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RT only or RT+hormone for pT3NoMo?

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Posted 11/12/2015 4:25 PM (GMT -5)
Hi All,

I need to make a decision in a week. My PSA went up from 0.02(2 months after surgery)to 0.1(8 months after surgery). I have started SRT for 5 days. Based on a phase III study (RTOG9601), the 10 year survival rate was 82% for patients get RT with hormone and 78% for RT only. See the link below:

https://www.astro.org/Meetings-and-Events/2015-Annual-Meeting/Abstracts/Late-breaking-Abstract-5.aspx

My RO is not very much interested in the 4% difference. He asked me to make the decision. I would like to get some advice from friends here on the forum.

Thanks a lot.

Andy
Posted 11/12/2015 4:44 PM (GMT -5)
Andy,

I think your Gleason score would be an important part of this consideration. Can you tell us what that is? If it's a Gleason 8 or 9, two to three years of ADT is usually recommended. If it's a Gleason 6 maybe no ADT. If your Gleason is 7 maybe an 6 to 18 months or so.
Posted 11/12/2015 5:02 PM (GMT -5)
I'm higher risk than you are (N1) but my RO won't do SRT without ADT (hormone therapy) - this is MD Anderson so I trust their protocol.
Posted 11/12/2015 5:10 PM (GMT -5)
If the numbers are correct (4%) then I do not think the side-effect load delivered by ADT is worth the small benefit delivered..The trouble with these studies and trials, they always seem to support whatever position the person who pays for the study wants supported......Some doctors say the benefit of adding HT to RT or SRT is large, a 50% improvement in cure rates..Then the next study only comes up with a 4% improvement...Who do you believe??
Posted 11/12/2015 5:38 PM (GMT -5)
I do not know why my signature is not attached with my post.
Here is my history

Jan 2015 diagnosed and PSA 47.9,CT scan and bone scan negative.
Feb/2015 Radical prostectomy.
Pathology: pT3a; Gleason 8. margins positive but the big one is less than 1mm.
PSA after surgery: 0.02@2,and 3 months;0.05@6 months;0.08@8monts.
Posted 11/12/2015 5:57 PM (GMT -5)
My PSA was 47.9 at a local lab and 42.4 was at the hospital before surgery.
Posted 11/12/2015 7:08 PM (GMT -5)
Gleason 8 and a high PSA? Positive margins? I'm not a doctor, but I would think you would want to include HT. I'm of the belief that you should treat an aggressive cancer aggressively.
Posted 11/12/2015 7:47 PM (GMT -5)
Andy,

You're looking at the wrong numbers and the wrong studies.

Here's a review of RTOG 96-01 that may make more sense to you (about halfway down the page):

Anti-androgen therapy enhances outcomes of salvage radiation

They are the wrong numbers because you're looking at "overall survival" rather than "prostate cancer survival." The antiandrogens reduced death from prostate cancer at last follow-up from 7.5% to 2.3% and it also cut the incidence of metastases from 23% to 14%. These numbers are low because the disease is slow-moving and the length of follow-up was 12.6 years. Overall mortality reflects deaths from any cause.

It is the wrong study because RTOG 96-01 only looked at the use of an anti-androgen (bicalutamide), whereas the standard of care nowadays is androgen deprivation therapy - ADT (e.g., Lupron). A more relevant study is GETUG-AFU 16. After 5 years, progression-free survival was already significantly better with ADT - 80% vs. 62% without ADT.

Combining ADT and salvage radiation therapy improves outcomes

You might want to share those with your RO.

- Allen
Posted 11/12/2015 8:38 PM (GMT -5)
HT is synergistic with SRT and for high risk cases like yours it particularly confers an advantage. The issue of the duration is controversial . My doc uses 13 months as a standard.
Good luck
Bob
Posted 11/12/2015 9:46 PM (GMT -5)
Thank you so much Allen.

