Yet another consultation update.
I am struggling now about deciding to add hormone deprivation to SBRT.

On Feb 8, I had a 2nd consultation with Dr.Haas at Winthrop / Cyberknife.
My basic reasons were to discuss supplementary hormone deprivation in conjunction with SBRT and to review the 2nd opinion prognosis of my biopsy that was done by Dr. Epstein at Hopkins.

(He said there was no significant difference between the initial Gleason 5 +3 and the 2nd reading of Gleason 4 +4).

First note: Dr. Haas said that Winthrop has done 4000+ prostate treatments and that he has done high risk (Gleason 8/9) Cyberknife prostate treatments both with and without hormone deprivation. He did not initially recommend hormone deprivation to me.

If they do hormone deprivation, they recommend 2 months before radiation and only 6 months afterwards.

6 months after sounds a lot better to me than the 2 years after that was suggested by Columbia P&S.
Still, I worry about the side effects compared to the potential cure rate.

Dr. Haas did say that if it was his father with my diagnosis that he would go with ADT to improve the probability that the treatment would be a cure. On the other hand, he said that with no ADT, if there was rise in PSA around age 80 or so, they would probably treat that again with Cryo and that would probably be successful.

What do you think?

I am waiting to see the update next week of the study by Dr. Katz before making a final decision.

In the 2014 6 year follow-up paper by Katz & Kang, I think they found no significant difference in Biochemical disease-free survival in high-risk patients by adding ADT. If they have similar results in the follow-up study, I would be tempted to skip the ADT and the extra side effects.
/www.ncbi.nlm.nih.gov/pmc/articles/PMC3901326/

Also, among the high risk factors, Katz & Kang only saw worse Biochemical disease-free survival for patients with initial high PSA (>20) and not those with high Gleason like myself. My last PSA was 10 last October. I am getting another test done in a few days.

Specifically they said:
"It is interesting that the Gleason score or the T-stage did not have a significant impact on outcomes, and PSA remained the only significant variable. "

Max Vision,
Many thanks.
Lupron was the suggested ADT for me. I have to learn more about this and associated side effects.

It sounds like your Lupron side effects totally disappeared within 9 months. Is that right?

Redwing57,

Yes, I understand that the synonym that doctors use for ADT is "medical castration".
Thanks for the reminder. I try not to over think it.

Katz & Kang actually use "chemical castration" buried deep in their paper.

I am thinking about that description as I try to reach a conclusion.

I will go with it only if I am convinced that there are really significant benefits. Right now I doubt it and am trying to learn more.

In addition to the medical castration problem, other sided effects seem to be weight gain, breast enhancement, depression, etc. Those are probably enough to worry about.

When using ADT drugs it is "chemical castration", and it reverses when the ADT drugs are gone from the system. Another form of "medical castration" uses a scalpel and is not reversible, an orchiectomy. Both achieve the same objective, to reduce Testosterone to the lowest possible level. The former is much more widely used, but a few do choose the latter.

ADT will metabolize out of the body when the shots stop, but it takes a while. A rule of thumb is that a shot like Lupron or Eligard has a half-life equal to its duration. So a four month shot has a half-life of four months. The drug is still effective when it has as little as 15 % left in the system. So, your estimate of 9 months to recover is on track, but many find it may take longer to get the T levels back in the normal range. Generally the longer one is on ADT and the older one is, the longer a recovery takes.

As to side effects; weight gain, hot flashes, man boobs, low energy, and loss of libido/sexual dysfunction are all very common. Depression affects some but of a much smaller proportion than the others. There are lifestyle aspects based on diet, exercise, stress management and socialization that can have very positive effects. There are also some drugs that will reduce some of the side effects and some spot radiation can help prevent the man boobs. ADT can raise the probability of developing diabetes and coronary disease, so the importance of weight control exercise as essential.

I agree with your plan to measure the need very carefully. I didn't have the same choice due to my PSA level and the only consideration among 6 different specialists was whether it would be for 24 or 36 months duration. Avoid it if you can, but don't neglect it if you really need it.

No, I don't actually regret the decision. With my case, I'm pretty much willing to throw anything available at it. The possible survival improvement was significant enough for me to consider it worth the side effects, at least as I understood them at the time.

The reality of 3 years on it is of considerable impact. I'm pretty sure my body will never be the same, though I've recovered much of what the ADT took away. Not 100%.

My point, though I'm feeling grumpy today I guess, is just to be sure you understand the side effects from it and select it based on a positive choice. Not, "Well, it might help so why not.". It's not a benign treatment, and the side effects are quite real. So do it because both you and your doctor consider it to be necessary, medically worthwhile, to do so.

