Recently diagnosed, am I intermediate or high risk?

I do have a question about Combidex. It seems many on this forum have had it done. Did everyone go to Holland just for that? Is it worth it? One of the big unanswered questions for me is whether to radiate the lymph nodes and of course, I can't really know that without Combidex (or surgery).

Welcome jacknsan.

It is not possible to overstate the importance of the experience and talent of the practitioner, so it may be worth waiting till Jan, especially if you can start neoadjuvant HT in the meantime.

On the other hand, you don't have much to lose by getting a consult with Dr. Subir. A consult with Dr Lam seems like a great idea to help you sort through this. Have you considered an MRI as another datapoint?

Good luck.

jacknsan..any chance you could see Dr. Vogelzang in Las Vegas, a great prostate research doctor with all the latest trials and he is associated with UCLA. He would see you and reccommend and follow your treatments with and along side a UCLA doctor so you could get treatments in CA and see him in LV as little or often as you can...you can see him on you tube..Nicholas Vogelzang.

Yes! To everyone who responded, thank you! I may be confused still but I feel better about my path ahead. I will take Dr. Bahn's advice and treat it as a T3a stage with ECE. I have asked my uro at Kaiser for a referral to a medical oncologist, but he wants to discuss it with me beforehand, so I have an appointment next week with him. I may do a short 4 month term of Casodex, if they will go for that, while I decide to stay with Kaiser or switch insurance and go to UCLA for the HDR BT with Dr. Demanes and perhaps a followup of IMRT.
Once again, I thank everyone for their valuable pearls of wisdom!

Hi and I'll also welcome you Jack. As you've seen there are lots of good experience and knowledge out here - it's a great place to be at this point in your journey.

For my weigh-in I would say that you would have been considered intermediate risk, but with the staging being what it is that pushes you into the high risk category, and a combination approach to treatment.

I know you've stated that switching to a different insurance will cost more - not sure how much more, nor am I suggesting that you may be "independently wealthy" - but just let me say that I would highly encourage you to seek out the BEST practitioner for the treatment approach you decide upon, and let the cost be a secondary consideration. And if HDR BT is where you may be headed, everything I've come across points to DeManes. Just something else for you to consider as you continue down this path.

When I was at that point in my journey, not yet deciding on what my treatment approach would be, I made up my mind that I really didn't care where I had to travel to or what it would end up costing (and BTW I'm not independently wealthy...) - that I would go to the best. I convinced myself that my life, and at quality of life, trumped anything else.

Best of luck to you brother.

Hi jacknsan,

I agree with JohnT and others that you would have been intermediate risk, but the extracapsular extension (ECE), which stages you at T3a, puts you in the high risk of recurrence category.

I think a conversation with Dr. King will be useful to you (full disclosure-- he's my RO). I happen to know that he's been working on a new high risk protocol using SBRT tailored for cases like yours. What he does is kind of interesting:

• he treats out to about 5-6 mm outside of the prostate (on the side away from the rectum), contouring to any known ECE
• he boosts the dose to any observed lesions or suspicious areas within the prostate
• ADT is optional (it hasn't been observed to be of any extra benefit when used with SBRT).

So, in effect, it's like getting an HDR boost to the prostate with external beam treating the prostate bed, but you get the amplified cancer-killing power of hypofractionation even outside of the capsule without the toxicity of IMRT. Also, it's all done in 5 five minute treatments.

So far, only about a hundred men nationwide have received this kind of therapy.The oncological and toxicity results in the first 5 years have been excellent.

So far it does not seem that adding ADT to either hypofractionated therapy (SBRT or HDR) increases the effectiveness of the therapy, and it may add to the side effects. Although you are high risk, it is questionable whether ADT would be of any incremental benefit even with LDR or IMRT. It seems to make a difference with Gleason 4+3 but not with 3+4:

Is androgen deprivation therapy necessary in all intermediate-risk prostate cancer patients treated in the dose escalation era?

jacknsan-

The point they were making in that study is that ADT was of no benefit with a Gleason Score of 3+4 but may be of benefit only with a Gleason score of 4+3 or higher. Because your increased risk stems from the ECE rather than a higher Gleason score, I would infer that the ADT might provide no benefit in your case. But you (and your wife) have to feel comfortable.