IMRT Gleason 3+4, Is HT needed

I thought I would ask.

I have 3 more consultations. My biopsy had 6 of 12 cores pos, 4 were Gleason 3+3 35% and 20%, the other 2 were 3+4 with 35% involvement and 10% was Gl4. My PSA is 8.1 and staged T2A.

anyhow one of my options is VMAT IMRT. Before anyone says go SBRT, I am looking into that and have a consultation lined up to discuss that.

I also have one for surgery and HDR Brachy scheduled.

what is everyones thoughts on adding HT to IMRT for someone with GL3+4? The RO whom I met didn't think it would add much to the outcome and would come with side effects. His feeling was that I had two cores with only 10% GL4 and when looking at the big picture didn't put me at high risk, like a GL 4+3.

I am especially interested if anyone on here did their IMRT as a Gl 3+4 without the ADT?

Would appreciate any feedback.

Post Edited (Turboz) : 11/6/2017 8:24:11 AM (GMT-7)

Thanks

If I go IMRT, will be doing the 79.2 Gy 44 Fr.

How bad is the HT part, guess you can get hot flashes and fatigued.

I am just not sure. the two cores with Gl4 were about 35% involved and 90% was Gl 3 and 10% Gl4.



Hopefully some other folks will respond.

I am just trying to lay out the options. I can deal with the 44 sessions, the centers are local and I think they use good equipment, Varian True Beam with the Rapid Arc and Cone Beam Ct to check for prostate, bladder, rectum locations prior to each treatment.

RO indicated he had only a single grade 3 Gu toxicity in case load last 3 years, so I figure maybe 1%. The physicist who does the plans has over 20 years experience and work at MSK in the past.

I just had my bone scan (negative) having CT scan today. My oncologist Mark Ritter at Carbone decided not to go with hormone. So it depends on your physician and you. My Gleason is the same as yours 3+4.

3+4 is sometimes called, "intermediate favorable risk" Not always treated as aggressively as 4+3, but often more aggressively than 3+3.

That thought is in the back of my mind, hence my research. I will be talking to two more RO's and will ask there opinion.

However I would love to see some data either way to make a better informed decision should I go that route.

Specifically any RT tests comparing 80 Gy with and without HT, even with intermediate risk stratified 3+4 or 4+3.


I did find a set of data which was interesting. Compared clinical biopsy to post RP pathology. it was on over 500 patients.

For the intermediate Gleason 3+4 from clinical biopsy. after RP pathology, 33% were classified as GL 3+3, 38% stayed Gl 3+4, 20% to Gl 4+3, 9% GL4+4 or greater. So yes you run a 30% risk your cancer is worse.

I'm with TA on the Hypo-fractionation or SBRT versus IMRT. The data shows similar (or better) efficacy with less bother.

I also cannot imagine anyone "volunteering" for HT unless there can be a real medical benefit shown to having it. The side effects and potential after effects are just too burdensome to many. (Note that I did not have HT, but I am hypogonadal, so experienced all of the same side effects prior to my TRT.) That (the side effects of HT) is just a place that I, for one, would not go voluntarily unless it was necessary for disease control. From what I remember from my treatment research, for favorable intermediate risk patients (G3+4=7), there was no significant improvement in outcome for having HT. TA's link should clarify that.

I admit that sometimes I do proceed on the "it may help" plan, but my personal experience with very low t is not a place I would voluntarily revisit.

Even with my GS4+3 and moderate % of the positive cores I only had 1 RO out of 3 that suggested HT in combo with the IMRT she wanted to do. I definitely felt she was just going for the long term, many visits, high $ return. The 2nd RO wanted to do the same IMRT but said there was no reason to do the HT even with the enlarged prostate I have. That RO was from a highly regarded teaching institution. The 3rd RO is Dr. Meier at swedish in Seattle where I will be going and he definitively stated that HT is "seldom" ( his word ) beneficial except in the highest of risk cases which a 4+3 is not.

