Early versus late hormone therapy for new G9

First, thanks to all of you for the input and time you dedicate to this Forum. It is an incredible source.

My question pertains to early versus late HT. My husband is a G9 who was diagnosed in March 2015. His PSA at diagnosis was 11.4. Based on scans, he is likely SV+ and has two enlarged prostate area nodes. He is about to finish six sessions of the new "early chemo" protocol, with his last session being in two weeks. Then he will have RALP with node removal. His PSA has gone down to 9.5 on the chemo with no HT. Scans show some shrinkage of the nodes and no other progression since on the chemo. His bone scan is clean.

Based on his stats, we know he will likely do radiation and we will also face the decision about HT in the coming months or year. My husband would like to avoid HT as long as possible.

The book "Surviving Prostate Cancer" by Patrick Walsh says, "Whether a man is treated with HT immediately, as soon as the diagnosis of advanced disease is made, or the doctor waits until the man has signs of progression and then begins treatment — and study after study proves — survival is exactly the same." He then goes on to say there is no reason to take away a man's quality of life sooner then necessary -- wait until clinical progression or rapid PSA doubling time. Our oncologist generally believes this as well.

So if this is the case, why do we read about so many men on this forum and others that make the HT move very quickly when diagnosed with advanced disease — even when they are asymptomatic?

Post Edited (peanut307) : 9/2/2015 10:33:37 AM (GMT-6)

Others here at HW are much more knowledgable than I about this topic. I can tell you that from my own experience that medical oncologists disagree on when and under what circumstances HT should be used, as well as how long. I have read Walsh's book as well. And my local MO agreed with yours on delaying the start of HT. I did get other opinions from two other MOs that lead me to take 12 months of HT with SRT.

Peanut,

Welcome to the forum. Sorry you find yourself here but glad you found us.

Since your primary question was about the timing of androgen deprivation I will respond to that first. As the Tall One said, Walsh was talking about a different situation. It sounds like your husband's doctors are trying for a cure, not simply to manage the disease long term. When ADT is combined with other treatments to make them more effective -- more likely to bring about a cure, or at least a long-lasting remission -- then the rules are different. What Walsh was talking about was giving a man with incurable cancer a few more months, or maybe a year, of normal function before starting hormone therapy that will last the rest of his life. But when the hormones are part of a combination treatment where they increase his chances of a cure it turns into a pay-me-now or pay-me-later proposition. Putting up with a few extra months of hormone side effects now may be a good trade for the chance of years of normal life after his treatment is over. Provided one is convinced that the hormones do improve his chances to an important extent.

It's hard to overtreat Gleason 9 disease. If it were me I'd start the HT sooner rather than later. But I wouldn't be happy about it.

I did a bit of Googling and found a paper that talks about early adjuvant treatments before RP surgery.

Rationale for and Review of Neoadjuvant Therapy Prior to Radical Prostatectomy for Patients with High-Risk Prostate Cancer

It talks about a number of approaches and it is a confusing read but my takeaway is that several of the combination therapies appear to be promising but that it is early days yet, and the studies that are out there are mostly a but underpowered because of the small number of participants.

This might be a good time to talk to some radiation oncologists. You already know he will probably need radiation after the surgery and it wouldn't hurt to talk to someone about the possibility of radiation instead of the surgery. It's always a good thing to have more than one option. If you tell us where you live (nearest big city is enough) then we might be able to recommend someone.

I was reacting to what you said that you are doing surgery with the idea of doing salvage radiation, and that the cancer has already spread outside of the prostate. Even with an extended pelvic lymph node dissection (ePLND), with risk of lymphoceles and lymphedema, the "cure" rates are lower than with combo radiation therapy. Here's a recent analysis of this issue:

Is Radical Prostatectomy Appropriate for Very-High-Risk Prostate Cancer Patients? No.

One could argue that surgery plus salvage radiation might have equivalent outcomes, but then why would one not just give potentially curative radiation to begin with and avoid the higher complication rate?

"De-bulking" is a procedure to delay, but not stop, progression when a cure is not a possibility. It can be done with either surgery or radiation. But I don't think that's what you mean - it sounds like you are looking for curative therapy.

He is obviously not a candidate for brachy monotherapy, but he may be a candidate for the kind of combo radiation therapy that has the best outcomes. The brachy part may be either low dose rate (seeds), or high dose rate (temporary implants), and they are combined with external beam radiation that gets to areas that the implants can't reach. You have to talk to a specialist in this kind of therapy. I'm not familiar with the Mayo (MN?) team, and don't know if they offer this.

If you are comfortable that you have talked to all the right specialists, and that this is the right decision for you, I wish you all the luck with this novel approach. I just wanted to make sure you had.

- Allen

It could be because many radiation oncologists perform brachytherapy and some simply don't recommend procedures they don't practice, particularly when they see a different path (surgery + HT + *maybe* RT in your case) to a cure.

