Delay SRT to allow ADT to have more impact?

Yep, been discussed and researched a lot.

I'm far from convinced there is any significant benefit from hormone treatment in combination with persistent PSA IMRT. The RO sure doesn't have to suffer the side effects!

If you are determined to possibly up your positive outcome by a few % go for it, but no need to delay RT by more than a week or two at the most. Mayo is correct as usual, IMHO.

Good luck, and keep us posted.

You meant ADT. Two months is typical. the neoadjuvant ADT is thought to radio-sensitize the cancer. What they usually like to see is the PSA drop to undetectable before starting the radiation. That indicates that the cancer cells have been "crippled" to the point that they are no longer active and releasing PSA. In this inactive state, the cells are not capable of using DNA-repair to recover from the radiation injury.

Much of our knowledge about it comes from its use along with primary radiation. An early randomized trial proved that 2 months neoadjuvant (added before radiation begins) + 2 months concurrent ADT significantly improved oncological outcomes, especially in intermediate risk men:

www.nejm.org/doi/full/10.1056/NEJMoa1012348

The benefit was maintained even at higher radiation doses:

www.redjournal.org/article/S0360-3016(12)03331-7/fulltext

One study suggested that an extended course 6 months of neoadjuvant ADT before primary RT had better results:

/www.ncbi.nlm.nih.gov/pubmed/23618502

But a randomized trial (RTOG 9910) proved that 3 months neoadjuvant gave equivalent oncological results with less toxicity.

www.thelancet.com/journals/lanonc/article/PIIS1470-2045(11)70063-8/abstract

PSA response during neoadjuvant ADT is the most significant prognostic factor.

Most of the protocols with salvage radiation have followed what had been learned from primary radiation. In fact, I've never seen an SRT clinical trial that did not include 2-3 months of neoadjuvant ADT. There's been much less study on the timing and duration of adjuvant ADT given with SRT. We finally learned from an RCT (GETUG AFU-15) that adjuvant ADT improved survival when used with SRT. There is an RCT running (RADICALS) that will provide more info on optimum duration:

/pcnrv.blogspot.com/2016/08/combining-androgen-deprivation-therapy.html

If your RO can provide the European study showing that a shorter neoadjuvant ADT period is sufficient with SRT, I would love to read it.

Allen, in reading the citations above, I don't get a clear picture of how they directly apply to AZ Guy, or me, directly.

We've both had recent surgery, we both have persistent PSA of around .40, we both have relatively good pathology and we both have a small positive margin. I don't know if AZ has had a PSMA PET/CT scan like I've had. No less than Dr. Matt Biagioli in Orlando, and Dr. Chris King in LA have suggested that ADT is not advisable with my stats.

The above studies address either intervention after primary RT or BCR a number of years after surgery. They don't cover the situation of AZ Guy or me. He's planning to start ADT almost concurrently with salvage IMRT, and I'm hoping to skip ADT altogether because of it's questionable benefits and potential side effects. I have citations suggesting this viewpoint is correct, but it will take me some time to dig them out and into an easy to follow format.

Am I incorrect, wishful thinking, or barking up the wrong tree? Thanks for your always, most knowledgeable insights.

I had my Lupron injection end of July and radiation started three or four months later. My prostate bed needed to heal before getting nuked. After reading about the SEs of Lupron (or ADT), I wanted no part of it but my radiation oncologist at MD Anderson refused to continue with me without the Lupron regimen. They are convinced of the benefit of ADT with SRT.

..... the decision whether to add ADT and for how long should be made on a host of factors: PSA, GS, stage, genomic risk, healing time, comorbidities, quality of life, and radiation dose.

 

Thanks, Allen! That's what I'm working on, while trying to avoid my own bias and wishful thinking!    Low PSA, GS 3+4, stage2, Decipher low .37, healing time OK, co-morbidities of LUTS & in-remission colitis, QoL very important, rad dosage 66Gy with a bit more on tumor for 33-35 fractions (as of today) and so it goes.....Gary

<<<Mayo also doesn't believe I should do Casodex along with the Lupron>>>

YAY!!!


<<<We will be doing a pelvic MRI on Monday as well and we'll see if that sheds any light on my condition>>>

Good luck; wishing you the best!

AZ Guy-

Great news that your PSA is stable for now.

I think that Casodex only has to be started before Lupron when there are known metastases, and there is danger that the testosterone flare at the start of Lupron might spur met growth and cause bone pain. Firmagon (rather than Lupron) gets around the problem because it doesn't cause a testosterone flare. There are no standard protocols - everyone does it differently.

Hi Forecaddie and welcome,

You are asking a difficult question with no clear answer, and lots of open questions, as you read in my blog on the subject.

I think your stage T3b, your tertiary 5, and ECE puts you at especially high risk that SRT may not be successful. I think you should consider improving your odds however you can. You can see the effect of adding ADT in the following nomogram:

/pcnrv.blogspot.com/2016/08/probability-of-remaining-recurrence.html

Forecaddie-

I think August 2016 was when I transferred my blogs that I'd written over the previous two years from the New Prostate Cancer Infolink. I still write for both. I hope you are able to use the search bar to find the info you want rather than wading through all of that.

There is no nomogram about ADT side effects, but here is a good article about it with lots of references at the end. Some of the side effects don't show up except with long-term use.

/pcri.org/preventing-and-treating-the-side-effects-of-testosterone-deprivation-therapy-in-men-with-prostate-cancer-a-guide-for-patients-and-physicians/

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