PSA down due to ADT or SRT?

You won't know until after the ADT and the SRT are both finished. Hopefully, your PSA will remain undetectable afterwards. 18 months of ADT (and 70 Gy) is the standard of care for GS9 - a good topic for discussion with your RO.

- Allen

Well, with combo therapy of SRT+ADT, it is the combination that "does the trick." It is thought that the neoadjuvant ADT sensitizes the cancer to the effects of radiation, and the adjuvant ADT - for at least 18 months (not 15 months) for high risk - cleans up stray micromets that may be circulating systemically. There are also immune-enhancing effects of the combination, and part of the demonstrated effectiveness of such therapy may be due in part to an abscopal effect.

There has been a demonstrated survival advantage in high risk men who had 18 months of adjuvant ADT vs shorter term ADT. It really is only of academic interest as to which part of the therapy does what; the important thing is that the combination works better than without the combination.

It is absolutely your call. For some men 18 months of ADT is a long season in hell, while it is tolerable for others. There may also be certain comorbidities that enter into the decision, and the risk of lasting ED. But you should be aware of the risks and potential involved in both sides of your decision.

- Allen

Bob-

There are two very different uses of ADT.

One doesn't worry about castrate-resistance setting in when ADT is used adjuvantly. You're not on it long enough for that to happen -- it usually takes many years.

The other use, which does not apply in your case, is when all curative therapies are exhausted, and ADT is used, continuously or intermittently, to keep the cancer from progressing. So far, I have not seen any evidence that starting it earlier in that setting results in shorter survival. The most recent study, a retrospective data analysis, showed that survival was not reduced by starting later, but it did not show significantly shorter survival by starting earlier. This is controversial, and it remains for a randomized clinical trial to provide proof.

There is no evidence that I'm aware of to support your conjecture that Lupron maintenance therapy might be less effective after it has been used adjuvantly with SRT.

- Allen

This is why there are RO's that do not like to mix HT with SRT. Of course, the HT alone will drive the PSA down to near zero in most cases ,at least at first. These RO's of this school of thought, prefer to see if the SRT was effective by itself. If not, then they would likely advise adding HT at that point. In your case, since you are doing both together, there's no clear way to know which is which as far as results.

David

I'm in the same boat, post opp psa was 0.60 entered a trial RT plus Zoladex for six months or two years, I lucked out I ended up with the two year, good thing I don't play the lotteries . PSA droped to 0.01 almost instantly and has stayed there except for a small dip lower or higher. I still have nine months left to go but have no idea if RT did anything. The SEs are the absolute hell but as long as psas stay where their at or go lower I have to stick with it.

Am on the Zolodex for 2 years and have had 11 out of 33 Radiation treatments (1/3rd of the way thru!!). When is it usual for PSA to be tested? I got the impression from my RO that we might not bother with a test before I finish the Zolodex, but I am kind of anxious to know if the treatments are actually working now.

Mmm.. it's a difficult one to call, and that's why my RT docs here in the Netherlands said that they do not do HT with SRT.
I asked before my SRT started and they said that if they used SRT on it's pwn and it worked then they would know that the recurrence had all been in the area targetted by the SRT, ie the prostate bed.
But if you add in HT they said that that will supress the PCa reagrdless of where it is without you ever knowing for certain where.

My RT docs (and uro) were thus pleased that my PSA was undetectable at the first test after my SRT.

Alf

I myself would like to know if the RT helped or not,but on the other hand studies have shown that adt combined with RT have indicated a better response with t3 disease. Although I ***** and complain and struggle with the SEs of ADT iam comfortable with my decision to participate in this trial. Then again I have always been a (if at first it doesn't work hit it with a bigger hammer ) type. Like fairwind mentioned it takes years for rt to show it final affect. With just RT alone the numbers are all over the place I couldn't handle it )

The studies show that for high risk at least 18 months of ADT are required. I had 36 months plus two forms of radiation.

At this point you can not determine which is doing the job....they both are. Radiation and ADT are complimentary in their cancer control, that is why they are used together. In my opinion your stopping ADT so quickly is just not giving it enough time to work. Dr. Myers, one of the most respected oncologists usually always uses least 9 months of ADT. For a G9 his information in his books indicates he would probably go longer.

