Adjuvant therapy guidelines?

Men who undergo radical prostatectomy may encounter an opportunity to have adjuvant therapies added after the RP pathology comes back. I know many here have followed in my foot steps on this one. Similar to "combination" therapies, adjuvant therapies such as IMRT radiation or hormonal therapy provide an extra hit at the cancer before it strikes back. Study data is showing that adjuvant therapies in these high risk cases is leading to longer biochemical windows and longer periods of prostate cancer specific survival. Today some criteria was released on the InfoLink offering some guidelines for choosing adjuvant therapies...

prostatecancerinfolink.net/2011/08/09/immediate-adjuvant-therapy-for-men-with-positive-surgical-margins-after-rp/#comment-13731

In short, any post RP patient with any one of the following should be considered candidates:

> Positive lymph nodes
> Positive seminal vesicles
> A pre-surgical PSA level of > 20 ng/ml
> A pathologic Gleason score of > 7

In addition, the authors note the following:
> Many men with positive surgical margins and a Gleason score of 7 fall into the > 70 percent risk category.
> All men with positive surgical margins and one of the above criteria should be carefully considered as candidates for immediate adjuvant therapy.

One might ask why not just go with these therapies and that answer is where the controversy lies. For me I was aged 44 when surgery gave me two of the above criteria. It was a good decision for me using these guidelines. But this might not be as true for a 75 yo man. Clearly there are risks associated with aggressive therapies. I know that long term radiation data is scant and there is risk of bowel issues and secondary cancers that normally do not come with RP. For all the negative talk about RP, I at least was afforded additional therapies as an option and that weighed in my decisions. So far so good but time is the judge. None the less the above data should be helpful to those who like me have high risk factors...

Tony

Tony,

I have 3 of the 4 factors mentioned in the article (PSA was 54.9, SVI, G9). It was a no-brainer to add adjuvant therapy. However, for the me the gray area is how long to stay on HT. My oncologist recommends 3 years of HT based on the Level 1 recommendation for radiation when used as a primary treatment combined with HT for high risk cases. But, he also admits there is no trial data specifically addressing my situation. He recommends 3 years based on exptrapolation from that study, but states it is my decision. My uro says longer is better but thinks one year should be ok if Lupron is making me crazy. (It is not.) Since I get 4 month Lupron injections, I have decided to take it 4 months a time as far as decision making goes. If I am feeling ok, then I sign up for another 4 months. October will make 1 year for me on Lupron. I may ponder calling it quits at 2 years .. not sure and do not have to decide right now. I am interested in hearing from others that are T3b that had adjuvant radiation+HT and how long they decided to stay on HT.

HD,
You are in a gray area. Many doctors would still have you consider it. The only thing I would consider doing in your case is get a second pathology opinion on the prostate. If Epstein or Bostwick have a look at it and find G7 present then you would make a better case for adjuvant therapies.

SC,
I had just one but if you look at the second set of qualifiers because I had G7 I had more than one qualifier. Also my PSA wasn't greater than 20 but it was 19.8. It was still a no brainer for me to move forward being that I was just 44 at the time...

Tony

I wish that I had this information two years ago. I went into surgery with a biopsy gleason of 3+4. My pathology report indicated that the tumor was capsule contained but the gleason was upgraded to G8. I had done my homework and knew that with a G8 my chances of a BCR was 35% or better. I talked to my uro/surgeon about AHT and his reaction was "what are you crazy" you are very likely cured, lets wait to see what happens. I didn't let it drop. I went to a highly respected local medical oncologist, and got the acknowledgement that the possibility of BCR was indeed 35% or better, but AHT would do nothing to extend my life span. Although it may hold down PSA for a while. His recommendation was to wait and see. 12 months later I have rapidly risen PSA. This time I went to Dana Farber and had SRT with HT. These guys, BTW, were still recommending SRT without HT.

Tony,

I think the guidelines that you provided make a lot of sense. In my case, when at biopsy with a 4+3 and a PSA of over 16, I discussed adjuvant RT post surgery with my uro/surgeon. He tends to want to see evidence of BCR before pulling the trigger, and after my pathology came back with a downgrade to a 3+4, we both thought it was safe to wait. That downgrade should have been a good sign. And as you know, my surgery failed fast and the SRT failed fast. Not trying to second guess my or the doctors decision, but can't help wonder if an opportunity for a cure went out the window by now having adjuvant RT after my surgery. Guess I will never know that.

David

Hi Everyone

This is a real worry for me, given my  Path report (which was better than expected). I see my Uro in 4 weeks. I guess he will give me his opinion on whether AR is appropriate. I am half hoping he will say it isn't, but then again I have a nagging doubt that maybe I should opt for it in the pursuit of a "cure". 

One question for you guys: is my Uro the best person to be giving me advice on AR/SR, or should I seek a second opinion from an Oncologist. Or will my Uro refer me to one for the final decision?

Any opinion/advice appreciated.

Thanks guys.

Ozbob,

You have time to get second opinions, decide, etc. You would not want ART this soon anyway. You should heal and be continent before starting ART.

Thanks for the replies guys. I guess I'll just await the PSA test result and hear what my Uro has to say before I make a decision.

K2,

It would be nice to be able to read the actual study. I saw the abstract for the study on PubMed a month ago, but the study itself is not available for free. Unfortunately, the abstract does not shed any more light.

It is possible they mean their logic to apply to 4 + 3 = Gleason 7, rather than the 3 + 4 variety. Gleason 7, as we all know, is the Dr. Jekyll, Mr. Hyde version of the disease: without the breakdown, we can't tell which it is.

The same illogic applies to the D'Amico risk categories. More and more, researchers are finding that the "high risk" category used in so many studies has in fact masked the extreme differences between the types. Gleason 8-10 in fact turns out to be quite a different animal than PCa with a PSA > to 20. But this takes us off topic a bit...

I hope your treatments bring you great success.

Nellie

Yeah SC, the time thing (how long on HT) is under heavy debate..One year, two years, three...Studies are looking at it, but it takes a long time to get results..My R-doc wants two years, but is willing to negotiate downward if I just can't deal with it...

This also bothers me...By doing HT at this early stage, are we destroying the ability of HT to be effective at a later date should this treatment fail? Burning our bridges behind us so to speak?

Fairwind, you just said:

...By doing HT at this early stage, are we destroying the ability of HT to be effective at a later date should this treatment fail? Burning our bridges behind us so to speak?
--------------------------------------------------------------------------------

This was one of the points my new oncologist was making to me on my last visit. He elluded that this can happen, depending on the variant and nature of a person's specific PC. I am hoping to get more details and clarification on this when I meet later this month again, and will be happy to share what he tells me.

He did feel, that too many men pull not only the HT trigger soon, but even pull the SRT too far in advance.

David in SC

Tony,

The dr. and I haven't fully discussed the details in his thinking, that's why I said he "elluded" to it, and also, said "sometimes" it doesn't work. Wasn't presenting it as a fully developed answer or strategy. Hoping in my next visit, to fill in the blanks with more dialouge.

David

Hi tony,

This was a good study and maybe I worry too much considering my pathology as I wait for my first post op PSA test next week. I do not meet any of the criteria in the study, but I have seen  cases in here with similar stats as mine who had PC return and the need for rt and ht followup. The one thing in my Path that worries me, is the 60% tumor involvement which to me seems way high but my URO said it isn't that big a problem as it appears the tumor was 100% organ confined.

Terry the Water Guy