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Posted 10/16/2016 6:07 AM (GMT 0)
Hello all, I dont post often but follow the forum post closely.
Below is my history:
Age 62, good health, active runner.
June 2015: PSA 8
June 2015: Course of antibiotics, second PSA 10
July 2015: Biopsy, Gleason3+3
August 2015: Third PSA 9
Following consultations re treatment options RALP was completed September 30, 2015
Pathology revealed, Gleason 4+4 with a tertiary Gleason pattern 5,tumor both lobes, established extraprostatic extention present left and right base, SVI bilateral,Resection margins negative for tumor, no lymph node concern, bladder neck margin is negative for tumor. Stage: T3b NX.
December 2015: 10 weeks post surgery uPSA 0.05. Due to G8 and SVI involvement HT and radiation recommended.
December 15, 2015: started 3 month injection,Zoladex
Feb 2016 - April 2016: 5400cGy to prostate bed+nodes
800cGy to prostate bed bst
March 15, 2016: second Zoladex injection
June 15, 2016: third Zoladex injection
June uPSA <0.01
September 15, 2016: Fourth Zoladex injection
September uPSA <0.01

Question: A December 2016 uPSA is planned but treatment team is considering no HT injection in December and then a uPSA in March.
The <0.01 is telling me the HT is working assuming cancer cells remain and by stopping the HT, i guess is the only way to determine if surgery+radiation and one year of HT did the job.
My question is wondering if one year of HT is adequate? Are there studies that address one year v.s two years with my pathology? My RO has always been a shorter term HT guy rather than long term.
Physically I feel great, handling the HT just fine (yes,hot flashes and some fatigue but I push through it with being active runner, no weigth gain) and handled radiation well.
Interested in comments. Have much respect for forum.
Posted 10/16/2016 12:13 PM (GMT 0)
Greetings.

My RO told me that the 'new standard' is 3 years of ADT chemo. That is what I got. A year and 6 months after that ended my testosterone screamed up to 184.6 ng/dL and my PSA went up from <0.02ng/dL to = 0.03ng/dL. All I had was some smelly little G4's left over...looks like they haven't quit though. shocked August blood test showed that 0.03 so I am off the 6 month blood tests and back to 3 months. Next one is in 2 - 3 days..."to check the velocity".

My sig tells the story well enough - I got the whole 9 yards right off the bat.

I am an advanced Taekwondo practitioner, run 50 miles a week, lift weights and am in robust health...other than a touch of prostate cancer. sad After 3 years of the chemo I gained almost 15 pounds, though 5 have dropped back off. Some of the weight gain is due to the fact that the chemo shuts down your pituitary gland. One of the hormones it produces tells your kidneys how much water to leave in your blood stream. Without that hormone you experience water weight gain in addition to the 'loose muscle, gain fat' aspect of loosing your pituitary function. Additionally, your metabolic rate slows down so you burn fewer calories just staying alive than you did.

So t he crux of the dog biscuit is your testosterone recovery. If your T goes up and you get a concurrent rise in your PSA then you go back to the chemo. You have G4's and G5's to contend with. Those scare me pretty badly, for cause. Just my take though. Your mileage may differ. wink
Posted 10/16/2016 12:42 PM (GMT 0)
Good question on how long to stay on hormonal therapy. I do not know if there is a one size fits all answer. Since I am high risk I am scheduled to be on Lupron for two years no matter what my PSA level. My team stated that two years is the accepted time for high risk cancer if the PSA stays low. (In my case PSA may not be the best way to follow the cancer. I have a form of cancer (Ductal) that does not always rase your PSA. I will be getting scans.)

Low risk men may be on it for only half a year.

My team are discussing the possibility of a "vacation", where they stop treatment and only restart once a certain PSA level is reached. This would be done to lengthen the time before the cancer becomes hormon resistant, and, of course, reduce the side effects. As I am handling the side effects well, and I have a rare form of cancer, I probably will stay on it for two years. Chances are I will not have a vacation. For men that have issues with the side effects of hormonal therapy a vacation may be an option.

Here are a couple of review articles:
https://www.cancer.gov/types/prostate/prostate-hormone-therapy-fact-sheet
http://www.cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-treating-hormone-therapy#

Good luck!
Posted 10/16/2016 1:11 PM (GMT 0)
Even if you have no problems with side effects from ADT I would not do it longer than absolutely necessary.

