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Should I Be Considering Chemo?

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Posted 7/14/2018 6:35 PM (GMT 0)
Greetings.

This question has been plaguing me now for a couple of weeks, and I'm not geting any real clear answers from the medical professionals, so I thought I'd try to get some responses here.

My signature area (below) provides most of the Dx and other personal information needed. However, to help summarize, I'm a high-risk (high PSA, high Gleason) patient, with no clear sign of mets anywhere (MRI, CT, bone and PET scans all negative for mets), but I've been denied surgery based largely upon the perceived likelihood for cancerous activity outside of the prostate gland itself, and my RO has indicated that he'll probably also treat areas outside the prostate (i.e., lymph nodes, right seminal vesicle, etc.) with LDR-BBT and beam therapy (IMRT).

After hearing that, my wife and I both thought to ourselves . . . "well, even without firm evidence of spread in the form of diagnostic imaging, if in-fact it has spread outside of the gland, or if there's even a slight chance that it has spread, wouldn't I/shouldn't I, be a candidate for chemo, in addition to radiation?

We asked my MO that very question a week or so later, and we were told that he wouldn't necessarily "recommend it", but that he would agree to research it further, and seriously consider it, if I felt that strongly about it. Problem is, I don't have any more information on the subject than he does, so I really can't (and don't) feel all "that strongly" about it. Basically, I'm just unsure??

Anyone have any firm information or views on this subject?
Posted 7/14/2018 6:51 PM (GMT 0)
Even though you're high risk, the LDR with IMRT is possibly curative. The question of mets is still open and you may or may not have that. The radiation with your HT is a good combination. I'd doubt that adding chemo now is going to be helpful.

The path you're on now is agressive treatment, and I'd be inclined not to do more right now.

Andrew
Posted 7/14/2018 6:56 PM (GMT 0)
The data don't support it. In one study, the 4-year overall survival was 93% with it, 89% without it. The difference is not meaningful enough to support the added toxicity. In another recent study, SPCG-13, found no difference in biochemical failure rates after 5 years. This was for EBRT. With BBT, the cure rates are higher, so the added docetaxel is even more unnecessary.

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

Another point to consider is that CHAARTED only showed a benefit to early chemo (without radiation) in men with multiple detected mets, but not in men with low volume of detected mets.

You will be getting systemic cancer cell killing with ADT, if you will be getting that.
Posted 7/14/2018 7:28 PM (GMT 0)
InTheShop:

Thanks for the feedback, and yeah, I think you're right - the BBT+IMRT+ADT is a relatively aggressive approach. My guess is that they (the RO and MO) just want to wait and see what positive results those three regimens alone will yield before moving into anything else. Thanks again.

TA:

Tall Allen said...
You will be getting systemic cancer cell killing with ADT, if you will be getting that.


Yes, as indicated, my RO plans on ADT through the end of the year (180-days total), or for about 30-days post-IMRT. I had read that most others get ADT for far longer, and to be truthful, I had some initial concerns in that regard, but he seems extremely confident that those with Dx's like mine, who are doing the triple-play, but getting 12, 18 or even 36 months of total ADT exposure, do not experience significantly better results than just 180-days. I guess time alone will tell, but thanks again for your continued contributions here.
Posted 7/14/2018 9:19 PM (GMT 0)
Balladeer,
My situation that put me into the chemo treatments (just completed) was as follows:

1) I had my first PSA test in several years in May 2017. It was 18.6
2) My new general physician had me do an MRI and said I shouldn't get a biopsy. MRI showed tumor, 99% likely it was cancer.
3) Did a RGCC blood test to see if there were any circulating tumor cells. There weren't. Assumption was the cancer was just in prostate.
July 2017, PSA=35
Sept 2017 PSA-58
4) Started Casodex in September.
5) Went to discuss proton therapy / radiation. Dr. said given my PSA doubling time and high amounts, he said I needed to do a scan--one that was a C-11 Acetate scan which would show even the smallest mets if I had any. I had mets in lymph and bone.


