I wonder what the experience and clinical view is about when to start radiotherapy for advance but contained (as far as can be known by a PMSA scan).
I had an unusual path as my Gleason 6 and contained one side PCa with a PSA of 7 (3+4 <10% 4) suddenly jumped to Gleason 9 after 3 months following focal HIFU and a reduction only to PSA if 5 and then a PSA of 8 at 6 months. A new MRI and biopsy diagnosed Gleason 9 both sides and was immediately put on Bicalutimide 150mg.
I remained on just Bicalutimide for 8 weeks due to concerns about my other conditions and the impact of Zoladex. By 5 weeks my PSA was 1.8 and then at 8 weeks 0.85.
A new oncologist just ignored the comorbidities and I am now on Zoladex implants monthly for now as I want to monitor the effects to judge if I can do the whole 18 months or 2 years.
I am aware that the purpose of the hormones is to shrink and weaken the cancer cells. Of course the bicalutimide did reduce the PSA but is the Zoladex use adding more than just PSA reduction and is the recommendation would be to wait for 2 or 3 months before starting the Radiotherapy to have some hope of either longer term control or unlikely but possible cure or a 10 year delay to biochemical recurrence.Or us it just guess work and there isn’t a no answer just a balance of probabilities irrespective of where it’s 3 months of Bicalutimide and a month of Zoladex then RT or the added 3monthd of Zoladex even if the PSA is well below 1
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well thanks for the optimism, the surprise and obvious initial shock of the urologist and two oncologist about the change in my Gleason score despite 3 MRIs and 2 biopsies was a little depressing! Everyone and every PCa is not the same but one always hopes that means it’s better than your worst fears! So I’m trying to be more critical and hitting with what I can manage.
BTW- you may want to pay Epstein at Johns Hopkins for a second opinion on that GS9. Be sure to let him know that you'd had HIFU. HIFU causes tissue changes that can make Gleason scores hard to read for all but the most experienced pathologists.
Well, I am from London UK, but the GS9 was from the untreated side - I try to let go of ‘what if’ decisions as the original oncologist I saw after 1 year on AS and a slight rise in PSA was incredibly negative about radiotherapy and virtually said the side effects risks of radiotherapy would ruin my quality of life and I would probably die of something else given my disability and age (not the view shared by my polio physician)So when my PSA rise to 7 and then 8 in a few months and treatment after another biopsy and MRI remained GS7! I went for focal treatment with HIFU. I probably should have had more faith in myself and gone for the radiotherapy and not been influenced by the oncologists negativity around my polio as it’s not a condition that any current physicians have experience of. Stupid of me but it is not something I can blame myself for or spend energy worrying about, and who knows anyway!
You might want to look at the Ascend RT trial results and other info for treatment when you are Gleason 8 or more and no spread found. You can find some good info about this on Tall Allen's website. RT plus brachy therapy plus ADT is something that might work for you but everybody is different.
per conventional wisdom from studies, ADT raises the probability of radiation treatment success. However, that is not to say that zero or short course ADT will not result good outcome from you...just lower probability.
Somewhere in the presentation, he suggest that most ADT benefit comes with 12 months ADT, though longer ADT does bring somewhat better success, but QOL tradeoff???
He also emphasizes brachy benefit for Gleason 9 men, but all about high level skill and experience of brachy Doc!!!
I'm curious....did your later MRI detect more serious PIRADS areas of concern......and was the bad Gleason result found in one of those areas???
For what it is worth - my Gleason was 4+5, clean PSMA , no lymph node involvement. I went on Lupron right away with Casodex for the first month as well. I will have my last quarterly Lupron injection in a couple weeks 😀 (total 18 months of Lupron). I had beam radiation 5 months after starting Lupron, a two week rest, and then the brachy implants. We generally went with the ASCENT study guidelines on when to start the beam radiation - but there seems to be flexibility and TA has concisely laid out the PSA issue. It's curable - hang in there, takes a bit of a mind tweak to get used to the treatment schedule. I'm doing pretty dang good - just came back from a week long climbing trip back east.
thanks - I was told that I could not have brachytherapy plus radiotherapy and ADT as I’d had focal HIFU one side - due to fibrous scaring brachytherapy not possible - whether this is right or not I don’t know. In the U.K. HIFU isn’t use much as a primary treatment- I went for it as my original was one side GS7 and ADT + Radiotherapy side effects for me would be bad - yet here I am anyway as turned into GS9
I was on AS for 16 years (2003-2019) taking only Avodart to lessen size of prostate. GL was 3+3, and PSA was stable between 2.3 and 5.1 Then PCa went aggressive to GL 4+5 and PSA to 18.6, all within six months.
Prostate Oncologist referred me to Radiation Oncologist who immediately put me on 30 days of Bicalutamide (Casodex) and the start of 18 months of planned three-monthly ADT, namely Zoladex, which is designed to lower testosterone (T) level to as close to Zero as possible in order to make radiation treatments more effective. That was September 2019. At that point, I was 76. That just happens to be the age that prostate cancer was discovered in my Father. He made it to 88 although he did suffer quite badly in the last two years when the cancer spread throughout his body.
I do a lot of research and learned that 6 three-monthly Zoladex injections were just as effective as 8, and that 25 radiation sessions were just as effective as the 40 that the rad onc originally had laid out for me. In both instances, the rad onc agreed with me, so I saved a lot of treatments.
After two Zoladex injections over six months, my PSA was <0.02 ug/L (undetectable) and my T level was <0.4 nmol/L (also undetectable). I then had 25 EBRT sessions over 5 weeks ending in May 2020.
My Side Effects (SEs) from the injections and rad treatments have seriously impacted my QOL. If I had to do it over again, I would discuss with rad onc having just 3 injections. In any event, 29 months after my last rad session and 21 months after my last injection, my SEs are still terrible (hot waves, arthritic hands, and Fatigue! are the worst) but my T has returned to normal at its pre-treatment level, and my PSA, which always rises when T rises, is only 0.06. No concern there until or if it reaches 0.2.
I am monitored every three months and next blood-letting is scheduled for early December.
I would have had the brachy along with the rad, but I have had three TURPs over the years, so onc ruled that out.
Bottom Line; Discuss with your rad onc the pros and cons of staying on Zoladex. As I mentioned, I wish I got off it after only 3 injections, two before radiation and one after. At some point QOL becomes almost equally important as killing the cancer but at a nasty cost.
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post prostatectomy psa
Active surveillance....trending down 
Is creatine safe?
ADT before Surgery?