Dr. WHO said...
This would be done to lengthen the time before the cancer becomes hormon resistant

Yes, if you continue ADT you may become resistant. So I would do a vacation as your RO suggests.

Here I discussed the usual duration of ADT till resistance: www.healingwell.com/community/default.aspx?f=35&m=3718372&g=3723974#m3723974

George
Posted 10/16/2016 2:01 PM (GMT 0)

George_ said...
Even if you have no problems with side effects from ADT I would not do it longer than absolutely necessary.

Dr. WHO said...
This would be done to lengthen the time before the cancer becomes hormon resistant

Yes, if you continue ADT you may become resistant. So I would do a vacation as your RO suggests.

Here I discussed the usual duration of ADT till resistance: www.healingwell.com/community/default.aspx?f=35&m=3718372&g=3723974#m3723974

George


Evets - Please note that George_ and Tall Allen had a lengthy exchange on that thread. It's long and a bit contentious, but read as much of it as you can to get a sense of both sides of that one. It's not simple, and it's not "settled science". I have been following it with some interest, since eventually I may need to find my own way through that decision thicket.
Posted 10/16/2016 4:47 PM (GMT 0)
Hormone Therapy, ADT, is not curative..If it ever CURED anyone of prostate cancer I am not aware of it...SRT on the other hand CAN be curative...When HT and RT are combined, the curative power of RT is increased by 50%...You have been on HT for about a year..which MAY be enough..The argument of how long HT is needed for maximum effect is still under discussion...Originally, it was 3 years..Then it was discovered that 2 years worked almost as good..Now, some feel that one year is enough...It's still an open argument.......But considering the heavy side-effect load and major quality of life issues associated with HT, RO's and Oncologists must use their experience and judgment to arrive at a duration that provides the most benefit while preserving quality of life...
Posted 10/16/2016 6:24 PM (GMT 0)
Fairwind,

when combining RT and HT the duration of adjuvant (post radiation) ADT can depend on the risk the patient is staged with. Sometimes physicians recommend six months at low risk, i.e. Gleason 6. Two or three years are done if it is a high risk patient. So I think one year can be ok in this case.

George
Posted 10/16/2016 7:41 PM (GMT 0)
How long ADT works depends on the ratio of hormone-sensitive cells to hormone-insensitive cells in the cancer and how fast the cancer grows.

Dr. Walsh's book states as follows:

"There is a mathematical model, called tumor kinetics, of how these cancer cells grow. A tumor must double in size thirty times before a doctor can even feel it, before there’s a centimeter of cancer. This growth is exponential— two cells, then four, then eight, and so on. Say a tumor is at its tenth doubling; it has 1,024 cells. And say that three-fourths of these cells are responsive to hormones. The patient is castrated, and all the hormone-responsive cells drop out of the picture, leaving only 256 cells. What happens? These cells aren’t affected by the hormones; they continue to grow. The now smaller tumor starts to double. There are 512 cells. It doubles again— 1,024 cells. It’s back to where it started. And when it doubles again, there will be twice as many cells as before."

While on ADT and based on the above, I assume the higher the Gleason score the faster the hormone insensitive cells grow. Not sure how you would get a read on the ratio of hormone sensitive cells to hormone resistant cells before starting ADT?

In any case, rest assured those devil hormone resistant cells are hard at work while on or off ADT.

So, I wonder how intermittent ADT works better than straight ADT without stop if these resistant cells are always multiplying? I mean, when ADT is temporarily stopped the cells that are hormone sensitive but now working because they're off ADT are spinning off more castrate resistant cells along with the resistant cells that are also multiplying.

Wow, very perplexing.

Allen's comment in another thread about why starting ADT early is better as there are fewer castrate resistant cells makes a lot of sense after reading the above.


Bobby Mac
Posted 10/17/2016 1:50 PM (GMT 0)

Evets said...
Hello all, I dont post often but follow the forum post closely.
Below is my history:
Age 62, good health, active runner.
June 2015: PSA 8
June 2015: Course of antibiotics, second PSA 10
July 2015: Biopsy, Gleason3+3
August 2015: Third PSA 9
Following consultations re treatment options RALP was completed September 30, 2015
Pathology revealed, Gleason 4+4 with a tertiary Gleason pattern 5,tumor both lobes, established extraprostatic extention present left and right base, SVI bilateral,Resection margins negative for tumor, no lymph node concern, bladder neck margin is negative for tumor. Stage: T3b NX.
December 2015: 10 weeks post surgery uPSA 0.05. Due to G8 and SVI involvement HT and radiation recommended.
December 15, 2015: started 3 month injection,Zoladex
Feb 2016 - April 2016: 5400cGy to prostate bed+nodes
800cGy to prostate bed bst
March 15, 2016: second Zoladex injection
June 15, 2016: third Zoladex injection
June uPSA <0.01
September 15, 2016: Fourth Zoladex injection
September uPSA <0.01

