Should I be on ADT right now?

My plan is to have salvage brachytherapy or cryotherapy. The thing is these treatments will take time to be scheduled, especially brachytherapy as this would be with Dr Zelefsky in New York and I don’t have an interview with him until Nov 19. I meet with my urologist on Oct 29 to go over the recent biopsy and I hope we discuss cryotherapy but he may want to schedule that for another visit. My guess is it’ll be December of January if I decide to do cryotherapy with him. Same for Zelefsky or even longer. So that means 2-3 more months for an opportunity to spread.
I’m kinda freaking out. Some articles say with negative PSMA, Gleason 4+3 and PNI there is not a sense of urgency; other say ADT should be started immediately. I believe I've read somewhere that starting ADT before salvage might cause tumor shrinkage and the make MRI guidance less effective in the placement of seeds.

I know this is ultimately a question for the docs, but I’d like your opinions

Post Edited (hrpufnstuf) : 10/19/2024 2:17:35 PM (GMT-4)

Thanks Mumbo for the reply. I appreciate it. It disappointing that yours is the only one. I suppose my other recent posts on more less the same topic have most of the usual responders thinking they're already responded so a response to this post would be redundant. I suppose it would be but when a member is in a dark place, it's helpful when others give them a little encouragement.

I was doing pretty much okay mentally until I happened to see a podcast on how to treat 4+3 with PNI and it said immediate ADT was recommended. That is not what I had seen in several other comments. I feel a sense of panic now. I had anticipated that I would probably have to take it in combination with salvage but not before. Now, because Duke has delayed this process for so long I'm behind the 8 ball. I had my first PSMA on February 14. Then I had to wait until May 20 to get the mpMRI. Another month to see the urologist on June 24. Almost 4 months later to get a biopsy for a patient with PI RADS 5. That's 8 months from PSMA to biopsy. At least my most recent PSMA om October 4 was negative for mets and I don't have any spread to seminal vesicles.

You're right—I do have meeting with the Duke urologist in a week who did the biopsy and would do cryotherapy if I'm eligible and I decide that's the treatment I want. I'm sure he will address the issue of ADT. That would at least settle the question about cryotherapy and ADT, but not brachytherapy and ADT. I'm reluctant to start ADT based on what the Duke urologist says. I need to hear what a RO thinks, preferably Zelefsky but I've had no luck in getting anyone in his office other than an admin call me back. I'll reach out to my RO who did the Proton and see what he has to say.

Thanks again for writing.
P.S. When the question is asked about how many cores were positive on biopsy, how is that determined? In my case, the target lesion says 3 of 4 core fragments. That core is labelled A. The other cores are labelled B-M for the prostate. Seminal Vesicles are labelled N-Q. In addition to the target lesion I had 12 systematic and 4 in seminal vesicles. Does the target lesion count as 1 positive core or 3? It seems to me it would be 1 since it's labelled as a single core (core A).

Post Edited (hrpufnstuf) : 10/20/2024 4:31:55 PM (GMT-4)

Weekends tend to be slow, especially if the weather is good this time of year. Don’t read too much into it.

The internet is good and bad. It takes mental discipline to take in everything and keep your perspective. Very few men are in your exact situation so don’t expect clear and concise standards of practice anywhere. Also don’t conflate primary treatment with secondary treatment considerations as they are very different.

I think you understand the cores vs. fragments correctly. I assume you had 17 core samples based on your description. It and PNI are not really important at this point, you have some active cancer after primary RT and a PSMA scan not showing any detectable spread.

My guess is ADT will be recommended at some point to address what can’t be detected and help a focal treatment work better. Your next visit should be helpful in establishing next steps since you have all your questions lined up.

Prat, the phone contact I have for Dr Zelefsky is answered by his Admin. I have asked to speak to someone in medical, e.g., NP, PA, nurse. She said she would forward the request but no one called. I suspect she didn't message anyone. Do you have a contact number that might get me to one of the medical staff?
I created an account on mychart and I can already see test results in my chart. When I try to message someone it says I don't have a medical person assigned yet.

Thanks for writing.

Post Edited (hrpufnstuf) : 10/22/2024 4:26:50 PM (GMT-4)

I met with Dr Polascik at Duke yesterday to discuss my recent biopsy results and to discuss possible salvage cryotherapy. As I already knew, I have Gleason 4+3 with PNI and a finding of ASAP in one of the systematic biopsies. Dr Polascik didn't think the PNI or the ASAP was of any consequence.

He said he thought I was a good candidate for focal ablation but he would do the whole gland if I preferred. Unless I learn something in the next few weeks to change my mind, I will go with focal as it has similar efficacy but fewer side effects.

He did not think starting hormone therapy now was necessary even if the procedure is 6-8 weeks away. He said it wouldn't affect the procedure in any way if I wanted to take it while waiting if taking it made me feel better.

He agreed to try to get me scheduled ASAP. He does Cryo on Tuesdays and there are always cancellations because patients fail the anesthesia review and have to have additional tests to qualify.

I still plan to see Dr Zelefsky in 3 weeks to see what he has to say.

Mumbo, I agree with you about ADT combined with brachytherapy. From what I understand ADT does not enhance cryotherapy effectiveness as it does with radiation.

This will be a difficult decision as to which treatment to choose. With focal Cryo, I can have the treatment without significant delay, out-patient procedure, and no ADT. Negatives are catheter for 2 weeks and follow up mpMRI and biopsy in 6-12 months.

Don't know about Brachy yet. I might have to have a colonoscopy before treatment. It'll be 5 years in January and I'm scheduled for another in February. I tried to get it moved up but couldn't. I would hate to wait until February to have Brachy. I definitely wouldn't be comfortable waiting that long without ADT. Zelefsky might want me to do ADT for a few months then follow with treatment and another few months of ADT. I'll find out soon enough.

Post Edited (hrpufnstuf) : 10/29/2024 5:32:32 PM (GMT-4)

OldSalty, Dr Armstrong at Duke is my MO. I dont see him regularly since I'm not on ADT.
I'm scheduled for focal cryoablation on December 11 at the Duke Ambulatory Surgery Center in Durham. I had hoped for an earlier date but it didn't happen.
I agree that scheduling in Durham seems lengthy. I had my first PSMA scan on February 14 so it took 10 months to get me treated, all the while giving my cancer more time to spread. I realize I couldn't go from PSMA directly to cryoablation but a mpMRI and biopsy shouldn't take 10 months. I will make my complaints known to the patient relations department when I've completed the ablation.