IMRT Gleason 3+4, Is HT needed

I visited a RO in Boston last week and was examined and did a consultation on SBRT, Cyberknife and RT.

He did a DRE and reviewed my testing. He doesnt put patients in fixed boxes and indicated I was slightly less favorable than I thought since in his opinion I have a lot of cancer on the right side, 6 of 7 positive cores all on the right side, 2 of 6 with Gleason 3+4 with 35% involvement and of that 90% was GL 3 and 10%4.

Anyhow he said that the lower % involvement and low amount of GL4 was better but he would recommend I have Hormone Therapy to improve my treatment.

He stressed he knows about the side effect profile of the hormones and doesnt take it likely but highly recommended I consider that.

He also mention a high likely hood of some ECE but said he uses a +5mm to +3 mm margin in the plan. He quoted some studies by Mayo and Cleveland Clinic about the distance ECE penetrates into surrounding tissue from pathology and said about 4 mm would deal with 90% of patients, and if someone was high risk he would increase the margin.

I also learned he uses the gold fiducials, 175 beams in the plan, has dosing restrictions based on cc volumes of the OAR, has patients use enemas for bowel prep each morning, has less 1% acute grade 3 retention (requiring catherization) and never had a patient with a stricture. He indicated they have dosing restrictions on the Urethra in their plans.


He discussed that the IMRT and SBRT had equal safety and outcomes and the SBRT is more controlled with the intra fraction tracking and also more convenient due to the 5 vs 45 treatments.

They use multiplan which must be the Accuray software, have 3 physicists just for Cyberknife, who create the plans, reviewed by all 3 and signed off by the chief physicist.

So how bad is HT. He indicated I would be on Casodez and Lupron.

Is Casodex used for the whole 6 months or just first few weeks to diminish initial spike in Testosterone? I didnt think to ask, he said he would work with my Urologist on the HT and see if my Urologist could perform the fiducials which he indicated transrectal was adequate.

How many folks here have had SBRT with HT, and I know some studies showed no need for favorable intermediate, but benefit for unfavorable which he put me in that bucket based on the volume of cancer he sees from my DRE and biopsy.

Regards

How bad is HT? It's a bit of a slog, although six months is probably tolerable and that you could power yourself through that. I felt that it "aged" me, although that was more of a cumulative effect and I don't think that was as bad during the first six months. I'd say that most guys really find the hot flashes to be the most bothersome. Complete lack of libido is really, really odd--depending on how actively intimate you might be with a spouse/partner that could take some adjustments.

I would imagine that you would stay on Casodex the whole six months and that, yes it would precede the Lupron by a week or two.