I'm not a Dr -- far from it -- but given your PSA scores, you might want to consider an advanced scan to see if there's anything outside prostate before treatment like chemo. The scan I got is unfortunately not covered by insurance. $3,000 at Phoenix Molecular Imaging. I've done 2 so far-- a before chemo and after chemo. The most recent scan last week showed over 90% of PC has been gone after Casodex/Lupron/Taxotere. 12 mets are now 1 plus two tiny spots. Just a suggestion--but it gave me a much greater degree of confidence over what a normal PET scan might show... Best of luck. We are all pulling for you.
Posted 7/14/2018 9:41 PM (GMT 0)

steve55777 said...
Balladeer,
My situation that put me into the chemo treatments (just completed) was as follows:

1) I had my first PSA test in several years in May 2017. It was 18.6
2) My new general physician had me do an MRI and said I shouldn't get a biopsy. MRI showed tumor, 99% likely it was cancer.
3) Did a RGCC blood test to see if there were any circulating tumor cells. There weren't. Assumption was the cancer was just in prostate.
July 2017, PSA=35
Sept 2017 PSA-58
4) Started Casodex in September.
5) Went to discuss proton therapy / radiation. Dr. said given my PSA doubling time and high amounts, he said I needed to do a scan--one that was a C-11 Acetate scan which would show even the smallest mets if I had any. I had mets in lymph and bone.

I'm not a Dr -- far from it -- but given your PSA scores, you might want to consider an advanced scan to see if there's anything outside prostate before treatment like chemo. The scan I got is unfortunately not covered by insurance. $3,000 at Phoenix Molecular Imaging. I've done 2 so far-- a before chemo and after chemo. The most recent scan last week showed over 90% of PC has been gone after Casodex/Lupron/Taxotere. 12 mets are now 1 plus two tiny spots. Just a suggestion--but it gave me a much greater degree of confidence over what a normal PET scan might show... Best of luck. We are all pulling for you.


Thanks very much Steve. I appreciate your post and your warm sentiments. I've been very-very torn on the need for an advanced imaging scan of some form for quite a while now. I'm aware of the fact that insurance won't cover it, and I'm certainly willing to absorb the cost myself, if I thought it had a chance of being truly "definitive", but I'm just not getting that feeling from others. It sounds like it has served your own purposes very well indeed, but the key question in my case is this . . . if positive, would such scan results change the proposed treatment plan for me? Several RO's and MO's are telling me "No", it wouldn't.

My RO had actually suggested an Axumin PET scan at one point, but he alerted me that it wouldn't be covered by insurance, and like most other PET scans, that lt could easily yield another frustrating "false negative" result. Perhaps most importantly, he said that regardless of outcome, his proposed 'triple-play' regimen of BBT+IMRT+ADT would remain the suggested approach, even if the advanced PET scan(s) revealed minor distant mets. He indicated that he would simply expand the radiation treatment areas (both BBT seeds and IMRT), to include pelvic lymph nodes, and one or both seminal vesicles, etc.

Given that backdrop, I just couldn't bring myself to justify getting on an airplane and spending $3-4k for an Axumin, C11-Acetate or any other advanced PET scan, and all I can do is hope that that decision doesn't come back to bite me oneday. wink
Posted 7/14/2018 9:46 PM (GMT 0)
You can't have a scan of any kind because you've already begun hormone therapy.
Posted 7/14/2018 9:50 PM (GMT 0)

Tall Allen said...
You can't have a scan of any kind because you've already begun hormone therapy.

Yup, tru-dat! Forgot all about that choice little detail! Not that I'm inclined to change my mind on it anyway, but that certainly would have been a deal-breaker.
Posted 7/14/2018 10:04 PM (GMT 0)
Balladeer, it sounds like you're on a solid, research supported path. It may be that you'll never need chemo, and I'd suggest focusing on that. Reality is that you're going to be looking in the mirror at this for the rest of your life--and taking it a day at a time is an excellent way to go if you can manage it. Celebrate today and the life you have. Don't worry too much about where you'll be in a year.
Posted 7/14/2018 10:22 PM (GMT 0)

halbert said...
Balladeer, it sounds like you're on a solid, research supported path. It may be that you'll never need chemo, and I'd suggest focusing on that. Reality is that you're going to be looking in the mirror at this for the rest of your life--and taking it a day at a time is an excellent way to go if you can manage it. Celebrate today and the life you have. Don't worry too much about where you'll be in a year.


