Decision Time

[MrGreenJeans]

Hi All,

I recently posted with my situation and have a follow-up (final I hope) with Dr. Gorovets at MSK to finalize my non-surgical treatment plan. Just looking for any input, thoughts, advice. Greatly appreciated as always.

I'm 60, GS 4+3, PSA 5.5, Decipher .55, clean PSMA Pet (full details in my profile).

I had an initial consult with Dr. Gorovets about a month ago and then spoke with his resident a few times after that. Final call with Dr. Gorovets is scheduled.

I’ve been given a few options which I’ve mentioned in my previous post:

SBRT + ST ADT +/- HDR Brachy boost

SBRT + HDR Brachy boost +/- ST ADT

Summary of write up from Dr:

A more aggressive option (than LDR) is HDR brachytherapy (Ir-192, 15Gy/1 fraction) followed by SBRT to the prostate only (25 Gy/5 fractions, every other day), which has been shown to be safe and effective for UIR prostate cancer (Kollmeier et al, IJROBP 2020, Spratt et al BJUI 2014). Both brachytherapy-based options are best suited for patients with appropriate prostate size (=60-70 cc) and fewer urinary symptoms (IPSS =18). In his case, we would favor an HDR-based regimen.

External beam radiation therapy options discussed included SBRT to the prostate and seminal vesicles 40Gy/5 every other day) and moderately hypofractionated radiation (70.2Gy/26 daily). Generally, SBRT is favored in patients with appropriate prostate size (<90cc) and a low burden of urinary symptoms (IPSS <21) like Mr….

We discussed that if either of these EBRT-based approaches are chosen, we would use MRCAT to facilitate MR-based radiation planning.

There is controversy regarding the role of ADT for UIR prostate cancer. While some studies show a potential benefit (EORTC 22991, TROG 96.01), these trials were conducted with lower radiation doses than are typically given today. At MSK, our typical approach to omit ADT if the patient is receiving a dose escalated form of radiotherapy, such as HDR brachytherapy with SBRT, or SBRT with boost to the DIL using MR Linac. However, we often recommend ADT for patients with radiographic evidence of extracapsular extension or a high risk Decipher score.

End of summary

In my initial consult with Dr. Gorovets, he mentioned that he very slightly favors the SBRT/ST-ADT route given my Decipher score of .55.

While discussing the MR Linac option with the resident, he said that would be available to me should I chose to participate in a trial where they would dose escalate the main tumor but then have no other therapies such as brachy or ADT. Trial - mskcc.org/cancer-care/clini... I was interested in being treated with the MR Linac as my understanding is that it is more accurate than the CT guided machines, but don’t wish to participate in this or any trials.

I’ve also seen a recent video from Dr. Sholz where he discusses a 2023 study that seems to indicate that ST ADT has no effect on overall survival for intermediate (both favorable and unfavorable) men.

Study - ascopubs.org/doi/10.1200/JC...

Conclusion - STAD did not improve OS rates for men with IRPC treated with dose-escalated RT. Improvements in metastases rates, prostate cancer deaths, and PSA failures should be weighed against the risk of adverse events and the impact of STAD on quality of life.

I’ve seen some comments on here that mention 6 months of ADT is very doable, but then I’ve seen others mention that it has ruined their lives and that some never recover to their prior T levels. Being a somewhat risk averse person, thinking that the SBRT/ST-ADT is the route to go, especially if I can get approved for Orgovyx.

Thanks!

[Xavier10]

You seem to be on top of it. Your conclusion is sound. Nothing wrong with a year of ADT. They may say 6 months.

[Tall_Allen]

You tube videos are a terrible sorce of information. Clinical trials that use overall survival as an endpoint for localized Pca are seriously flawed. Don't you want to be cured, or would you prefer to live with painful and crippling metastases?