The key is, do you want to knock this down now and get a long and durable remission? Or do you want to take a minimalist approach and look forward to the probability of always responding to a rising PSA? In my case, high risk, we opted to hit it hard up front and so far the strategy has worked.

ADT can be curative, but not likely on its own for G9. When used in conjunction with radiation, the killing and remission power is greater. G9 is tough and can be aggressive. The level of treatment should be commensurate with the risk level. As JohnT has often said, the problem is that low risk is often over treated and high risk is often undertreated.

What does your medical oncologist say? At this level of risk I would have a medical oncologist that specializes in high risk PCa make the determinations. I think it is past the uro and rad onc. With surgery over and IMRT underway it will now be the domain of the med onc.

Bob,

Based on my high risk situation, I consulted a med onc as part of my multiple opinion search before starting treatment. Now I check in with him annually. He is not directing my treatment, but I am getting value from his oversight. My attitude has been that if I need him to take over, I don't want to start from scratch with him. He is in the loop and part of the team and receives info from my rad-onc and uro with each visit. Thankfully my other docs have had no problem with this approach. What now adds a little complexity is that my uro's practice merged with another and there is a dedicated urological oncologist on their team. While I haven't consulted with him, I have heard good things about him.

Jack

Need to wait six months after all treatment stops. At that point the ADT will be "flushed" from your system. What your physicians will want to see, ideally, at that point is testosterone (T) levels returned to a "normal" range, and PSA "undetectable." If that combination continues over time, a reasonable conclusion will be that the SRT was effective. Best wishes.

Newspaper Lover
Age 70
11/09 DaVinci surgery upstate NY; nerve bundle taken; clean margins, clean seminal vessels, no incontinence, alas no erections.
06/11 PSA re-emerged.
Gleason 8
Time to recurrence 18 months
Three month doubling time (summer 2011).
PSA rose from .07 on 06/11 to .17 on 11/11.
09/11 hernia surgery to repair hernia resulting from the DaVinci.
10/11 Moved management of my case to Memorial Sloan-Kettering in New York City.
12/11 Started hormones (Lupron/Casodex).
02/12 Began radiation (SRT), including pelvic lymph. 40 sessions.
03/12 Last Lupron shot.
04/12 Finished SRT.
07/12 PSA and testosterone "undetectable."
01/13 PSA “undetectable”; testosterone (T) level at 452 ng/dl.
07/13 PSA “undetectable”; testosterone (T) level at 444 ng/dl.
01/14 PSA “undetectable”; testosterone (T) level at 435 ng/dl.
06/14 PSA “undetectable”; testosterone (T) level at 444 ng/dl.
Have received no treatment since spring of 2012.
Started “Paleo diet” in 2013. Only eat what I plausibly could have fished, hunted, or gathered 40,000 years ago (but not with current skill set). No processed food of any kind. No sugars. No starch. Feel physically strong and best in years on this diet.

I am with Tall Allen on the subject if which treatment did the trick, I just want the trick done. The idea is that the cancer is eradicated and stays gone. It is not like working out the best hangover cure so that you know whether is was the glass of milk, the bar of chocolate or hair of the dog fixed it so you can use just the one remedy next time around.

My RO explained the treatment as the hormone therapy will starve the cancer wherever it is in your body and make it weak and susceptible to the radiotherapy. We beam the radio therapy at the most likely place it is sitting (i.e. the prostate bed and lymph nodes) once the cancer is weakened. We then keep up the hormone therapy for the full 2 years in case the little blighters are elsewhere.

On the subject of the PSA testing (a question I posed earlier), he will test me 4 weeks after the SRT. The reasoning is that whilst the body is recovering from SRT the PSA can be unreliable. After 4 weeks, the body has settled and the PSA test can have some meaning. My understanding is the meaning will be - undetectable = so far so good, but wait until the hormones are flushed out your body (2 years time in my case) before you can be absolutely sure, detectable = we have a problem!

I hope to apply for provisional membership of the zero club in 5 weeks time!