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Good article on current options for managing early biochemical recurrance

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Posted 2/25/2013 11:39 PM (GMT 0)
So, one vote in the survey: When my surgical post-op pathology came back as a Gleason 9(4+5) with positive margins my oncologist strongly recommended adjuvant RT with neo-adjuvant ADT (starting 3 months before the radiation and lasting for two years).

So, he convinced me. He had his work cut out there, let me tell you, because I was NOT a fan of hormone therapy going in. If I didn't think is would improve my odds I wouldn't be doing it.
Posted 2/25/2013 11:44 PM (GMT 0)
Dr. Walsh & DeWeese (Johns Hopkins) belives you should start HT before and during RT for intermediate and high risk prostate cancer. The HT should be given for 6 months. "Surviving Prostate Cancer Chapter 9".
Posted 2/25/2013 11:51 PM (GMT 0)
I am not a fan of HT either. I plan on stopping my HT after 19 months at the end of April and not go the 24 months.
Posted 2/26/2013 12:17 AM (GMT 0)
Peter, with your Gleason 9 staring you in the face, it only made absolute sense, to throw the big guns at it while the going was good. Considering how scary your pathology looks, you are doing well.

david
Posted 2/26/2013 12:22 AM (GMT 0)
I was ready to take 6 months of HT along with SRT for my recurrent G4+3 but both the ROs I consulted recommended against HT and my urologist could go either way, so I'm only doing SRT. My RO didn't want to mask the SRT effect with HT. I confronted him with the idea that HT might weaken the PC cells, making SRT more effective. He said there was no proof either way, but that he could argue the opposite, that you want PC cells active and dividing during radiation.
Posted 2/26/2013 1:11 AM (GMT 0)
David:

My point is that the CURRENT standard of care seems to be shifting towards HT with SRT.

My doctors at Ford said just to do HT. In fact, after my poor pathology results they did not even recommend adjuvent RT. They said wait until the PSA goes up (hopefully it would not).

I could be wrong, but it just seems the more recent articles advocate HT with SRT.

Perhaps those who have recently faced SRT with even a G8 can comment.

Comments?

Mel

Posted 2/26/2013 1:25 AM (GMT 0)
In my case Drs Kriteman, Wilkinson, and Seay (my urologist, rad-onc, and med-onc) all told me HT, IMRT and HDR brachytherapy. They all used the Bolla study indicating I should have between 18-36 months of HT along with the radiation therapies. I consulted another rad-onc and urologist that both concurred. That is extremely consistent regarding a treatment therapy.

Kriteman (uro) said 36 months of ADT3, Seay (med-onc) said at least 18 months, and Wilkinson (rad-onc) stayed out of the HT discussion. I ended up going with the 36 months on HT and have completed 28 months.
Posted 2/26/2013 1:56 AM (GMT 0)
My RO put me on Casodex for 3 months during my SRT. But this was for 3 months only and without Lupron. He thought it MIGHT add some benefit, and at least it wouldn't have the SEs of Lupron. Neither he or my Uro recommended Lupron or other long-term HT for use at that time as part of my salvage treatment. If they had I would probably have resisted, given that other than what the lab tests were telling me, I felt good.

I've discussed HT with my Uro, in the event that my SRT fails. My personal feeling at the moment is that I would put it off as long as I could in the interest of maintaining QOL, but that is a judgment call knowing that I might be trading off some quantity of life for quality of life. But maybe I will feel otherwise when/if I need to make that decision.
Posted 2/26/2013 2:04 AM (GMT 0)
Reachout, that was pretty much the same thing my RO said. I had interviewed three different RO's at the same radiation clinic at the time. Two of them said exactly what yours said. The third tried to push lightly for HT in addition, but when I asked him for any kind of evidence to support it, he backed away and said he couldn't prove that it would help, and he couldn't prove that I needed it. The other 2 RO's. plainly stated that they wanted to see the SRT work or not work on its own merits, without the masking effect of adding HT.

Both my regular oncologist, and the new one I met recently at MUSC in Charleston, felt strongly about not having SRT and HT mixed together.