Thanks Halbert. Yeah, I think that's wise advice, and although it may not seem like it from my various postings, I'm awfully close to that most difficult, yet necessary, state of resignation. Whenever I feel myself struggling against the current, I try to focus on the legions of unfortunate and totally innocent children, fighting cancers of various kinds around the world. Its then that gratitude and humility both set in for me. Life is a rodeo, and I plan on riding it right up until the bell, but at the ripe old age of 66, I'll not once feel victimized, slighted or misfortuned by any such bump in life's road. Not ever! Been blessed beyond words.
Posted 7/14/2018 10:37 PM (GMT 0)
Tall Allen,
Why can't you do a scan after you've begun hormone therapy? I certainly did, on the advice of Dr. Rossi in San Diego. My first scan was after 6 weeks of Casodex. The results (which showed bone and lymph mets) got me started on Lupron, even though Casodex had lowered a climbing PSA from 58 to 21.6 at scan time. Not sure what you mean...
Posted 7/14/2018 10:57 PM (GMT 0)
Because the purpose of ADT is to shrink mets. Moreover, it will make no difference to Balladeer's therapy and is a waste of time and money at this point.
Posted 7/14/2018 11:05 PM (GMT 0)
Balladeer-

If you want to do everything (including unproven) therapies for your treatment, one thing you might ask about is hyperthermia. I think that Duke has a hyperthermia center. It only requires one or a couple of treatments. I don't know if Medicare/insurance will cover it, and I don't know the cost - but it's worth asking about...

/pcnrv.blogspot.com/2018/01/hyperthermia-and-radiation.html
Posted 7/14/2018 11:13 PM (GMT 0)
Tall Allen,
Yes, understood, thanks. In my case I had conflicting opinions on whether or not PC was contained in the prostate, so I did the scan to confirm that I had mets--even though I had begun Casodex. Thanks.
Posted 7/14/2018 11:25 PM (GMT 0)
Steve55777,

I think the other point that TA may have been considering is the fact that the mechanism of action for some of the ADT meds can hinder proper absorption of some of the isotopic tracers typically used in PET scans. Apparently, it wouldn't completely invalidate the results, but could affect the overall sensitivity of the scan. Radiologists confirmed this for me with respect to Casodex, and one can certainly abstain from Casodex for a week or two beforehand to improve the reliability of the results, but at that point, risk/benefit becomes questionable in my mind, especially if it yielded yet another false negative.
Posted 7/14/2018 11:28 PM (GMT 0)

Tall Allen said...
Balladeer-

If you want to do everything (including unproven) therapies for your treatment, one thing you might ask about is hyperthermia. I think that Duke has a hyperthermia center. It only requires one or a couple of treatments. I don't know if Medicare/insurance will cover it, and I don't know the cost - but it's worth asking about...

/pcnrv.blogspot.com/2018/01/hyperthermia-and-radiation.html

Thank you! Not sure that I'm ready for any 'unproven therapies', but I can certainly investigate that.
Posted 7/15/2018 1:14 AM (GMT 0)
It occurs to me that there are one or two other key pieces to this puzzle that I should consider including at this point for added clarity.

First, when I was initially diagnosed, the preliminary urologist and oncologist quickly called for diagnostic imaging of various sorts in hopes of getting a better picture of things. One by one, a CT scan, a 2T-MRI, a 3T-MRI, a bone scan and an FDG PET scan were all performed with (more-or-less) negative results (i.e., no nearfield or distant mets were found). Then came the RO's recommendation for the triple-play (i.e., BBT+IMRT+ADT).

Shortly thereafter, I posed a question for the RO, asking him if his proposed treatment plan would change in any meaningful way if firm evidence of mets was ever discovered? Basically, his answer was "No, it wouldn't". He indicated that although many of the imaging techniques that were used were indeed prone to 'false negative' results, none of them had produced results of any widespread mets in my case, and he was confident that had there been any "significant" distant metastatic activity, they would have shown-up somewhere in all of those scans. He further opined that he did not believe an Axumin PET scan would offer us any further benefits.

Significantly, he also noted that the report for the one and only FDG PET scan cited two small, white-colored areas of concern on one lung, but the radiologist concluded that their characteristics were more consistent with "infectious processes" of some form, rather than potential metastatic activity. Rightly or wrongly, this observation was considered significant, because it was deemed to be proof that the FDG PET scan was sufficiently sensitive and fully capable of detecting significant metastatic activity, had there been any present. Note: Whether this would be true with the pelvis, bone and deeper tissues, I'm not so sure.