Question: A December 2016 uPSA is planned but treatment team is considering no HT injection in December and then a uPSA in March.
The <0.01 is telling me the HT is working assuming cancer cells remain and by stopping the HT, i guess is the only way to determine if surgery+radiation and one year of HT did the job.
My question is wondering if one year of HT is adequate? Are there studies that address one year v.s two years with my pathology? My RO has always been a shorter term HT guy rather than long term.
Physically I feel great, handling the HT just fine (yes,hot flashes and some fatigue but I push through it with being active runner, no weigth gain) and handled radiation well.
Interested in comments. Have much respect for forum.

I'm probably one of the few who opted to go for less than the "suggested" time frame and as my Brachy URO strongly suggested, you need to stay on HT as long as you're in the process of killing the cancer cells.
Posted 10/17/2016 7:07 PM (GMT 0)
I don't think any of that discussion applies here, and will only confuse the OP.

Evets is asking a completely different question: How much adjuvant ADT do I need with my salvage radiotherapy?

We are waiting for the randomized clinical trial that will answer that question. What we do know now is that 6 months is definitely better than none, and 12 months is probably even better, and that 2 years of Casodex was better than none. Another study found that every extra month of adjuvant ADT was a associated with a 10% reduction of biochemical recurrence. You can read about this here:

Combining Androgen Deprivation Therapy (ADT) and Salvage Radiation Therapy (SRT) improves outcomes

Also take a look at a recent nomogram that shows the probability that SRT will be successful:

Probability of remaining recurrence-free after salvage radiation

What I want to call your attention to is the risk factor associated with radiation dose. There was a recent nomogram that allows you to figure out your odds of remaining recurrence free after SRT. From what you've posted, here's how I would calculate your points and probability:

any ADT - 0 pts
Gleason score - 80 pts (tertiary 5 risk is between an GS8 and a GS9)
EPE (no) - 0 pts
negative margins - 37 pts
SVI (yes) - 24 pts
pre-RT PSA (0.05) - 2.5 pts
Radiation dose (<66 Gy) - 17 pts
Total pts= 160.5 - which corresponds to about a 55% chance it will be successful.

Now your prostate bed radiation dose was only 62 Gy (54 Gy + 8 Gy). This is a very low radiation dose for modern salvage therapy. Your RO may have had some reason for doing this. The reason I raise this issue is that to some extent adjuvant hormone therapy can probably make up for a deficiency in salvage radiation dose. Because of this, I think you should consider staying on hormone therapy for at least 2 years. You can't stop and restart.
Posted 10/18/2016 4:38 AM (GMT 0)
My RO prescribed 13 months. Why? He dislikes ADTs effect on the body but acknowledges the synergistic benefits. So 13 is better than 12 and 12 or more has been found to be effective. Go figure!
Bob
Posted 10/18/2016 4:58 AM (GMT 0)
Thank you Tall Allen for the studies to review. You mentioned that ADT could not be stopped and restarted. Could you elaborate?
Posted 10/18/2016 6:12 AM (GMT 0)
Think of it like stopping and starting antibiotics - that's what causes resistant strains to develop and take over. You have to finish the full course of adjuvant ADT just like you have to finish the full course of an antibiotic.

Intermittent ADT is a completely different thing and has no relevance to your situation. It is a way for men on life-long ADT to get a vacation sometimes.
Posted 10/18/2016 11:58 AM (GMT 0)

Allen said...
What we do know now is that 6 months is definitely better than none, and 12 months is probably even better, and that 2 years of Casodex was better than none. Another study found that every extra month of adjuvant ADT was a associated with a 10% reduction of biochemical recurrence.

The RO I was originally going to go with recommended 3 years the RO who I picked for SRT at Cleveland Clinic Florida said 3 months, if I heard him correctly. Anyway, it will be my choice.

I think at one time 3 years was considered optimal then reduced to 2 when they found just as good as three.

Start SRT 10/25/16 for seven weeks --

Bobby Mac
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