psa after RP and SRT

ADT. Your RO knows this...now...it will turn out that he was OT with SRT...but you can never now in cases like yours.
He will now have ADT with everyone's blessing...
And live a long life...that's my take. Fwiw FYI ...I believe SRT is the single biggest culprit of OT in the pca dynamic...PERIOD

I agree with Andrew - it's time to see an MO, and at least start a discussion about ADT. There is recent evidence of a survival advantage to starting ADT sooner rather than later. I'm sure that between Fox Chase, UOP, and Thomas Jefferson, there are some really good ones. Among the best in the US is Howard Scher at MSKCC.

- Allen

Thanks for all your input. TA, Are there any specific MO's you would recommend aside from Howard Scher? I'm not likely to persuade DH to go to NYC under any circumstances.

Sophie

We met with the RO. He said it's still possible the psa could stay at this level and even drop lower. But in any case he doesn't want to do adt until DHs psa has a doubling time of less than a year, which could be years away. He said psa test in 6 months and see where it is then. If this a reasonable approach?
This is so different than what i expected after reading here. I thought the RO would retest in a month and then sent to MO for adt if it goes up.
I'm wondering if I should talk DH into having another psa in a month and meeting with an MO anyway.
Is it worth trying to see snuffy myers? Or is he for more advanced cases?
I thank you for any replies.

I'm not convinced early ADT is always the way to go? Also, why does the above study only mention overall survival, not prostate cancer specific survival?

Of course, in my case, after I have the 68 Ga PSMA scan on July 25th and it finds the cancer has metastasized, ADT will be in my future, but most likely w/o RT.

Here are some UCSF MD's take on the Aussie study Allen cited above.

"There is no consensus as to whether it is better to treat immediately or to delay androgen-deprivation therapy in patients with a rising prostate-specific antigen (PSA) level (“biochemical relapse”) after curative therapy for prostate cancer. A phase III study, selected for the Best of ASCO® 2015, found that immediate androgen-deprivation therapy improved overall survival and time to clinical disease progression, but the results were not definitive.

This trial has several issues that make it difficult to walk away with a firm conclusion, according to Terence W. Friedlander, MD, of the University of California, San Francisco, who reviewed this trial and its implications at the Best of ASCO 2015.

Study Details

about 20% to 50% of patients will relapse following definitive therapy for prostate cancer. The Timing of Androgen-Deprivation Therapy in Prostate Cancer Patients With a Rising PSA (TOAD) study sought to address the optimal timing of androgen-deprivation therapy in this setting. Men were eligible for the trial if they had a PSA doubling time of less than 12 months following curative therapy or metastasis or symptoms.

Only one-third of the planned accrual occurred, with 293 patients enrolled from September 2004 to July 2012. Median follow-up was 5 years. Most patients had slowly progressing disease, and about two-thirds of each arm went on intermittent therapy.

Patients were randomized in a 1:1 ratio to receive immediate intervention with androgen-deprivation therapy (arm B) or delayed therapy (arm A). about one-third of patients in arm A initiated androgen-deprivation therapy within 2 years, whereas 49% started therapy later than 4 years on trial or had not yet begun therapy.

The mean age was about 70 years at trial initiation. about two-thirds of patients had curative radiation therapy, and about one-third underwent surgery plus radiation as curative therapy. The relapse-free interval was less than 10 months in about one-third of patients and 10 months or longer in two-thirds.

Survival Data and Toxicity

At 5 years, overall survival was about 10% higher if androgen-deprivation therapy was started immediately: 86% vs 76%, respectively; 6-year overall survival was 81% vs 65.4%, respectively (P = .05). Nonsignificant reductions were also observed in prostate cancer–specific deaths and deaths due to all causes.

Overall, 46 deaths were reported, including 30 deaths in the delayed-therapy arm and 16 deaths in the immediate-therapy arm. “There were only 18 prostate cancer deaths in this study—6 of these deaths were in the immediate [androgen-deprivation therapy] arm and 10 were in the delayed arm. It is difficult to interpret these data to know if this is a real difference,” Dr. Friedlander commented.

Progression-free survival (both distant and local) was improved with immediate therapy (P = .001) compared with delayed therapy. However, time to castration resistance did not differ between the two study arms.

A subgroup analysis suggested that intermittent androgen-deprivation therapy might be superior to continuous androgen-deprivation therapy. However, due to poor accrual, the study was underpowered to detect a difference in this and other secondary endpoints.

Adverse events related to androgen-deprivation therapy were more common in the immediate-therapy arm than in the delayed-therapy arm: 80% vs 50%.

‘Not Practice-Changing’

“This was a challenging trial to conduct, and accrual was disappointing. It appears that overall survival may be improved by immediate vs delayed initiation of androgen-deprivation therapy, but the benefits are likely to be modest and have to be balanced with the considerable side effects of hormonal treatment,” stated Dr. Friedlander.

“This study is not practice-changing. When faced with a patient with a rising PSA following curative therapy, the physician should discuss therapeutic options incorporating the risks of treatment,” he said. The way forward will depend on finding better ways to identify which patients need androgen-deprivation therapy upfront and which ones can safely delay it.
Disclosure: Dr. Friedlander reported no potential conflicts of interest."


"Interpreted With Caution
In an accompanying editorial, Michael S. Leapman, MD, and Peter R. Carroll, MD, both from the University of California, San Francisco, explain that this finding does not mean that immediate androgen deprivation should become standard treatment for all patients with biochemical recurrence.

Selecting optimal management for patients with prostate cancer who relapse after surgery or radiotherapy as assessed by PSA levels has been the subject of much debate, they point out, and the current study "provides clinicians and their patients with much improved estimates of the potential value of such therapy as well as its trade-offs (ie, reduced quality of life)."

In addition, not all research has identified a survival benefit from immediate treatment and patients are increasingly worried about adverse effects of therapy.

"I do think the results provide more granular information about benefits/risks," explained Dr Carroll. "However, I think the results need to be interpreted with some caution as the patient population may not represent well all those who present with a rising PSA after primary treatment.

"Some of these men may be at a low risk of metastatic relapse and not benefit form ADT, but be exposed to its side effects which are increasingly being recognized as significant," he told Medscape Medical News.

Another factor to consider is that new technology and therapy will refine the timing and type of treatment for this patient population. "I also think that technology is racing into this space to better assess risk, such as circulating cell-free DNA," Dr Carroll said."

Bobby Mac

I want to make clear that although this is practice-changing (I personally spoke to an oncologist who is changing his practice because of it), it was not an outcome I or anyone else wanted to see. I provided links to the two commentaries to show that there are some who might quibble with some of the findings, but we ignore a major randomized clinical trial only at our peril. Immediate treatment cut mortality by about half compared to delayed treatment - a stunning finding. It is the only randomized clinical trial on this subject, and it provides the highest level of evidence we now have. This doesn't mean that immediate hormone therapy is for everyone, but it does mean that everyone faced with the decision after curative options have been exhausted should be discussing this study with his oncologist. For some, the side effects or QOL may be overriding factors.

I should also make clear that the study gives no guidance as to which kind of hormone therapy is optimal. We know from other studies that intermittent hormone therapy is not inferior to continuous HT for most men. We also have no intermittent protocol that has proven better than any other so far.

- Allen