New to the prostate cancer community

[bigdoggatto]

I am 76 years old and recently diagnosed with prostate cancer. A rise in PSA from 5.4 to 7.4 plus a bump felt on my prostate led to an MRI scan. That showed a 2.5x2 cm PIRADS 5 area on right side and smaller PIRADS 3 on the left. A biopsy with 20 samples, 12 random and 4 each of the two areas found by MRI was done. All 10 samples on the right side were Gleason 8, three samples on the left (from the targeted area) were Gleason 7 (4+3). The capsule on the right side was "disrupted".

I met with a radiation oncologist yesterday. His suggested course of treatment is 5 weeks of IMRT followed by brachytherapy. Lupron would start two months before radiation and last a total of 24 months. No scans yet. PSMA PET scan would be possible, but it would mean waiting 3 to 4 months because of backlog at UCSF. He doesn't like the idea of waiting that long but thinks he can get me an Axumin PET scan.

So I am full of questions. Would it be better to wait for PMSA PET? Is an Axumin PET scan good enough? Can it find cancerous lymph nodes? Should aberaterone be added to Lupron? Two years of hormone treatment is a long time, but I'd like to minimize the chance that anything will come back in a few years.

[Tall_Allen]

I'm sorry about your diagnosis but know that you will be getting the treatment with the best track record for curing your type of prostate cancer.

The PSMA PET scan could rule out distant metastases, but isn't worth waiting for without starting ADT. And if you start ADT, it won't tell you what is there after 4 months. Axumin, if he can get it for you, is next best. If insurance won't approve Axumin, all you can do is get a bone scan/CT.

No matter what your scan shows, you have to treat your pelvic lymph nodes. Scans can't find very small tumors, so you have to treat what is likely to be there, even if you can't see it.

18 months of ADT is probably all you need. It gave equivalent results to 3 years of ADT in high risk patients. It gave much better results than just 6 months of ADT in patients getting brachy boost therapy.

Some are experimenting with adding abiraterone (Zytiga), but at this point, it is experimental. A recent trial added both Zytiga and Erleada for just 6 months to external beam radiation and had very good results. But it is unclear if that is still necessary with brachy boost therapy and with whole pelvic radiation:

prostatecancer.news/2021/06...

[bigdoggatto in reply to Tall_Allen]

Thanks very much. I have some time before I have to worry about 18 vs 24 months of ADT.

My doctor told me of a phase three trial that compares treatment like that being suggested for me with adding both Zytiga and Erleada for 24 months. That seems pretty extreme.

[Tall_Allen in reply to bigdoggatto]

As you see, it was only for 6 months

[bigdoggatto in reply to Tall_Allen]

This is a new trial. It takes men that are in NCCN high risk category plus in Decipher score upper 1/3 then randomizes into two groups: 1. radiation plus 24 months ADT and 2. radiation plus 24 months ADT plus add-on of 24 months of both Zytiga and Erleada. Hypothesis is that the addition of those drugs will improve metastasis-free survival for men with a higher genomic risk score.

[Tall_Allen in reply to bigdoggatto]

And what about whole pelvic radiation? Brachy boost therapy?

[bigdoggatto in reply to Tall_Allen]

I don't know. There are not a lot of detail on their protocol page. This is their schematic for the study:

Scematic diagram

[Tall_Allen in reply to bigdoggatto]

I just read that NRG-GU008 was dropping abiraterone from their protocol because of ACIS results. But ACIS showed that apalutamide+abiraterone improved rPFS:

ascopubs.org/doi/abs/10.120...

Maybe your oncologist can explain the justification for the change.

[Tall_Allen]

Interesting! So they are stratifying on pelvic treatment and brachy boost, which means that it's up to you and your RO. But you may be randomized to 12 mos. of ADT, 24 months of ADT, or 24 mos. of ADT+Zytiga+Erleada. Are you willing to accept whichever way the dice roll?

[bigdoggatto in reply to Tall_Allen]

Ya, that's the problem, isn't it? Is Zytiga plus Lutron still approved for just metastatic prostate cancer?

[Tall_Allen in reply to bigdoggatto]

It's only approved for metastatic PC. A couple of trials have added Zytiga to RT:

annalsofoncology.org/articl...

redjournal.org/article/S036...

The latter trial only used it for 6 months, but it wasn't a comparative trial. Still, your RO may be able to convince your insurance to let you have it.

[treedown in reply to bigdoggatto]

I was classified M0 and had Lupron, Zytiga and IMRT. But my initial PSA was 156.

[TylexGP]

Hi I am in a similar situation but a few more high risk factors. 56 year old Gleason 9 (4+5) in 9 of 16 biopsy samples done in a fusion biopsy 1 3+3 and 3 (3+4) the other biopsies were benign prostate tissue. Gleason 9 cores were 75% or greater (upto 90 %) Perineural invasion, Seminal vessiel invasion (SVI) and likely extraprostatic extension (per MRI). In addition my biopsies showed cribiform and intraductal histology. I had the a CT scan and Bone scan done. Bone scan was clear and on a second read at MSK there is a suspect pelvic node which may or may not be N1 disease. I should have had a Auxim or PSMA scan done but wanted to start treatment. I truly expect that I have rogue cells floating around and that it is likely the one node is N1 disease. Also my PSA went from .8 to 2.5 in a year to 4.6 in 8 months and was 10.1 by May. I also have genetic testing be done at MSK as part of a study they have ongoing for genetic testing on high grade PCA. I researched and struggled with a my treatment decisions since their is a lot of doom and gloom around intraductal prostate cancer which I understand. After multiple discussion with Surgeons, MOs and ROs, I decided to be treated at Memorial Sloan Kettering (MSK). On May 7th I started ADT with Abiraterone. I am 6 weeks in and other than hot flashes, no libido I am feeling pretty good. I will have HDR Brachytherapy the end of July and start external beam radiation to clean up the pelvis and the pelvic lymph nodes with a little extra external be applied to the suspect node. We are all a N of one with our prostate cancer, but I am confident I have chosen the best initial treatment for me hopefully it buys me time so there are other new treatments available when and if I need them. Sorry for the long post but wanted to share my experience so far as we both have high grade PCA.

[bigdoggatto in reply to TylexGP]

I'm sorry about your situation. Thank you for posting.

[TylexGP]

I try to worry about what I have control over and appreciate everyone that shares their journey and experiences.