More Lupron continuing.....

Thanks for the response Pirate.........just wondering how long on 6-month Lupron "indefinitely" does it last as I heard at some point Lupron stops being effective as a blockade. I am like you with no real side effects......a little bit of night sweats right after the injection but it goes away in a few weeks or so. But Lupron has killed my sex drive, which is of course is a side effect too. It is good to know that 2 years is the norm.

Got a Q for you JNF.......was it your MD wanting you to take ADT for 3.5 years or was it you wanting it 3.5 years?
I am all for doing what is my best interest being a high-risk G9 to stay alive as long as possible. Do you attribute being on ADT for 3.5 years in addition to HDR & EBRT as being why your now 10 years later undetectable. BTW, congrats on being undetectable now. It gives the rest of us hope that we can make it 10 years. Do you have any additional advice that you believe got you 10 years further down the line. All ears.

At the time (2010) the best clinical study on ADT was the BOLLA and it showed for high risk that three years would be best. My urologist and radiation oncologist both suggested the three years and medical oncologist said at least two years. I was in agreement with the aggressive treatment including the three years on ADT. Also at that time doctors like Snuffy Myers were using intermittent with 6-12 months on then a vacation for as long as PSA remained stable. A few years ago another study from University of Michigan
Found that 18-24 months would be effective or intermediate risk, but that 24-36 months should still be used for the high and very high risk situations. I ended up on just short of 3.5 years as we got a little out of synch on shot duration due to shortages of the 6 month doses.

So with both studies, 3 years is standard of care for a G9. Some docs might be nuanced based on the subsets of risk based on the initial assessment determining the extent of the disease. Remember that all G9 men are different and not one size. Some G9 may not even use ADT if it is a very small amount and with super clean surgical results or combination of EBRT and brachytherapy.

The main reason that ADT is used for many months and years is that the prostate cells are very long lived often in the range of 2 years. Most of our cells live much shorter. Thus, to effectively treat the cancers cells by withholding the testosterone you have to keep the cell weak and inactive until apoptosis (programmed death). If not, then the cell will become active and divide and spread. The disease management is all about preventing the cancer cell activity.

In my case, I had a high estimated tumor lode, a lot of cancer close to the capsule, easily felt nodule, suspicious lymph nodes on the CT scan and very unfavorable nomogram findings. All pointed to capsular escape and possible local spread. Plus, my urologist said I should consider myself a G8 because G4 was found in two thirds of the core samples. He also said that in such cases in his experience that the actual situation was usually worse than the biopsy indicated. Thus, no surgery as it was almost certain I would also need radiation. So we used EBRT including the pelvic nodes, HDR-BT and long term ADT. What do I think worked? All of it and a lot of luck that my disease wasn’t systemic. Now 10 years later with what we know I would probably do the three years of ADT based on the studies and the evidence for high risk disease. Though I imagine a lot of docs would suggest 24 months.

Now, I continue to watch PSA and follow some lifestyle changes with diet and activity to stay as healthy as possible particularly bolstering the immune system. I feel like I am in a clearing, but not completely out of the woods. Studies indicate significant recurrences in the 10-15% range even after 15 years.

Hi Wayne. Certainly something to discuss with your doc. My experience has been that as long as you aren’t looking for something really exceeding the Standards of Care that your doc will probably go with it.

To learn more I suggest you look for the study of a couple of years ago from the University of Michigan. The lead investigator was Maha Hussein. You can probably Google and look for it on PubMed or Find her at UMich and there will probably be a link to her work. Also go to the Urologic Society website and look for the decision tree that shows the standards of care based on diagnosis. Also the Oncology Society and Radiation Society websites will provide some excellent resources showing standards of care. That way you will have scientific grounds for the request to extend 6-12 months, or you might conclude that on your case 24 months is sufficient. The guy on the board that is best finding this stuff is Djin Tonic. He can also help and may have already posted some of these items.

My rad oncologist originally proposed 24 months of ADT after 'triple-play' therapy (see my history). But once the radiation was concluded, he recommended 18 months (and I did not object).
His change of heart was based on the following Phase 3 trial:
https://meetinglibrary.asco.org/record/153341/abstract

Please note that this rad oncologist is an academic with well over 100 published papers in the field of prostate cancer.

Here is a summary of another relevant trial:
https://www.pcf.org/news/18-month-adt-optimal-for-locally-advanced-prostate-cancer/

JNF said...
Sr Sailor you were also G9 and used radiation and ADT, but for only 18 months. Were your pelvic nodes radiated? Your PSA has gone up to 1.3 if I am reading your signature correctly. Refresh us on the trend. Is it stable? How often are you being tested?

The protocol that was used was very close to the one described by Oermann et al. (2010)
https://pubmed.ncbi.nlm.nih.gov/20815416/ .
With respect to irradiation of the pelvic area, I was pretty naive about these things and never asked. I will see the rad oncologist again in Oct and raise that question.
With respect to the trend after treatment, I had my 'nadir' of 0.1 ng/ml shortly after discontinuing ADT (March 2015; at that point my T was rising and up to 59). My T continued to go up (hurrah) and six month later (Sep 2015) my PSA was 1.4. Six and 12 months later, PSA still at 1.4. From now on yearly tests. Around May 2018 a bounce (in retrospect) to 1.7 ng/ml. Fortunately, down to 1.4 in Sep 2018. Sep 2019 still 1.4; Sep 2020 1.3. In other words, pretty stable (for now).
Initially, PSA (and T) tests were run every 6 months, but after three years (and no bad news) the regimen was changed to once a year.

PS: Regarding irradiation of pelvic nodes, I re-read a (more recent) paper from the Georgetown group. They state that their policy does NOT include pelvic node irradiation for high-risk patients and they cite their reasoning.
https:// https://pubmed.ncbi.nlm.nih.gov/27200300/