Sequence of radiation and ADT - Prostate Cancer N...

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Sequence of radiation and ADT

conbio profile image

So, I'm starting ADT at the end of the month, which will last 18 months. During this time I will have IMRT and seed implants. The literature on when radiation to start is not definitive. The clearest results come from the ASCENDE-RT study in Canada - there the patients had beam radiation 8 months after starting ADT and seeds soon after. Curious on your sequence and how it worked out.

Also interested in how you dealt with ADT and the radiation phase. Cheers and thanks. One can certainly get buried wading through the radiation oncology literature.

65 yo, 2 lesions limited to prostate, no SV involvement, clear bone scan. Very active - rock climb/mountaineering, mt biking, hiking, backcountry skiing. Recently ramped up weight training -have trainer - getting ready for ADT

21 Replies

Opps - failed to mention - Gleason 4 + 5

As I live in Ireland, things are somewhat different than across the pond in the US and I had a slightly different journey than most given that my PSA began to rise during my first 6 months on ADT (Zoladex, Goserelin) so Casodex (Bicalutamide) 50Mg daily was added.

I was on ADT for 10 months prior to my 39 sessions of External Beam RT which included all pelvic lymphnodes as well as the prostate and seminal vesicles. Brachytherapy boost therapy was unavailable unfortunately.

The preparation each day for radiation was to ensure that I drank 2 litres of water per day (I started this a couple of months earlier) and to have a full bladder and empty bowel. Easier said than done as driving to the radiation oncology centre each day was a roughly 130 mile round trip.

At the centre I used the toilet and then drank 3 cups of water 40 minutes before going on the radiation table (the nurses/radiation staff managed me and the timings!!).

I had 3 small tattoos (didn’t hurt) placed on my pelvis and tummy as part of the radiation planning session (about a month earlier than the first treatment session), so each day when I got on the table I was aligned in accordance with the tattoos.

Then I had a CT scan to ensure that my prostate and other innards were where they needed to be; where there was a need to realign me, it was the table that was moved remotely (usually very small movements.

Then the machine arm moved around me twice as though I was the hole in a donut! From getting on the table to getting off of it took about 3 minutes or so, each day.

Then I dressed and went home. Getting the radiation was completely painless and no big deal at all, I just need to lie still on the table.

Luckily for me the addition of Casodex to the Zoladex took my PSA down from 87 to 0.51 prior to the radiation sessions. Since radiation treatment completed my PSA has been constantly less than or equal to (lowest reading possible at the lab) 0.08

I’m in my third year of ADT that is the standard of care here for very high risk prostate cancer and yes I have had and continue to have side effects from ADT, I’m coping.

There are many ways to counteract the side effects so that you can get the most out of life. I’d recommend not worrying too much until you have to deal with them.

Everyone is different, some people sail through with minimal adverse impact whilst others have very real difficulties. Don’t pigeonhole yourself, treating prostate cancer is a personal journey that you can’t traverse in advance, so don’t try.

Living one day at a time focusing on now, not yesterday or tomorrow works for me.

I wish you all the best on your journey and from my experience the people here on Malecare are very helpful and supportive.

Best wishes,

Hugh

conbio profile image
conbio in reply to Aodh

Thanks - best wishes. BTW - I have dual citizenship with Ireland.

It's usually 2 months before radiation begins. there was a trial of 6 months vs 2 months that found no difference. The important marker they look for is whether PSA has become very low. That tells you that the cancer is stopped and is maximally vulnerable.

They used 8 months in ASCENDE-RT because they wanted everyone to have the same size prostate before radiation.

Important to treat pelvic lymph nodes too:

prostatecancer.news/2021/08...

AlanMeyer profile image
AlanMeyerModerator

Hello conbio,

Starting ADT eight months before starting radiation is the longest time I've seen. As I understand it, there are two reasons for using ADT. One is that it shrinks the prostate. That makes the radiation target smaller, making it easier to concentrate the radiation beams and/or radioactive seeds into a more precise area. The other is that it weakens the tumor cells, which makes it more likely that the radiation will kill them. In my rough recollections, I think 6-12 weeks before the start of radiation is common.

I was treated in 2003-4 for a Gleason 4+3, PSA 10.7 cancer, with a combination of ADT plus high dose rate brachytherapy (HDR) plus external beam radiation. The ADT began about seven weeks before the first HDR treatment. It was planned to last for two years but was cut off after four months due to dangerously elevated liver enzymes detected after the first 30 day injection. A second 90 day injection had already been given before the blood tests were in that revealed the abnormal liver enzymes.

I had side effects from all three of my treatments - ADT, HDR, and external beam. ADT caused a complete shutdown of my libido. Sex was possible and pleasurable if I forced myself to do it, but I had to exercise an effort of will to get started. ADT also caused hot flushes about once an hour, and a significant weakening of muscle strength and stamina. I countered the weakening by exercise but I have read accounts from others who did harder exercise than I did that they retained strength better than I did. I recommend hard exercise.

Radiation side effects were complicated:

1. Radiation skin burns, much like significant sunburn (which, after all, is also a radiation burn.) IIRC, these lasted for just a couple of weeks after the end of the external beam radiation. They responded well to healing skin creams that are used for sunburn.

2. Exacerbation of preexisting hemorrhoids originally caused by a brutal rectal exam. These took several months to calm down. I won't ever go back to the urologist who did the exam.

3.Difficulty urinating. This was caused by my second and last HDR treatment. It inflamed the tissue surrounding the urethra causing it to swell and clamp the urethra shut. I could only pee when the pressure in my bladder was high, and then only enough to reduce the pressure, not enough to empty the bladder. It took about five months on tamsulosin (aka Flowmax) before I was back to normal. In the worst initial period of about seven weeks after treatmentI had to go to the toilet about once an hour, day and night.