[MrGreenJeans in reply to Tall_Allen]

Thanks for your input. I've personally found the PCRI videos informative along with this site. I've spent many hours watching Dr. Sholz' videos and perusing this forum and both have helped me in my decision to be treated non-surgically. I thought that this recent prospective study was interesting as it seems to suggest that ADT may not be for all at the intermediate stage. My RO at MSK seems to think that I can possibly skip ADT as well, and I will mention this study when I meet with him.

[Tall_Allen in reply to MrGreenJeans]

The misinformation it purveys is because he mixes his opinions (sometimes in conflict with best practice) with sciency-sounding advice. In this case, the bad advice that you seem willing to take is because the study you quote uses an inappropriate endpoint. Your doctors at MSK probably are at a whole higher level, and you can question them one on one.

[ADT-first-timer]

Wow. I went to MSK this year also and did not get nearly the quality of care you got. I was basically told SBRT + six months ADT for my G7 4+3. There was no Decipher test, no PSMA PET, no mention of Brachy or anything like that. Just an MRI and MRI Fusion Biopsy. So that's what I did because I assumed, being one of the top cancer centers, they knew what they were doing. Now I'm worried. Good for you for getting such great care!

[MrGreenJeans in reply to ADT-first-timer]

My PSMA Pet and Decipher tests were requested by some of the initial doctors outside of MSK that I initially met with. My Dad was successfully treated with LDR 22 years ago and was why I specifically wanted to speak to someone there about brachytherapy - they then scheduled a consult with Dr. Gorovets.

[Bourbon2024]

Get the ArteraAI test. Indicates response to ADT.

[MrGreenJeans in reply to Bourbon2024]

Thanks for the suggestion, I'll inquire, but not sure that I have time for any more tests. Was diagnosed in March of this year and want to take action ASAP. Also wanted to take the Prostox test, but when I inquired with the MSK resident, he said that it wasn't used widely there.

[AnOrangeADay in reply to MrGreenJeans]

we're in a similar situation. headed for sbrt mr-g

we got Prostox results--high risk for fast radiation. lower risk for slow radiation.

Doc thought we had urinary retention issues. bph, nocturia.

our doc suggested a compromise if we dont like the many fractions of slow radiation--that we do the 5 sbrt once a week. Qw instead of EOD.

so it will take 5 weeks instead of 2.5

might give the bladder/urethra more time to recover in between.

So if you have any urinary issues now, you might be able to elect Qw sbrt.

we also chose mr-g over CT-g for the accuracy/smaller margins. although treatment time is longer, before u can go pee.

[MrGreenJeans in reply to AnOrangeADay]

Thanks, I've asked a few times about Prostox when speaking with both the resident and RO at MSK and was told that it's not commonly used there which I find a bit odd. I also inquired about the MRI guided SBRT and was basically told that it's not an option for me unless I join their trial which I passed on. Doing the 6 mos ADT (Orgovyx hopefully)/SBRT route even though SBRT/Brachy boost was still discussed as an option when I had my final consult last week.

[Ocean20]

I was in exactly the same position as you regarding the decision with Dr. Gorovets, whom I find to be an excellent doctor. Same age group and stats except I don't have a Decipher score. I had started with Dr. Shasha, who was given to me randonly by MSK, but he went on a leave of absence and Dr. Gorovets took over. I chose the 5 SBRT at Basking Ridge with Orgovyx 6 months. I have two months left to go on the ADT. I find it tolerable and my PSA dropped from 7.7 to 1.4 in the first two months and it's probably still dropping. You just have to manage the hot flashes that wake you up at night, which I do by covering up with only a sheet, and taking OTC diphenhydramine now and then. On my own, I'm also taking supplements Apigenin, Sulforaphane, Tumeric, Turkeytail mushroom, and Fucodian. You can check each of these out on the National Medical Library. I've entered these on my med list so my physicians know I'm on them and have had no complaints from any of them. I'm also an exerciser and I try to eat smart, but I don't go crazy with either of those things. I notch my diagnosis up to the stress I was under over the past 4 years trying to care for a very ill child, so I'm doing my best to destress. Good luck with your treatment. You are in great hands.