David
Posted 2/26/2013 2:32 AM (GMT 0)
Not sure who you saw, but this doctor in Charleston has an interesting podcast in which he discusses HT and RT.
http://www.musckids.com/multimedia/podcasts/displaypod.aspx?podid=111&autostart=false

I hope this link is working, if not can someone fix it? It doesn't seem to be clickable.
Posted 2/26/2013 2:47 AM (GMT 0)
http://www.musckids.com/multimedia/podcasts/displaypod.aspx?podid=111&autostart=false

 

Posted 2/26/2013 3:06 AM (GMT 0)
Beejane,

This is my new doctor, Dr. Thomas Keane, Head of Urology at MUSC in Charleston. He is the one on the link you provided.
Posted 2/26/2013 11:53 AM (GMT 0)
David, I took a listen to this podcast to familiarize myself with the current thinking about SRT combined with HT. It seems that Dr. Keane feels that combining the two is definitely the better way to go, and that the results have been very good with this modality.

You wrote that both he and your onc don't believe in combining the two but, if I remember correctly, didn't this doctor think that HT should have been added to your radiation treatment plan? Did he happen to say which situations would likely benefit the most from the combined therapy, and why he feels that HT is not a good option for someone in your situation?

Hope you're doing well, and have had a chance to connect with your oncologist. Any further word from Dr. Keane?
Posted 2/26/2013 1:37 PM (GMT 0)
All,

My URO and RO both stated that I should go on HT for 24 months along with my IGRT and Seeds. I got a second opinion from Johns Hopkins and they agreeded with this treatment plan. Also, the current studies back this up for someone like me high risk--G9. To begin with I wanted to have my prostate removed that is the major reason for my second opinion at J.H.

Dave

Posted 2/26/2013 1:53 PM (GMT 0)
One RO said yes, but also added that she always did HT as a matter of practice. That wasn't an explanation. Another RO said "not needed", and my Uro/surgeon said "not needed". He prefers to do one thing at a time.

The medical oncologist I added in the discussion when my PSA started to slide up after RT said that I was doing things correctly.

Both the MO and uro are of the "one thing at a time" philosophy unless there are clearly mets. I started HT when both said it was time.

Practices change over time, so there is only marginal benefit in discussing what we did in comparison to what might be suggested now, months and years after the fact. I was on the NCCN site yesterday, and there is already an update to the guidelines for 2013.

Posted 2/26/2013 1:57 PM (GMT 0)
David:

I listened very carefully to the comments from your doctor, Dr. Keane.

I enjoyed listening to him. He has an excellent speaking voice.

Also, the comments were very informative.

I did not get the impression at all that he was anti-HT in the least. In fact, he indicated that under certain circumstances HT is the proper tx.

Mel

Posted 2/26/2013 2:11 PM (GMT 0)
At my last Uro appt, I asked my doc about HT in conjunction with RT.  His opinion was that due to my relatively young age (51), I should NOT have HT along with RT when that time comes (which he believes will be sooner rather than later).  His reasoning was that the side effects of HT would be a lot more severe for me than they would be for an older man who is already experiencing reduced testosterone levels in his system.  He explained that HT would be more of a "shock" to my system than someone who is older.

I have an appointment with a radiation oncologist in April and I am looking forward to hearing his opinion on the subject of HT and RT as a combined treatment in my particular case.

Posted 2/26/2013 2:25 PM (GMT 0)
I listened through the interview, and took away a positive message about the value of HT, but also a view on when to start it that closely mirrors my uro's opinion, being that until evidence of mets is seen, maybe it isn't the best idea. He did mention the idea that the high psa-producing cancer was not the one that kills you, it is the low psa-producing cancer. I liked his explanation of why intermittent HT would work - probably the best layman's description I've heard.

 

Posted 2/26/2013 2:28 PM (GMT 0)
142:

I've been wrestling with that issue. But with my rapid PSADT, evidence of mets is probably months away, so I will be starting HT next week (Casodex with Lupron 2 weeks after that!).