I am glad that you are lining up all of the "TRADITIONS". Wise move.

May all beings be well

Roger

I did the 6 month lupron and 81 gys...45 days....went very quickly after the first week....and had no problems to speak of.....hot flashes yes....a little weight gain -OK cause I`m skinny....the after effects of the lupron for me were sore nipple area ....it`s been 1 year since the end of the 6 month shot was over and my sore moobs are just now getting back to normal. I`m glad I got the Lupron shot ....dropped my PSA from 10 to .4 in a matter of a couple of months and prepared me for the rads ...I guess...who knows for sure ??....on PSA check #3 ...results on the 13th.....good luck ....Lupron not THAT bad , but it`s all crap

I was diagnosed with Gleason 3 + 3 in 2011. I had brachytherapy only. Five years later, I had recurrence in a mass attached to the prostate. This time I had HT and cyberknife. Now I realize that I probably had higher grade cancer close to the capsule. Brachytherapy did not kill it. If I had HT with my brachytherapy, I would not probably be hit by recurrence.

So I would recommend HT in addition to radiation for your more advanced cancer.

I had the same gl as you and I've gone 5 years with intermittent ADT. No sex drive but not an issue for me (wife died). PSA now is 1.2, had gotten up to 16.8 while taking care of my wife. I get 6 mo. Trelstar and se's are not bad and I plan on doing this until I become castrate resistant, so for me HT has worked but if I live long enough I will have to have RALP, can't do the radiation(long story) but personally I have found Tall Allen to be most informed. He had SBRT 7 years ago and is cancer free and like he said RO's are out to get rich. RO's do less and make more than most Dr so keep that in mind when getting advice. IMRT makes them a ton of money but better options like SBRT are making IMRT obsolete and 1 out of 3 RALP's require more surgery so there it is from both sides, hope it helps and good luck.

Philmire said...
I had the same gl as you and I've gone 5 years with intermittent ADT. No sex drive but not an issue for me (wife died). PSA now is 1.2, had gotten up to 16.8 while taking care of my wife. I get 6 mo. Trelstar and se's are not bad and I plan on doing this until I become castrate resistant, so for me HT has worked but if I live long enough I will have to have RALP, can't do the radiation(long story) but personally I have found Tall Allen to be most informed. He had SBRT 7 years ago and is cancer free and like he said RO's are out to get rich. RO's do less and make more than most Dr so keep that in mind when getting advice. IMRT makes them a ton of money but better options like SBRT are making IMRT obsolete and 1 out of 3 RALP's require more surgery so there it is from both sides, hope it helps and good luck.

If I understand you correctly, you opted to not do any RALP or radiation as primary therapy but instead are on intermittent ADT for 5 years?

and per RALP, are you saying 1/3 of RALPs need surgery to correct complications from the RALP?

Hi Turboz, yes you are correct but I didn't opt out radiation, because of a rare DNA problem I almost died from only 2 treatments so it's not an option (lucky me) and caring for my wife till her death was a priority for 2 years so I didn't go to my UO in that period and PSA went up to 16.8 and I was starting to have a small problem urinating but as soon as I got back on the HT I was fine. My UO told me after my last DX that where my tumors are the nerves on the left side can't be spared when they take it out so I'm putting it off and yes, stats say 1 out of 3 have to have more surgery. I'll soon be 70 and with my wife gone I don't have a lot going on in my favor so if I make a bad decision it will only hurt me, all my family are gone. I'm not recommending IADT for anyone but for me it works, at least for now I only told you my story so you could see that HT is not a bad thing for everyone. Talk to Tall Allen, you'll learn a lot in his articles. Good luck my friend

Turboz, our numbers are about the same. My PSA is .13. My oncologist said that he is not going to recommend HT just the radiation. Shucks, I will be on radiation during Thanksgiving, perhaps Xmas and New Years, but it is what it is.