•Reduced rate of metastases — from 23 percent to 14 percent
•Reduced death from prostate cancer — from 7.5 percent to 2.3 percent
There were significant statistical differences (p<0.001)

These findings seem proof that I should take either AAT or ADT. My RO seems more interested in ADT, that is to use Lupron 1 injection/4 moths X 6times in the two years.
What do you think?
Thanks all
Posted 11/12/2015 10:01 PM (GMT -5)
What ever Allen said is what I say.
Andrew
Posted 11/12/2015 11:14 PM (GMT -5)
ADT, definitely. Cancer cells can evade destruction by bicalutamide (they can start to use it to activate the AR) much more easily than ADT. The new generation of anti-androgens (enzalutamide, ARN-509) might do a better job, but you won't be able to get them before mCRPC sets in. As long as ADT drives your PSA low enough, you are doing all that can be done.

- Allen
Posted 11/13/2015 1:32 PM (GMT -5)
To have ADT, the most often used drug may be Lupron. Is this right? How often this Lupron is used? My RO said 1 injection for every 4 months. 6 injections during the two years. Is this a good protocol?
Any other drug is better than Lupron?

Thank you Allen and all.

Andy
Posted 11/13/2015 2:21 PM (GMT -5)
Lupron is as good as any. They make injectionables for 1 month, 3 months, 4 months and 6 months. The injection schedule is just a matter of convenience and patient/doctor preference. Because it causes testosterone to briefly spike before it goes down, some doctors like to start with a week or two of Casodex, but that's probably unnecessary in a case like yours. Firmagon accomplishes the same thing without a T surge, but it requires monthly injections, and may cause initial injection-site reactions.

- Allen
Posted 11/13/2015 6:40 PM (GMT -5)
with that PSA of course and I would think HT would be for 2-3 years. good luck.

ed
Posted 11/14/2015 12:10 PM (GMT -5)
I concern the side effects caused by using ADT, especially the hot flashes. It seems there is no way to treat or stop the hot flashes. Do you have any suggestions to overcome this problem?

Another concern is the resistance to ADT. After 2 years use of Lupron, if resistance happens, that means PSA goes up again, what can we do?

Andy
Posted 11/14/2015 12:48 PM (GMT -5)
It's confusing because ADT is used differently in different situations, and what a man can expect from it is different depending on how it is used.

Resistance to ADT is something that usually happens over many years and is more typical of men who are on it permanently. You are using it as a temporary adjuvant treatment, so it is not likely to happen to you.

Also, side effects accumulate with the amount of time on it. Hot flashes are pretty common though. One man in my support group is trying acupuncture this week. I'll report back to you on how it goes. It actually has some fairly decent studies in support of it for hot flashes. It's done in the ear and it somehow corrects the thermoregulatory mechanism. The chemical remedies, Megace or Estrogen patches, or anti-depressants, work pretty well but carry their own side effects.

- Allen
Posted 11/14/2015 1:06 PM (GMT -5)
HT is certainly no walk in the park, but I do think it's something that most guys can power through if they need to. The hot flashes were the most bothersome for me--I know some here have had some relief with various drugs. I took gabapentin and it helped a small amount.

For the record, I did 1-month Lupron shots, which aren't common. I figured I could always pull the plug faster if I needed to that way. But I plodded along for all 18 months of my sentence. (Which is shorter than for a lot of guys...)
Posted 11/21/2015 4:00 PM (GMT -5)
Thank you all for your advice.
Especially thank Allen for your extensive knowledge. I read through the posts and notice that in 2014 Allen said "Recent studies suggest that Lupron makes the bones more hospitable to mets,". Allen, could you please let me know where these studies from? What is the update?
Thanks a lot

Andy
Posted 11/21/2015 4:17 PM (GMT -5)
Hi Andy,
I put everything I knew at the time into the following:

Zometa for mHSPC

The problem seemed to be adequately solved by starting Zometa or Xgeva at the same time as ADT in the situation of mHSPC.

- Allen
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