Any thoughts on using Avodart after RP to prevent or delay recurrance?

After having a prostatectomy 3+ years ago, my PSA has been slowly rising, starting below .01 and last fall moving to the range of .04 - .06 where it has bounced around for the past six months. (unfortunately the lab changed machines twice during that period so I don’t really have a good baseline any more.)

I realize this is well below the official recurrence point of .2 but I like to think things through in advance and have a plan for what might happen. So I talked three of the highly-regarded docs whose names are often mentioned here. (Two are leading medical oncologists, one is a leading surgeon and urological oncologist.) All three docs said that if I’m having a recurrence, the chances of radiation being actually curative were somewhere between 25% and 35%. And all the docs agreed that if I do need radiation, it would be good to add a short course of hormone therapy along with it. Other than that, the docs disagree.

Doctor 1 said: “You probably have radiation in your future but let’s not pull the trigger yet. I want to wait and see how the PSA increases over the next two tests, two months apart. I don’t want to send you for radiation unless it’s clear you are at risk for a clinical event.” When I asked about the risk due to waiting he said. “We know there is a difference in the success rate of early vs. delayed salvage radiation but there’s no evidence that “super-early” is any better than “early”. At this point there’s no evidence that waiting until it’s 0.1 or higher does any harm.”

Doctor 2 said: “You should call [Dr. so-and-so] now, and schedule radiation.” Asked if it was worth waiting another couple months to see how the PSA trend behaves, he said “I’m convinced you are in the early stages of a recurrence. You don’t benefit by waiting at this point. Your odds of success just go down the longer you wait.” Asked about Avodart or anything that might slow or arrest the rate of increase, he said “none of the hormone therapies or other treatments are curative. Why give up your chance of a curative treatment, even if the odds are low, for something that you know can’t ever be more than a delaying treatment?”

Doctor 3 said: “Let’s put you on Avodart. Avodart, with supplements, diet, and exercise has a good chance of stopping the rise of PSA and causing it to plateau in which case you won’t ever need radiation and have to suffer the side effects that go with it. And if the Avodart doesn’t work, you can always get radiation in a few months.”

At this point I am inclined to go with the Avodart approach but I am a little hesitant because it is not the “standard of care” in any of the official guidelines. Clearly neither Dr. 1 (who is the lead in urological oncology at a major cancer center) nor doctor 2 (a urological oncologist in private practice) favor that strategy. So I’m wondering if there is any downside to the Avodart approach – given that if it doesn’t work I can always go back and get the radiation treatment.

Any thoughts, questions, or suggestions? Thanks in advance.

My gut feel?

I pulled the adjuvant trigger before my first post-op PSA. Interesting that my insurance would pay for adjuvant RT at < 0.1, but not salvage RT until >0.2 three times.

Toss a coin. Based on my uro's policy of "no ultra-sensitive", I would have still been fat & happy with your Post-op & PSA numbers.

And yes, HT is not considered a curative approach, but RT is.

And no, I'm not much help cutting the fog in the Twilight Zone.

right you are on that 142. rt/srt is the gift that keeps on giving. I am coming on 4 years out from srt, and the damage to me is permament, and I am still keeping my eyes open for what else may develop from it. still a bit afraid at some point, that my unbroken record of zero ED will someday change due to the srt, been told it can sneak up on you years later.

despite what happened to me, I am absolutely not anti rt/srt, just want to make sure for someone else, that's it truly needed. it is the last curative card a failed surgery guy can play, and for some, it does do the trick

david

I think Complier used Avodart only for awhile before HT.

Hello Proscapt,
There is a recent randomized trial reporting a benefit is cases like yours by using Avodart. See:
www.ncbi.nlm.nih.gov/pubmed/23176897

5AR inhibitors are a minor form of androgen deprivation by reducing the conversion of testosterone to DHT. In the case of this trial the reduction of risk was 66.1%. There are side effects but they are minor and avoiding salvage treatment for a time seems to be a good option.

Wish you the best outcome,

RalphV

Regarding the (very interesting) study that Ralph posted, keep in mind that this did not show any improvement in overall survival or prostate cancer specific survival -- as it was not designed for these purposes.  

z06Dude - my stats are below in sig line. I had been scrupulous in getting all the data from the same lab on the same machine, but then one doc sent me to a different lab, and then when I went back to the first lab they had switched to a different machine for the testing. So the last two measures are on two different assays and hence are not comparable. Hopefully it is plateaued but the next test will be a direct apples-to-apples comp and I will know more. The last six readings are basically at one-two month intervals from October 2012 through April of 2013. I am watching it more closely now but if it levels off here I will go back to quarterly or every six months.

I checked the MSKCC nomogram and it said basically I had a 90% chance of no recurrence so I'm hoping that things stop moving right here. But as the saying goes... hope for peace, prepare for war.

A few for-what-they-are-worth observations:

The plans proposed by doctors 1) and 3) are quite similar. They differ mostly in the Avodart. Doctor one says to test PSA frequently and delay SRT until such time as the PSA tells you. Doctor three says to take Avodart, test PSA frequently and delay SRT until such time, if any, as the PSA tells you.

It is not immediately clear how relevant Ralph's study is to your situation. To be included in the study the men had already have confirmed BCR after radical treatment. It doesn't speak to whether the drug would delay or prevent BCR and if it says what sort of radical treatment was represented (how many men had RP and how many RT) I must have read by it. Still it does seem encouraging. Avodart seems to slow down progression and occasionally prevent it.

Might be worth a shot. You might ask Dr 3) what sort of PSA behavior he would be looking for to pull the trigger on SRT with the Avodart. Seems like it would be different than without it.

Proscap, I am on an off period of HT and I am following Dr Myers program to maintain a remission as long as possible (delay the recurrence of PSA). Your Dr #3's approach sounds very much like Myers program for delaying PSA recurrence. Avodart, diet and supplements.

I concur with what some of the others have said and would not jump into RT vat this point. Your PSA is rising very slowly and is still at a very low level. It could possibly take several more years just to .2. Also, I am very surprised that your Drs said that SRT only had a 25-30% chance for a cure. With your stats I would have thought it would be much higher.

Peter - thanks for suggestion re clarifying the criteria for moving to SRT after Avodart: what would constitute treatment failure in that case. Haven't seen any research or commentary at all on that. I think the default assumption would be same, i.e. a threshold of .1 or .2 with a confirming higher value after that. But it's just a guess.

I have been on Avodart in the form of Jalyn from the beginning. It reduces the DHT, which is actually more powerfull feesing cancer than testosterone. My uro and med onc both agreed to put me on and keep me on for the long haul. Myers takes a similar approach. Since I am also on Eligard/Lupron, I am unaware of side effects from Avodart. When I come off them I may be able to tell. For me it has not grown any hair.

BB --- I am also on the Avodart off season as prescribed by Myers...He also put me on some "other" things if you want to email me we can compare notes.

 

In the recent past we did a thread on the use of 5-AR inhibitors in the treatment of PCa. For years there has been confusion about these chemicals. For years it has been known that the inhibition of DHT results in androgen dependent prostate cells death. In other words, this treatment is a form of selective androgen deprivation in which testosterone is preserved (and even increased) while preventing the formation of the most powerful androgen (DHT).

Some medical oncologists recommend its use to slow down progression of recurrent PCa. Since validation of this recommendation by clinical trials is not available, current use of these chemicals remain low and confusing for many patients. See the past thread at:
www.healingwell.com/community/default.aspx?f=35&m=2391225

RalphV