4. Long term impotence. This manifested itself over a period of years, but eventually became pretty complete. I was told that my chances of that were about 50/50. I came out on the wrong 50. I have to say that it changed my sex life, but did not cancel it. You can learn to live with what you've got and make the most of it.

Will your side effects be the same as mine? There's no way to tell in advance of the treatment, but I think that radiation techniques are a little more advanced than they were in 2003-4 and the targeting will be more precise, with some reduction of the side effects.

Would I do this treatment again if I knew then what I know now? The answer is yes because the treatment worked. I have had no treatment since 2004 and my PSA bounces around but still remains low. In the last 10 years my highest PSA was 0.26, my lowest 0.07. Most recent PSA is 0.09. Life has its ups and downs but, in my view, the ups more than cancel the down.

Best of luck.

Alan

conbio profile image
conbio in reply to AlanMeyer

Thanks for the details - glad you are managing well

I had a RP in 2019 with a biochemical recurrence late last year. I started Lupron two months before 33 sessions of IMRT. I experienced hot flashes and some fatigue from Lupron but no additional side effects from IMRT. My PSA was 1.13 before Lupron and is now at .03 a month after completing IMRT. I will be on Lupron for 18 months. Everyone is different but I feel blessed to only have minimal SEs so far.

conbio profile image
conbio in reply to Lasered

:)

conbio profile image
conbio in reply to Lasered

Encouraging -thanks, seems you are hanging in there

Follow the instructions for the radiation and you should have no problems. Your fitness level will help you with every aspect of the radiation but especially the ADT. Good that you ‘ramped up’ the weight training.

My only advice is to ramp it up some more. In fact, the main challenge lifting on ADT is to not get discouraged. Remember you are doing an intervention on the sarcopenia, which is beautiful, but your results may seem poor. Just keep in mind where you’d be without lifting!

Abdominal fat and fatigue go with the territory too. Eat healthy and less if you can-metabolism is noticeably slowed.

Simple, not easy. Absolutely must be done in order to thrive on ADT. Great luck to you!

For you and other men here, what were primary reasons for accepting SEs from 2 therapies , radiation and ADT, rather than surgery with no ADT?

Burk profile image
Burk in reply to maley2711

For those of us who fall into the high risk category it is assumed that we have micro mets. The ADT and RT is targeting possible micro mets with a curative intent. Surgery would do nothing for micro mets.

Thank you all for your valuable information. I was diagnosed with PSA 8.5, then up to 10 and Gleason score 7 (4+3) in January.

A subsequent PSMA PET scan indentified that it has metasticised onto pelvis, ribs and skull, but not into organs. I am on Aberaterone plus prednisol and PSA is now at >0.5, so all good there.

However... I also have a form of blood cancer, Essential Thrombocythemia, where the bone marrow produces too many platelets and I take a chemo drug called Hydroxicarbamide, which has controlled it for 6 years.

Sorry for the preamble, but my question is, will I be able to have RT as chemo is probably a non starter and of course surgery isn't going to help? If I do, and my oncologist has mentioned RT if the ADT seems to be stopping to be effective, your detail of personal experinces is most helpful

Stephen

74 y.o. G(4+3=7)Grade 3 turned to 4. VMAT-RT 3Gy X 20 = 60Gy and ADT 24 weeks.PSA went from 13.6 down to 0.03 (my NADIR),

No skin burn but over a year I started to have urinary and rectal problems. Now I have a permanent Foley and on Friday Sept 10th Colonoscopy Argon,

10 months Post-ADT = No libifo, penile shrinking of penis and 2 breast A cup.

My sequence was 1 mo of Firmagon, then ADT for one 3 mo injection, then IMRT for 25 "fractions" (sessions), and continuing ADT for two more 3 month doses, then brachyboost. As far as the actual procedures - external beam and brachy - they were uneventful. But, my god, was I an anxious mess. The unknown, the "what ifs," the "my life is going to change forever;" all of that swirling around in my head and emotions. And, of course, the impact of all on sexual function. Docs were worthless in this area.

It's a rough road. As much as I thought I knew what was happening, I really did not appreciate the significant changes that would occur and in a relatively short period of time. A true mind fuck. As you can tell from my comments, this was not a fun time!

There are many men who seem to weather all of this well and for whom ADT is not much of an issue. Envious as hell of them. Re ADT, exercise is critical. And, I suggest "Androgen Deprivation Therapy: An Essential Guide for Prostate Cancer Patients and their Loved Ones."

Good luck to you. You'll find support and info here.

EdinBaltimore

thank you

Diagnosed August 2018 Gleason 9. I had external beam radiation and bradytherapy plus Lupron for 24 months..

Still in remission.

No side effects from radiation.

Mild hot flashes.

Still have loss of libido but enjoy looking at pretty women. Just one less complication in life.

My main complaint is fatigue and lost of muscle mass.

I didn’t start an exercise program and that is what I wish I would have done.

All the best to you.

conbio profile image
conbio in reply to diatom

thanks

AlanMeyer profile image
AlanMeyerModerator in reply to diatom

> I didn’t start an exercise program and that is what I wish I would have done.

It's not too late to start an exercise program. If you're still not doing it, I recommend that you start. I concentrated on aerobic exercise - mainly jogging on a treadmill. If I were doing it again I'd do the aerobics but also add a lot more muscle exercise - pushups, situps, weight lifting, etc.

My impression was that exercise was very hard to do on ADT, but the benefits were really valuable in having greater strength, stamina, and energy.

Alan

As I noted, I'm pretty active. From what I've read it is particularly important to weight train. In addition to my usual activities I've now got a trainer once a week, and I weight train another day on my own. Interestingly I've just been recruited to a study that looks at the effects of ADT on muscle mass and function.

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