Mel

Posted 2/26/2013 2:51 PM (GMT 0)
I want to make this clear, without another "war" starting up here. I made it plain, that Dr.Keane, in general, was not anti-HT. It definitely has its place as a legitimate treatment, and there are plenty of men that need to be on it.

He was totally, against me being on it at this point, despite my high post-surgery, post-radiation PSA number. But he was also the same doctor, that said that I should have never been started on SRT when I was, that he would have never agreed to that in my case.

The question here on this thread, has to do with do you or do you not mix HT with SRT. Even based on the answers to this thread, indicate that the majority of poster's doctors do not agree with mixing the two. This vindicates a point I have made for some time here at HW.

And for those patient's whose doctors feel strongly the other way, and have HT with SRT, I wish every one of them well, and hope they get the results they are looking for.

From this pod cast, anyone can see, that Dr. Keane is a top notch oncologist, and unlike my regular oncologist, Dr. Keane is a highly esteemed surgeon. It's his surgical skills and understanding of complex bladder issues is why I was referred to him. His primary interest in seeing me is with those items, not my prostate cancer. Though his opinions about that are an added bonus.

david
Posted 2/26/2013 3:03 PM (GMT 0)
Mel,

I think the real challenge in deciding to start HT is that the doctors leave all this up to us as the final decision-maker. Sort of like the spy crunching down on the pill. We willfully pick one poison to avoid another. My uro would have happily put me on HT sooner, but more out of habit than need. once we taked about wh & when, he gave me some doubling parameters to consider. When I hit those, we did another round of bone scans, and they came back "very suspicious" where there had not been problems before. So I pulled the trigger.

At least you are not starting in the summer. I was sitting on the porch at 3 a.m. in sweatpants and a t-shirt in 36 degrees / 30 mph NW winds thinking how nice it was to cool off. I'm heading back out for another cool-down now ;)

Posted 2/26/2013 3:35 PM (GMT 0)
HD_Rider:

Not to disagree with you but my personal experience makes me question the T cessation shock theory. I seem to be having fewer side effects from HT than most men and my pre-HT T levels were rather high, at least for my age. As a sort of an informal condition to going on ADT I had both my urologist and my oncologist order T tests so I could have some idea of the T level that was normal for me. I was a little suspicious that my oncologist might do the Gypsy Switch on me, driving my T levels down for a couple of years then returning me to a low-normal level (where I hadn't been since I was ten years old) and telling me he had put me back to "normal". I don't remember the exact numbers but both tests came back well north of 700. I am currently cruising at 4 (two and one half orders of magnitude down) and while I don't like the ADT very much and am counting the days to my last jab (for now) I seem to be tolerating it fairly well.
Posted 2/26/2013 4:03 PM (GMT 0)
I do think I see a trend towards more high-risk patients being recommended combination treatments that include both radiation and neoadjuvant HT. There are a couple of men currently sharing their treatment decision processes with us who are consulting at very well respected centers and seeing widely known doctors and it seems like the triple-whammy is the most common recommendation they get (although seldom the only one). The triple whammy in this case refers to some sort of aggressive treatment for the prostate itself (surgery/seeds/high doses of external radiation) PLUS a more spread out radiation treatment of the prostate bed PLUS neoadjuvant HT (although the durations vary).
Posted 2/26/2013 5:16 PM (GMT 0)
David, obviously I misunderstood a few of your statements...didn't mean to upset the apple cart.

This is an interesting thread but I'll keep my 2 cents out of it since I don't understand alot of what is being talked about.
Posted 2/26/2013 5:39 PM (GMT 0)
Sephie, nothing wrong with anything you posted. Was just trying to clarify the new doctor's position. His positions in general don't interest me as much as his specific views in my case. He's also aware of the fact that I had rapid PSA velocity in the year before my PC dx, how quickly I had BCR post surgery and how fast the SRT failed as well. I also liked that he concurred fully with my regular oncologists position about me and my case. That made me feel even a step better, since Dr. Keane is a much higher level oncologist.

David
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