And lastly, the RO then concluded that particular consultation with me by stating that he would proceed under the clear assumption that localized metastatic activity was entirely likely in my case, and that he would be treating those extra-capsular areas (i.e., pelvic lymph nodes and seminal vesicles), with both BBT (Pd-103 seeds) and IMRT (beam) therapies. He is the one and only person in my year-long travel on this journey to use the word "cure". Specifically, he said to me . . . "rest assured that it is entirely possible to permanently cure this", and there was no mention of any need for near- or late-term chemo.

A bit lengthy perhaps, but I hope this information has added some clarity.
Posted 7/15/2018 2:12 AM (GMT 0)
Well, sir, he is giving his best judgment and opinion on your case, and he is presumably the real expert in this process. Why are you questioning him? Let's say that he gave you odds (most good ones won't) of 90% that this will cure you. Would that be good enough?

It's proven that the various scans will only reveal mets above a certain size. If they don't show any, then yes, it may be wrong...but not so wrong that you need to move immediately to chemo. If you develop distant mets, they can be zapped with pinpoint radiation, or excised, or treated with systemic chemo--but it's a HUGE if. It can't be proven that chemo would be overkill in your case...but it can't be proven the other way either.

Listen to the experts....and none of them are on this forum.
Posted 7/15/2018 3:54 PM (GMT 0)

halbert said...
. . .Why are you questioning him?


Um, who is "he" or "him" (the RO or the MO)? And where exactly did you see or feel that I was "questioning" him?

I'm not "questioning" or doubting anyone. The RO doesn't believe there's sufficient evidence of mets and he's not in a position to prescribe chemo anyway (that's the MO's job), and the MO said that he would consider it. So I'm not sure how you made the leap to my questioning anybody. I'm just trying to learn. But thanks.
Posted 7/16/2018 9:55 PM (GMT 0)
Great! All these months of back-and-forth discussion about 'false negative' imaging scans including speculation about whether distant micro-metastasis may (or may not) have occurred in my case, and what its ramifications would be for or against RP surgery and/or radiation treatments, etc. . . . then I suddenly learn just today (!), about the Circulating Tumor Cell (CTC) test. Say, what???

My RO's staff has been busy scheduling both pre- and post-OP visits for the LDR-BBT procedure in the next couple of months, and when I asked for some details about what lab tests (if any) they would be conducting at the pre-OP visit, they said " a CBC, CMP, PSA, Testosterone and CTC". Great, except, until now, I had never even heard of the latter (CTC) test, and I have to wonder why not? Given my T3b staging, and all of the uncertainty surrounding a suite of 'negative' diagnostic scans, I have to wonder why this test hasn't been discussed, offered or conducted previously?

Is the CTC test just another potentially pointless exercise in the quest for evidence of low-grade (micro) metastatic disease? Is it just "wishful thinking", or does the CTC test actually hold some degree of promise for those (like me), who are caught in the middle as 'indeterminate'?
Posted 7/16/2018 10:24 PM (GMT 0)
CTC is a weak biomarker of metastases. Values greater the 5 cells per 7.5ml of blood are correlated with metastases, but men without mets can have values greater than 5 and men with mets can have values less than 5. Men with high risk PC can have values greater then 5 as cells from the primary slough off, but that doesn't mean they are capable of forming metastases. Recent innovation in CTC analysis includes a genetic assay of the cells.
Posted 7/17/2018 1:35 AM (GMT 0)

Tall Allen said...
CTC is a weak biomarker of metastases. Values greater the 5 cells per 7.5ml of blood are correlated with metastases, but men without mets can have values greater than 5 and men with mets can have values less than 5. Men with high risk PC can have values greater then 5 as cells from the primary slough off, but that doesn't mean they are capable of forming metastases. Recent innovation in CTC analysis includes a genetic assay of the cells.


Thanks TA.

As feared, it sounds like it's nothing more than an additional source of continued uncertainty, and although it appears to be a rather routine measure for all of his 'new' PCa patients, it makes you wonder why the MO is even ordering it?
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