VMAT with or without short term ADT

As I mentioned in another thread, I don't think ADT us usually the standard of care for intermediate risk PCa - unless I've missed something in your pathology. My biopsy report showed mostly G3+3=6, with one core of 3+4=7, and I am classified as favorable intermediate risk. My RO does not administer ADT until the patient is unfavorable intermediate risk or higher.

As I also mentioned elsewhere, IIRC the studies have shown no disease control benefit to ADT in low and favorable intermediate risk cases, so they recommend against it due to its potential negative side effects. I know I was majorly relieved to hear that, as I did not want to go there. . .

Adjuvant ADT

There is no evidence that ADT does anything for patients with "favorable intermediate risk" PC like yours. In a retrospective study by Castle et al. where intermediate risk men were divided into favorable or unfavorable intermediate risk, favorable risk patients had no discernable benefit from the addition of ADT. Unfavorable intermediate risk patients had significantly higher 5-yr freedom from failure if they also received ADT, 74% vs. 94%, respectively. Similarly, Edelman et al. found that ADT combined beneficially with RT only in intermediate risk patients with GS 4+3, more than 50% positive cores, or multiple intermediate risk factors.

Another retrospective study by Keane et al. confirming that finding was presented at the recent Genitourinary Conference. They analyzed the oncological outcomes of 2,668 intermediate risk men (71% favorable, 29% unfavorable) treated between 1997 and 2013 with dose-escalated RT and with and without adjuvant ADT (median 4 months). After a median follow-up of 7.8 years, they found that there was a significant amelioration of the risk of prostate cancer-specific mortality among the unfavorable risk patients who also received ADT, but adding ADT did not make a difference to prostate cancer-specific mortality in those men categorized as favorable intermediate risk.

www.redjournal.org/article/S0360-3016(12)00856-5/abstract
www.redjournal.org/article/S0360-3016(11)03443-2/abstract
meetinglibrary.asco.org/record/105877/abstract

VMAT

VMAT just means that the radiation is delivered very precisely and quickly by rotating gantry arms of the linac. I was treated using a VMAT linac for a kind of external beam radiation called SBRT. That means the treatments are condensed down to 5 treatments from the usual 40 or so. The only purpose of the 40 treatment regimen is to make the RO richer (he gets reimbursed by the number of treatments). There's a lot of high level proof now that a reduced number of treatments (called hypofractionation) is no worse and it is certainly less costly and more convenient:

/pcnrv.blogspot.com/2017/06/eigthth-randomized-clinical-trial-of.html

I thought I read that the University of Alabama at Birmingham is offering SBRT now. Since it's only 5 treatments (every other day), it may be worth the trip. It's been around since 2003 and the study with the longest follow-up is 9 years (see links in my signature), which is about the same as the longest f/u study of IMRT.

Welcome to HW.

You should check out SBRT. We're hearing lots of good things about it and your case seems great for it.

Not sure you need ADT at your risk level.

Keep us updated on your progress,
Andrew

TA - Thanks for stepping in with those links.

Danioro - In case you didn't "connect the dots" in my signature, I was treated with CyberKnife SBRT radiation. I had my 5 treatments over a 10 day period last November. I had some pre-existing bowel issues, so my side effects were a bit more annoying than most, but after a couple/few months, all was back to normal (except as Allen noted, near-complete loss of ejaculate).

I found the entire process to be rather interesting, since I am a techie/gearhead by nature. The schedule worked out very well, as I am still working and by taking only a few mornings off work, nobody at the office is any the wiser of my situation. I'd suggest you look into SBRT. It may make good sense for you, too.

One problem I see with non-surgical treatment (assuming that's an option) is the Doc has no idea how extensive the cancer is, what grade it is, if it spread outside the capsule, etc. I was a 3+3 on the initial reading of my biopsy slides, MD Anderson reread the slides as a 3+4 and pathology revealed a 4+3 and a positive node as a bonus.

So I moved from relatively low risk to intermediate risk to a high risk (or high intermediate?) A Decipher genome test affirmed the high risk. Then the treatment plan moved to the next level with Lupron and salvage radiation. If pathology was more favorable I probably would have been done after surgery.

Having said that, maybe if your entire pelvic bed gets zapped, that will be a completely effective treatment in and of itself.

Danioro-

It is true that Gleason scores are upgraded from biopsy to surgery about a third of the time, and they are downgraded about 10% of the time.

But the risk categories are based on clinical assessments: biopsy-detected Gleason score (right or wrong), DRE-detected stage (right or wrong), and PSA (which may be due in part to other causes). It is those risk categories that correlate with success of the various treatments. So the statistics - the probability that a treatment will be successful - are based on clinical assessments, not what is actually there. The "inaccuracy" is already built into the statistics.

John-TX-

Whole pelvic radiation is reserved for those who have a high probability of spread to lymph nodes, which is rare (<1%) in any but high risk cases. Radiation does treat a margin outside of the prostate, so it kills cancer outside of the capsule that surgery cannot. I agree completely with you that a benefit of surgery is the pathology report. For myself, I found I could live without knowing what was in there - but everyone's different. Another drawback of radiation is the often slow, bumpy ride of PSA, which many find disturbing.