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Lupron for 3-6 months before treatment?

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Posted 8/31/2016 6:38 PM (GMT 0)
Thank you again to everyone here for being so helpful and kind. Once again, I'm a 50 year old, recently diagnosed G 9 with confirmed cancer in one pelvic lymph node. I'm in the process of finding an RO for either brachy/EBRT or SBRT based upon the recommendations of many here including specific ROs to contact.

In the meantime, I've now had two local opinions. One from the Cleveland Clinic (CC) , one from University Hospitals Siedman Cancer Center - Cleveland. Both of these teams are suggesting that I consider surgery as an initial treatment. The RO on the team at CC even indicated this (maybe they were overruled by the other team members?) although they said they would do RT if I wanted but external only, no brachy boost. I went to the Siedman Cancer Center yesterday and met with an oncologist with training/working experience at Yale and the Mayo Clinic to get a second opinion and he recommended surgery as well. The catch in both of these cases is that the recommendation for surgery is that it be after a time of 3-6 months on Luprun to "make sure that the cancer responds ADT and doesn't spread further".

I got the Luprun shot and am fine in that the 3-6 months gives me further time to explore the RT options, and it seems that Lupron before RT is typical. However, when I look at signatures of other G 9s here, I see many seem to have started a local treatment within a month or two of diagnosis. The thought of "waiting too long" is driving me a bit crazy. While from Tall Allen's posts I know that waiting time is okay even for G 9s, I'm wondering why there seems to be a disparity on waiting times to local treatment with some guys getting it so much faster. Is the waiting 3-6 months more common than I am noting here?

One other note. The CC never had me do the CT and Bone scan but never mentioned an MRI. The Dr. I saw yesterday for a second opinion says that a MRI is needed ASAP to assess where my cancer is in relation to the prostate capsule before ADT might shrink it away. I can't figure out why the MRI wasn't asked for by the CC?

Thanks in advance for helping me to reduce some of the anxiety I am feeling over this.
Posted 8/31/2016 7:30 PM (GMT 0)
Schoolpsych- The anxiety is real and is tough to manage. As I am still relatively new to this I still have it but it is getting better. I was Dx June 3rd and just started EBRT yesterday. I was told by my 2 RO's that they wanted the HT to have taken it's full effect. I'm just short of 3 months since my first shot. As for surgery or EBRT/BRACHY I made my decision based on the fact that I didn't want to go through surgery and then likely end up with RT down the road being that I'm G9. I also chose the triple play HT+EBRT+Brachy but because of my urinary issues pre treatment the plan was changed to HT+EBRT/IMRT only . 8 weeks of radiation +24 months ADT. I really wanted to have the triple play but decided that the risk of further urinary problems post BRACHY was more than I was willing to risk.

I'm sure you will hear from both sides of the issue surgery vs RT and that is a tough decision. I recommend that you listen to the guys with much more knowledge than I have.


That is kind of my story. Knowledge is power so keep doing your due diligence . -Mark
Posted 8/31/2016 7:50 PM (GMT 0)
I can think of a few reasons:
(1) anxiety
(2) doctors rushing patients
(3) spouses and friends putting pressure on patients based on what they know about other cancers
(4) limited options due to health insurance plans or family obligations
(5) ignorance of other options and what the data show
(6) patients not taking the time to do their due diligence, which may be related to any of the above

Many patients never get further than the first urologist they meet. They are scared, and have all kinds of baggage, some relevant, some irrelevant. When someone with knowledge, experience and in authority is basically saying, "This is what you must do or you will die," many of us take heed and do as dictated.

In 2010-2013, a registry showed that surgery was chosen by over half of newly diagnosed PC patients, regardless of risk group, but radiation was chosen by less than 20%. I believe this is occurring because most patients never get past the first urologist they meet with.

