Diagnosed: Gleason 8, stage 2c, 12 PSA

I have a good friend, 81 years old in NJ who was diagnosed as noted above in September. I joined him today on his consult with a radiation oncologist at Morristown Medical Center. Based on his biopsy, 11-core cancer volume, PSA, age, etc, she initially recommended 28 radiation sessions with a boost to seminal vesicles and prostate with radiation field covering the pelvic lymph nodes combined with 24 months of ADT. After some conversation about radiation SE, she changed her recommendation to 5 SBRT sessions to prostate with 2 years ADT. My friend has 3 stents and takes Omega 3 and a statin. His cardiologist cleared him over the phone for this treatment path during the consult.
My concerns: Why the about-face on the treatment plan? was it due simply her concerns about gastro SE? If so, doesn’t ridding the cancer take priority over potential SE? (my friend is going to ask her that tomorrow). Also, why two years of ADT on a 81 y/o with a heart condition? When I pressed her on that, she said the ADT would reduce his mortality rate by 15-20%. He is still awaiting 2nd opinion on biopsy from Johns Hopkins, but according to this doctor, any differences wouldn’t move the needle very much on the treatment plan, unless the Gleason is downgraded, which would result in a shorter ADT cycle. Any thoughts you could share on his proposed treatment would be much appreciated.

thanks, Mumbo, for your quick and helpful feedback!

First, to answer your question: his cardiologist cleared him for radiation and the 2 years of ADT.

My friend is planning on starting the ADT in the coming days — preferably the pill form so he can stop immediately if he can’t deal with the SE. And, by doing so, he can buy some time for a second opinion, as you suggested. I will also suggest this to my friend.

Question: Do you happen to know if SBRT can be applied to the whole pelvis?

More information is necessary to give an appropriate response.

Does he have symptoms attributed to prostate cancer?

What is the history that led to PSA 12 and biopsy at age 81?

Are the biopsy report and urologist exam findings available?

What is his history of heart problems?
(You have summarized the treatment, not the problems.)

I would suggest a meeting with a medical oncologist (who specializes in prostate cancer, if available) before initiating treatment.

I am not clear what case facts allow a PSMA PET scan before any treatment under traditional MEDICARE. If on a MEDICARE ADVANTAGE plan, I would expect resistance. I definitely would want PSMA PET scan if available.

If treatment is initiated, it would definitely be wise to proceed as outlined, and start ADT with ORGOVYX immediately to see how tolerable the inevitable negative effects will be.

It is not inconceivable that the best plan at age 81 (once all possible facts are considered) would be to do nothing.

Paul...all good questions by the other posters re your friend. Obviously he needs to get the scoop re why the change in radiation plans but probably either of the options is appropriate given the situation if it stands. Given that the heart doc has cleared him them I wouldn't put too much worry into the "heart condition" considerations. I know tons of guys with stents who are living normal lives and probably have normal life expectancies. On "average" he probably has 8-10 years more life...certainly worth preserving if he is otherwise in good health. So, yeah, ask the questions but IMHO proceeding with radiation treatment and ADT seems reasonable.

Jim