[MrGreenJeans in reply to Ocean20]

Thank you for your reply and comments on Dr. Gorovets, he is somewhat of an unknown quantity to me. Glad to hear that you are very happy with him. I will also look into the supplements you are taking.

[Larry954]

I am also a risk adverse person and taking ADT for an undecided period (just 3 months so far). For me the risk of recurrence has a much higher weighting than the risk of long term ADT effects. The current side effects of the ADT are not pleasant but that’s the costs to realize the goal of winning the battle.

[Ocean20]

No problem. Feel free to reach out to me about anything because we share the same profile, diagnosis and provider.

[Nodrogear]

I am sorry it all of the terms you use are too confusing for me BUT what I can say is that I had Brachytherapy in 2016 to deal with a cluster tumour. Subsequently my PSA reading dropped to below zero BUT the cancer came back in 2023 and, as there was scarring on the gland they couldn't accurately target radiotherapy so I am now on a second dose of Decapatly which is a hormone therapy treatment. After first course of the Hormone my PSA dropped back from 16 to near zero so I have hope. Hope your choices work out

Gordon

[cscmetsfacil]

Sorry to say, I am also confused by all the abbreviations you are using. In particular, my understanding at this point is that both HDRT and SBRT are ablative treatments to the areas where you know you have cancer. I have never heard of someone doing both. The standard with which I am familiar is either SBRT or HDRT to the prostate (and possibly seminal vesicles) followed by 4-5 weeks of EBRT/IMRT to cover lymph nodes, etc. in the pelvic bed. The purpose of ADT prior to the RT is to shrink the prostate (if enlarged) and weaken the cancer cells so that the lower dose EBRT to the surrounding area can be effective. I had HDRT with 5 weeks of IMRT and 4 months of ADT. Nor recurrence in the areas irradiated, but the primary treatment was too late and it was in my blood already - undetectable at the time of primary treatment. Many members of the Bay Area Prostate Support Community PCa support groups use Dr. Scholz as a member of their care teams along with more standard research docs at UCSF Med Center, etc.

[MrGreenJeans]

Thanks for your reply and comments.

SBRT + temporary seed (HDR) brachytherapy boost is my understanding of that option. I've seen some men on this site that chose this treatment although it was a few years back. There are also a few videos/studies on that combination from Dr. Zelefsky, Dr Stock. Tall Allen may have questioned this as well when replying to an earlier post of mine, but this seems to be offered by MSK currently. I'm leaning towards (at least now) for the SBRT + 6 mos. ADT (hormone) option. Not sure what acronyms you are not familiar with as you use quite a few in your reply. A few defined: UIR - Unfavorable Intermediate Risk, DIL - dominant intra-prostatic lesion.

[Njugs]

like  ADT-first-timer there was no mention of brachytherapy until I met the oncologist who recommended it for my case else I was heading to EBRT after 3 months of Hormone Therapy pills and zoladex injections . I still have two weeks to make the decision. Meanwhile I have been invited and am considering a clinical trial of "A randomised trial of 5 fraction prostate stereotactic body radiotherapy (SBRT) versus 5 fraction prostate and pelvic nodal SBRT" icr.ac.uk/media/docs/defaul...

[groundhogy]

sorry im late..

Here is a good website to compare odds of cure for the major treatment paths. You have to determine your stage, low risk, intermediate, or high risk (risk of recurrence). So if you are intermediate, pull up the intermediate chart and you can see the odds of 10-20 yr survival, etc. based on the treatment you pick.

prostatecancerfree.org/comp...

It is best viewed on computer or just print it on paper. Not so viewable on phone.

To make the graphs easier to read, i drew a dot on the endpoints of the elipses, and then drew a line through the dots. This turns the elipses into lines.

Also be aware the the graphs don’t show any salvage radiation benefit. This would boost the surgery odds up a bit.

And, this is a very dysfunctional industry from my view. Loads of bad info mixed in with the good info. Same with the docs. Some of them are more dangerous than the cancer.