Anxiety and sadness are very natural reaction to stressful circumstances and bad news. For most of us, those feelings diminish in intensity over time. Those emotions evolved to protect us from immediate danger: the tiger is at the gate -- better run or shoot it now! However, those same emotions may interfere with decisions that require a lot of thought and deliberation. As the adrenaline levels go down, we think better. It is always a good idea to wait as long as we can to make decisions requiring careful thinking. (BTW- there is a wonderful book about this that I highly recommend: Thinking, Fast and Slow by Daniel Kahneman) One can also learn how to deal with ruminative thoughts and emotions in a different way through the practice of Mindfulness.
Posted 8/31/2016 9:15 PM (GMT 0)
Thank you Allen and Mark. For the record, I am looking toward radiation in my case. For what ever reason, my local medical entities aren't being helpful in that respect so I am working on setting up appointments with at least a couple of the ROs recommended by Allen in my initial thread. I'd like to get an opinion on whether I am a candidate for the brachy/EBRT and if not, SBRT. I am waiting to hear back from my local RO at the Cleveland Clinic who won't do the brachy/EBRT but I have contacted him to ask about getting SBRT through him as it would certainly be nice to have it local. Still I'll travel if I must.

On the MRI bit, after talking with the second opinion oncologist yesterday, I'm really thinking that I should go ahead and get the MRI he suggested as his suggestion that it would give a benchmark prior to the effect of the ADT seems logical. Still, I worry if I do it now, insurance might balk later as it seems that one is needed just before RT.
Posted 8/31/2016 9:53 PM (GMT 0)
I would check with your ins,but I got two MRI's before treatment. The second one was for my rehearsal for IMRT.

Allen.. Great list..nailed it!
Posted 8/31/2016 10:18 PM (GMT 0)
Here is my story. I hope it is of help. I was 58 when they did a biopsy showing that it was Ductal (rare) with a Gleason of 8 (4+4). They did a bone and CT scan which showed that it moved into at least one pelvic lymph node. They never offered to do a MRI. They found it in Febuary of 2016 and operated in April. I was told that it would be better not to have hormonal treatment before the surgery as it could "hide" some of the cancer. Even though it had spread to at least one pelvic lymph node, I elected for surgery because the Ductal version I have does not respond that well to radiation or hormonal. about two months after the surgery they ran another CT and bone scan. Again, no suggestion on getting a MRI. The same day that I had the scans they finally started hormonal treatment. This was followed by S. Radiation two month later. I finally got an MRI that they used to determine where to "zap" me. They follow it by PSA. That is where I am now. I am in the middle of radiation treatments while on hormonal therapy.

Many people here with a lot more knowledge than I have may disagree with my desision to get surgery with a G8 that had spread to a lymph node. However, I believe it was the right call for me - expically since it is Ductal. It may not be the right choice for you. Please take the lull time you have to do your own research and to get a second opinion.

Good luck! We are all pulling for you!
Posted 8/31/2016 11:23 PM (GMT 0)
schoolpsych-

One reason I chose surgery was that I had, and still do have, a voiding problem. The radiation would make it a lot worse during treatment.

However, had I known I had positive lymph nodes I most likely would have wanted radiation.

Is there a particular reason they are suggesting surgery?

Good Luck!

Bobby Mac
Posted 9/1/2016 4:34 PM (GMT 0)
In 2013 I was part of an NIH (Bethesda, MD) study using MRI for targeted biopsy of PC. Surgery was scheduled, but when they found the cancer had spread to the lymph nodes, I met with all the doctors involved, and all the doctors agreed, even the surgeon, that in cases where the PC had spread, surgery was no better than radiation. So, the surgery was called off. I started Casodex then Zoladex, and two months later IMRT began.

My doctor told me the Androgen Deprivation Therapy (ADT) weakens the cancer cells, making it easier to kill them with radiation. And I believe the MRI allows more precise positioning of the IMRT radiation.

Starting ADT quickly is more important than when radiation begins (1 - 3 month waits are typical).
Posted 9/2/2016 3:55 PM (GMT 0)
Here's a Clinical Trial using MRI that's open & recruiting:

Evaluation of Local Response of Prostate Cancer to Irradiation Using Multiparametric MRI and MR-Guided Biopsies

NCI PROTOCOL ID: NCI-13-C-0119
INVESTIGATOR: Deborah E. Citrin, M.D.
REFERRAL CONTACTS
Deborah Citrin (link sends e-mail) 301.496.5457
Theresa Cooley Zgela (link sends e-mail) 301.451.8905

https://ccr.cancer.gov/Radiation-Oncology-Branch/deborah-e-citrin?qt-staff_profile_tabs=0#qt-staff_profile_tabs
Posted 9/2/2016 4:22 PM (GMT 0)
Thanks for that link to the study ksargent. One of the exclusions of eligibility seems to be those that have already started ADT. In my case, I started ADT two weeks ago.
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