FWIW, I'm always reluctant to offer differing opinions once someone seems sets in their treatment options. It is an extremely personal choice after all. But if you are open for food-for-thought, as a G9 that was considered 50-50 that the cancer had left the mother ship, I opted for brachytherapy (high dose or HDR), coupled with external beam radiation (IMRT) and HT. I did this for the very reason that TA mentions: I didn't want to face the SEs of having both surgery and radiation and I didn't want to take the 50-50 chance that I would need salvage radiation. Now that was just me and I'm one data point, but I'm doing very well in the early innings with no SEs.

Most important, I wish you and your husband well no matter what option you select. All the best to you!

Thanks Allen, we are in Iowa.

I was high-risk G7 and two urologist-surgeons and a med onc said no to surgery. They knew I would also have to be radiated and saw no reason to subject me to the risk and side effects of both surgery and radiation. They said only operate when you know it will cure.

I opted for early HT (three years of complete androgen blockade), HDR Brachytherapy, and IMRT to the pelvic area. I am now five years out from dx and am PSA undetectable and side effect free. For HDR info please see www.cetmc.com the website of Dr. Jeffrey Demanes, the father of HDR brachytherapy. He is also the department head at UCLA Medical Center.

Why haven't some rad oncs suggested brachytherapy, you ask. Simple, they probably don't practice it.

Find a few specialists and you may get a different recommendation. Also make sure your med onc does a lot of advanced high risk prostate cancer work and can demonstrate to you that he/she has successfully treated men far more advanced.

As to Walsh's book. Well, it is a bit dated and written by a surgeon with a strong surgical bias. He really specialized with low risk men, thus his very high stated success rate. When I mentioned Walsh to the surgeons I met with five years ago, they said he would not take me on because he would know surgery alone would not solve the problem.

Peanut, Welcome, and sorry you need to be here.

I don't know whether my husband made the right decision about his treatment. I wish he'd gotten another opinion because the SE's of surgery have so deeply impacted the quality of our lives. He has very similar stats to yours as you can see in my signature below. I'm telling you this so that you will understand the importance of being sure that you know all your options before making your decision. I have deep regret . We may have ended up deciding surgery was best anyway, but we didn't explore other options.

His oncology team all recommended surgery knowing that he had ECE, and thinking he likely had lymph node invasion. They told him up front that both erectile nerves would be removed. My husband refused to get another opinion, or see any other doctor. He had the surgery. After 3 months he reluctantly started using the pump, purely for rehab, and i finally talked him into trying the trimix injections. The injections haven't been very successful, and now he most likely has peyronies, so no more injections and he refuses to go to another doctor. I don't blame him after everything he's been through. Our sex life sucks, and he would rather be dead than consider an implant. He is going to see his urologist so I haven't completely given up hope.

He also has lymphedema from having lymph nodes removed during surgery, which caused an infection in his knee and foot so he was in too much pain to walk for most the summer. That cleared up and he is doing physical therapy to rehab his foot and knee

Fortunately he regained continence around the time his salvage radiation began.

His first psa test after radiation will be mid october.

Sophie

peanut,
I agree with Allen in that if the cancer has appeared to be out of the prostate then surgery would be a poor choice of options.
Re starting early HT:
The premiss put forth by oncologists Drs Strum and Scholz is that HT works only on androgen dependent cancer cells. It does not work on androgen independent cells. Over time one in every one million cells that are androgen dependent will morph into independent cells. If you can kill these cells off while they are androgen dependent they will never turn into cells that can't be killed. Also there is no drug used in any oncological approach to any type of cancer that works better at late stages than in early stages.
I had the same procedure that JNF had except I had low dose Brachy and was on HT for only one year. Short term side effects were the same as his and were completely gone after stopping HT. I lost about 15 pounds because I was working out heavily during this time, which helped with the radiation induced fatigue and HT side effects. Never had ED or incontinence, just loss of libido and normal bowel issues for about two months during radiation.

Peanut,

Surgery and radiation, for me, resulted in a few weeks of incontinence and that was it. I was back to normal in a few months.

Hormone therapy takes your sex drive to nothing. But I was able to go 3 years with no hormone therapy and a normal testosterone...

How did you do on the chemo? Hair loss?

Jerry

Peanut
Just another 9 here welcoming you to the site.
As the guys above mentioned, treating early and often seems to be successful for many of us. It can be a tough road but the benefits are waiting in the other side.
Best,

Thank you all again for a great discussion. It has influenced us greatly and we have made an appointment with a 2nd RO, who is highly regarded. The first one, believe it or not, was prosurgery first. Still not sure the direction we will go.

Additionally, many of you seemed surprised to learn about our "chemo first" protocol. Our MO recommended it based on the Chartered study that took ASCO by storm last year. While there is no guarantee it will work, many say this could become the standard for newly diagnosed advanced cases. We had nothing to lose by trying it. My husband has handled it well with very manageable side effects (some hair loss, low white blood count countered with Neulasta, taste issues, fatigue 1st week of cycles, etc.).

Peanut
I sincerely hope that the treatment you've chosen works. You could be helping to set a new treatment standard!
Best
Bob