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.
Prostate Cancer, Brachytheropy and Haemorrhoids
55 and prostate cancer - Scared shitless
Newly Diagnosed Prostate Cancer
Post-HIFU cancer
Prostate cancer diagnosis 2 weeks ago scheduled for surgery 
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...
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.
As you see, it was only for 6 months
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.
And what about whole pelvic radiation? Brachy boost therapy?
I don't know. There are not a lot of detail on their protocol page. This is their schematic for the study:
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.