Hello friends could used some help.
Does anyone know if the NCCN guidelines recognize the use of genomics, specifically the Decipher Assay, as a stratification tool to be considered when deciding on long term ADT therapy? I am post prostatectomy, and finished salvage EBRT in June and was hoping for a break. However my MO states he gives no weight to the Decipher score. He states as his singular reason that the NCCN guidelines are silent on the issue and he strictly adheres to them.
"The panel recommends use of nomograms
and consideration of age and comorbidities, clinical and
pathologic information, PSA levels, and PSADT, and Decipher
molecular assay to individualize treatment discussion. Patients
with high Decipher genomic classifier scores (GC >0.6) should
be strongly considered for EBRT and addition of ADT when the
opportunity for early EBRT has been missed."
He's right that Decipher isn't validated for use after salvage radiation. What decision did you want it to help you with?
Allen, I’ve completed 6 months ADT and I’m having a rough go of it. The Decipher assay put me in the low risk category and the Interpretation reads “These patients may be optimally managed with observation/ PSA monitoring after surgery. Patients with a rising or persistently elevated PSA may be treated with radiotherapy alone, without concurrent hormone therapy.” That was what I had, persistent BCR with a PSA of .6 four months after surgery.
But MO said no dice. I need to stay on Eligard long term because NCCN guidelines do not sanction the use of the Decipher assay in deciding the best course of action in terms of whether to remain on ADT long term. He then gave me a short course on how it takes years to be approved by NCCN and become accepted practice. It is simply not Standard of Care currently he states.
I also asked for a script for Tamoxifen because my breasts hurt so bad and they are swelling in front and along the sides but he stated he has never prescribed Tamoxifen to any male patient because of its dangerous clotting issues. I pressed on asking what I should do then and his answer was that if I decide to forgo ADT it may resolve on its own. My research indicates that if used prophylactically concurrent to ADT the gynecomastia might have been avoided. I insisted on the meds then he offered to refer me to another provider for that so here I am trying to decide what to do about it all. I pressed back because I’ve learned a lot from this site about being my own advocate and I tried to put some of that to use last Friday but I left there doubting myself about it all now. Thanks again.
I don't know what you mean by "long term." NCCN guidelines are for 6 months of adjuvant ADT.
Ask him if he is willing to prescribe transdermal tamoxifen. It will not have the same clotting issues that pills have.
Allen when you say it isn’t “ validated” do you mean not NCCN guidelines?
No, I mean that there is no valid use for Decipher after salvage radiation
Allen If the NCCN guidelines state “The Decipher molecular assay is recommended to inform adjuvant treatment if adverse features are found post-radical prostatectomy and can be considered as part of counseling for risk stratification in patients with PSA resistance/recurrence after radical prostatectomy.”Given the language above do you not agree that this is a valid use of Decipher to determine if I should continue on with adjuvant ADT treatment now that salvage RT is complete?
Here's what NCCN says:
"In addition, results of a retrospective analysis of RP specimens from patients in 9601 suggest that those with low PSA and a low Decipher score derived less benefit (development of distant metastases, OS) from bicalutamide than those with a high Decipher score."
The words you quoted were excised from the current NCCN recommendations.
You had persistent PSA, not recurrent PSA, which puts you at higher risk. Additional risk factors include stage T3a and the lack of positive margins. This may seem counterintuitive, but if you had positive margins, the mystery of your persistent PSA would have been resolved and prostate bed radiation might have been sufficient. As it is, your cancer is clearly outside where the prostate was.
redjournal.org/article/S036...
PSA of 0.6 is the dividing line for needing adjuvant ADT with radiation. Given your low Decipher score, I am struggling to understand why your doctor is recommending long-term (> 6 months) adjuvant ADT.
redjournal.org/article/S036...
prostatecancer.news/2016/08...
Thank you Allen. I was persistent post RP and my PSA reached .06 last December so I started ADT.
3 months later I had my 2nd 3 month shot and immediately started 7 weeks of RT which I have just completed.
With my outlook positive now and my feelings lifted by the attached genomics report my MO instead gave me the full court press Friday insisting I get another shot that day and continue on for 18 more months of ADT treatment. It reached a point where he suggested a referral to another provider and man did I want to but I kowtowed.
As I mentioned he gives no weight to the genomics report because he stated NCCN Guideline's do not recognize Decipher as a reason to stop ADT treatment. He said it is not “standard of care”
I am T3a, N0, SV0, M0, EPE, Negative margin. I understand the logic of persistence and negative margins and hadn’t thought of that.
So if possible given what I’ve laid out can you share whether you think it might be unwise to not stop ADT with my particular risk factors.
Thanks in advance.
I don't understand. You wrote: "I was persistent post RP and my PSA reached .06 last December so I started ADT." But in a post above, you wrote:"That was what I had, persistent BCR with a PSA of .6 four months after surgery." That's a huge difference. Which is correct?
Current NCCN guidelines state: "Two years instead of 6 months of ADT can be considered in addition to radiation for patients with persistent PSA after radical prostatectomy or for PSA levels that exceed 1.0 ng/mL at the time of initiation of therapy, based on results of RTOG 9601." There is a difference between "can be considered" and "must be used." Decipher shows the odds of your having detectable metastases within 10 years if you do nothing. Judging by your persistent PSA and negative margins, you already must have some micrometastases. Did the radiation+6 months of ADT get it all? That's a judgment call.
One thing I think you should consider is how wide the radiation treatment field was:
prostatecancer.news/2022/05...
prostatecancer.news/2021/05...
Here is what I have • NCCN: PSA persistence/recurrence after RP is defined as. failure of PSA to fall to undetectable levels (PSA persistence) or undetectable PSA after RP with a subsequent detectable PSA that increases on 2 or more determinations (PSA recurrence).
Persistence means PSA never became undetectable.
Yes and six weeks post surgery I was .2 and over the next five months it went to .6 then I started ADT and continued for 6 months all thru SRT.
And if I am understanding the Decipher result it should be entirely within reason to take a break from ADT and go into watching mode do you agree? If so I wonder what I would need to do if PSA returns to a detectable level. Is Decipher indicating that if it does become detectable again do I remain confident that my tumor DNA has established that no matter what my PSA goes to ADT will not benefit me in any substantial way?
Really poor idea to stop and restart when you are on adjuvant ADT. That will only select for the most resistant types of cells (Just as you would never stop and restart antibiotics)
Thanks again Allen. I know that these are nuanced issues that require a complete understanding of the facts of each of our cases. Thanks for the navigation.
The National Comprehensive Cancer Network (NCCN), a not-for-profit alliance of 31 leading cancer centers devoted to patient care, research, and education.
Good Luck, Good Health and Good Humor.
j-o-h-n Tuesday 07/12/2022 6:01 PM DST
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