Treatment Decisions For G9

Welcome caratop-

That sounds like a great plan! With T4 and N1, whole pelvic radiation sounds like an excellent plan. I trust that distant metastases have been ruled out and it may still be possible to approach this with curative options. With your RO, you should discuss a few things:

1. Multimodal radiation with IMRT to the whole pelvis and a brachytherapy boost to the prostate and the areas that it has spread to. Because this may involve areas outside the prostate capsule that low dose rate brachytherapy (seeds) may not reach to, I would think he would be better off with high dose rate brachytherapy (temporary implants) instead. You should consult with an expert in this kind of therapy like Dr Jeff Demanes at UCLA, if you are in Southern California. If you're in Northern Ca (your profile doesn't specify), Joe Hsu at UCSF would be a great choice.

/pcnrv.blogspot.com/2016/08/hdr-brachy-boost-and-monotherapy-for.html

2. Recent evidence has shown the importance of expanding the radiation field more than was previously thought. Again, if you are at UCLA or UCSF, they know this:

/pcnrv.blogspot.com/2017/02/pelvic-lymph-node-treatment-area-is.html

3. Chemo has not been shown to add a great deal when used after radiation in high risk men, and does have a high toxicity cost, but if you want every last bit of insurance, it is not unreasonable. With known positive LNs and local spread (T4) (sometimes called "locally advanced") he is in a riskier position than the men in the studies described below, so it might have even more benefit.

/pcnrv.blogspot.com/2016/08/docetaxel-with-primary-radiation.html

4. Other adjuvant therapies. If you have an MO who has clout with insurance companies, he may be able to consider Zytiga or Xtandi as an adjuvant therapy as well. It would be given along with Lupron and get every little last bit of androgen out of his system. They are currently not FDA-approved for patients who are not metastatic or castration-resistant, but I've seen some patients get approval anyway. Maybe worth talking about.

If you read those articles, you will see that it is not unusual for men to have lasting freedom from recurrence after such treatment, in some trials, over 90%. Most of those trials did not include men with N1, but some early database analyses and a secondary analysis of the STAMPEDE trial suggest that radical treatment can still improve survival:

/pcnrv.blogspot.com/2016/08/adt-and-radiation-for-first-line.html
/pcnrv.blogspot.com/2016/08/adt-and-radiation-for-first-line_29.html

As for toxicity... all of these therapies have a toxicity cost. On the upside, being only 49, his side effects and recovery are usually a lot better than for older guys. Also, used at the beginning like this, the SEs are less debilitating than when men wait for a long time when cancer has worn down numerous body systems. On the downside, it will not be a cakewalk, and the next two years will be something he will be happy to leave behind in the rear-view mirror.

I know I overloaded you and your head must be spinning with the shock and all this new information to absorb. Please feel free to ask questions, and let us know as the process develops.

Thanks Tall Allen and Fairwind for the input. Much appreciated. No mets at this point, only one lymph node involved. But the tumor was at the top of the prostate, at the bladder neck, which I understand complicates it a bit further.

We are in So Cal and have Kaiser, so we are treating there. I had read some recent info on Zytiga and have it on my list of questions for our oncology meeting this Wednesday (MO, RO and UO panel). Since my husband is otherwise very healthy, young and zero family history, he is considered a bit of a complex case. We are also consulting with the geneticist at Kaiser Wednesday.

All in all I am pleased so far with the approach from Kaiser. They are being aggressive and have been very receptive to our questions and suggestions. I am especially pleased that genetics is being pulled in right away as I have been reading a lot of info on recent advancements in this area as well.

I will post an update after our meetings on Wednesday. Thanks again for the great input and encouraging words. We are ready to fight!

For many of us, this is an open enrollment period. If all goes well on Wednesday, and Kaiser offers all the options you want, that would be great. But if there are options you want that Kaiser doesn't offer, there are many great specialists in Southern California. Are they running genomic profiles on biopsies from the prostate and LN (somatic) or are they looking at germline anomalies?

I agree that the LN biopsy is probably unnecessary (and hard to do). And I agree that it won't change the treatment plan - he will require whole pelvic radiation in any case just because his risk of cancer in the pelvic nodes is very high, even if that enlarged node had not been found.

ATM is a very rare germline mutation, and he would probably have had other clues by now if he had it (e.g., sunburn toxicity, spider veins in his eyes, family history, etc.).

In the RTOG 0521 study that showed Taxotere was of some benefit with RT, they started the Taxotere 4 weeks after the radiation, not before. The increase in 6-year disease-free survival went from 55%-> 65%.

The French GETUG-12 study used Taxotere+Estramustine three months before beginning RT. They found that 8-year relapse-free survival went from 50%->62%

So they seem to be about the same improvement either way.

See the last 8 slides that are the ones relevant to your husband's situation:
oncologypro.esmo.org/content/download/70499/1257344/file/2015-Prostate-Pr

Geneticist will do a "full panel" on what? Biopsy tumors to look at somatic mutations, or blood to look for germline mutations? What does a "full panel" include?

"High Risk" is defined (by NCCN) as any of the following:

(1) Gleason score 8-10 OR
(2) Stage T3/4 OR
(3) PSA > 20

(or any 2 of those, or all 3)

It isn't necessary to have a PSA over 20 to be high risk. In fact, it is well known that high risk men may have very low PSAs. They should probably use a plural term like "prostate cancers" to describe the many variants that show their ugly faces.

Thanks Fairwind. There were no cores as my husband did not have a needle biopsy. He had a surgical biopsy and they sampled two pieces of the tumor, both of which came back 5+4.

Surgery is not an option for my husband as the tumor is at the bladder neck, and they would not be able to preserve the bladder neck if they remove the tumor completely. Prostatectomy in his case would also require complete removal of the bladder, which has issues of it's own.

We are forging ahead and feel comfortable with the treatment plan as laid out by the docs. Taxotere begins this Friday.

Thanks again for all of the helpful insight!