the article.

[Don_1213 in reply to Tall_Allen]

24 months was found equal to 36 months in another study. So it's unlikely to be better than 18 months (which was found equal to 36 months in this study.)

The first study was 6 months vs 36 months - and that's where the 36 month standard of care came from. Another study was 24 months vs 36 months, the results modified the standard of care to "24-36 months." The Nabid trial was 18 months vs 36 months it was a large enough and rigorous enough study that even my doubting urologist accepted it (he's notably hard on studies..) So at least my standard of care is now 18 months.

12 months certainly may be adequate - at least for some men. I think once PMSA scans become commonplace (and less costly) in the US health marketplace - that question might be answered. It might end up being a rather custom length treatment if regular scans end up not revealing new metastasis showing up.

And yes indeed - there are certainly reasons to use less (bad reactions to ADT kind of leads the pack) and more? Well - commonly given when someone's PCa remains hormone-sensitive after the failure of RP and then radiation and chemo. I have a friend who has been told he's on it for life. He got about 5 years out of the RP, then 5 from the radiation, and a few years from chemo. I think he's been on continuous Lupron for about 2 years now.

[Tall_Allen in reply to Don_1213]

Clinical trials only predict for the population tested, never for the individual. NCCN (which is often looked to for SOC guidance) says that 18 months to 3 years is acceptable.All those factors I mentioned should be considered.