Thanks for the feedback on the plus & minus of ADT.
It is not an easy decision.

Are there different drugs that are used for ADT? Are some better than others?

Tall Alan said there would be an update next week of the study by Dr. Katz.
I am waiting to see that since in the 2014 paper on high risk prostate cases by Katz & Kang, they saw very little difference in results for SBRT patients when comparing those who did ADT and those who did not. They did say that there was a big difference with and without ADT for people treated with lower dosage IMRT.

Tall Allen,
Are there any differences in the side effects that most prostate cancer patients experience between the drugs?
The ones I have read about for Lupron are weight gain, male breast growth, depression and of course the various sex side effects. All of these are potential problems.

The RO at Winthrop mentioned Lupron to be administered by my urologist.

JNF said...
I would look for the added advantage. A course of nine months will be very easy as long as you plan it that way. If you are looking for it to be bad, then it probably will be....More annoyances than anything.

I think this is all very true. Everyone is different of course but I'm of the mindset throw everything at it that you can. If the treatment isn't successful at least you did everything you could at the time.

I was terrified of the Lupron and it was one of the reasons I chose surgery as a primary treatment. Now that I'm on it it's really not that big of deal. Annoying at times for sure but as most have said all very manageable.

Wife and I laying in bed at times laughing at the fact we are both having a hot flash...

Eligard is also injected in the belly next to the navel. Leaves a lump for several weeks right underneath your belt. I found the Lupron shots better than the Eligard. I started on the Eligard so I could have a six month shot. When Lupron came out with their six month version we used it. Other than different injections there were no difference in side effects.

Tall Allen,
Are you attending the GU conference in Orlando today?
gucasym.org/

In an earlier posting in this thread you said:

Tall Allen said...
I know that Alan Katz will be presenting his updated report in 2 weeks at the GU conference, and Chris King will be presenting his first report there as well.

I looked at the posted abstracts on the conference website and did not see Alan Katz listed.
Is he doing a poster presentation that updates his 2014 paper on high risk prostate outcomes?

I read his 2014 paper in detail following your links.
I would be very interested if he has an update.

I have been waiting for the update before making a final decision on adding hormone deprivation therapy to SBRT/CyberKnife.

In particular, I am curious to see if he confirms 2 of his conclusions in the 2014 paper.
1. Adding ADT made no improvement for high risk patients who were treated with SBRT.
He thought that ADT helped with lower dosage radiation but not with high dosage like SBRT.

2. Their analysis showed biochemical disease-free survival failure seemed correlated with high initial PSA (>20) but not correlated with high initial Gleason.

I think I am reading those conclusions correctly.
Do you know if other high risk SBRT papers have come to similar correlations?

I thought I'd throw my 2 cents into your discussion regarding chemical vs physical castration. There are lots of comments about the man boobs and hot flashes and low libido, but it's worth considering that chemical castration can have very serious side effects, too, and not just take away your sex drive. And yes, it does that too. Lupron (as an example) can cause high blood sugar, increase the risk of diabetes, and increase the risk of heart attack and stroke. If you are on HT temporarily or intermittently, by all means go with Lupron or a similar drug that will clear your system at some point. But once you progress to the point of being on lifelong hormone therapy, it's worth considering physical castration. You can supplement with testosterone (if you have an orchiectomy) the same way you can take away testosterone with shots while still keeping your testicles intact. In my husband's case, Lupron caused his BP to go to 195/90, his blood sugar to spike, and a lot of other serious side effects. He felt WAY better after the orchiectomy.

Richard-

I gave you all I have. I'm sure they will eventually write it up for publication - that usually happens several months later after it is written up, edited, submitted, accepted, peer-reviewed and published. I think it's safe to say that his 8-year results are not very different from his 6-year published results, so you should feel comfortable with that.

What I would do for me should have no bearing on the decision you make for yourself. I am not in your situation, and the things that are important to me may be very different from the things that are important to you. I guess that what I'm urging you to do is take some time for self-examination to figure out what is most important to you. I never to tell people to "go with your gut" - that's always a bad idea - I prefer making it explicit (on paper or computer) and living with it for awhile - you have time. Write down the side effects you fear most rank ordered to the ones you fear least. Think about how much of a loss in probability in oncological outcomes you are willing to give up to spare you each side effect. If you want the surest thing available, brachy boost with adjuvant ADT has the best stats. If you are willing to trade off the tried-and-true to diminish the risk of side effects, you may want one of the monotherapies.

The decisions on whether to include whole pelvic radiation and whether to include ADT are difficult ones. We all have to make these decisions with the info there is.