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Lupron with RT? or not?

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Posted 5/11/2014 2:42 PM (GMT 0)
Because of my recent rise in PSA, I am scheduled to begin radiation therapy in a few weeks. Is this usually done in conjunction with hormones or without?

Doodlebugger
age 78, Da Vinci surgery 1/3/2013
PSA 4.09 pre-surgery
G8(5+3), PNI+, Lymph Nodes-, SV+
70% involved, 39 grams
Apical margin involved, bladder neck involved
pT3b, pN0 cM0
2/15/2013 PSA 0.09
4/16/2013 PSA <0.05
7/22/2013 PSA <0.05
10/14/2013 PSA 0.07
1/2/2014 PSA 0.08
4/8/2014 PSA 0.16
4/30/2014 PSA 0.19
Posted 5/11/2014 2:48 PM (GMT 0)
From what I have read, HT with radiation yields better outcomes.
Posted 5/11/2014 2:58 PM (GMT 0)
It will depend on what your uro and radiation oncologist decide. Some want them in combination, some do not.

My RO wanted it.
My Uro/Surgeon did not, as he felt like it would be more difficult to see any progress made by the RT if PSA were kept low with Lupron. He is also much the "one thing at a time" mentality.

We did the RT with no HT.
Posted 5/11/2014 5:08 PM (GMT 0)
I am in the process right now. I am on Casodex and Lupron for 2 mo. before radiation (40 treatments) and then 2 more years of just Lupron. My RO said this gave best outcome. Also said that a round of chemo was a possibility.

Good luck.

Carl
Posted 5/11/2014 5:44 PM (GMT 0)
Not sure about this in the setting of salvage radiation. The idea of HT before and during radiotherapy is that it "radiosensitizes" the cancer cells, so they're more susceptible to damage from the radiation.

In primary radiotherapy like mine, a very high risk case, I followed the RO recommended (and UO, MO concurred) plan:
1) HT for 2 months (ADT2, Lupron+Casodex)
2) radiation 79.2 Gy by IGRT/IMRT including pelvic lymph nodes
3) continuing ADT2 for total of 3 years.

Goal is for this to be curative, but we won't know if the radiation really caught it all until the ADT2 wears off and we see if the PSA stays low while testosterone recovers.
Posted 5/11/2014 5:52 PM (GMT 0)
This is a controversial issue. In fact, there are a lot of controversial issues for you to discuss with your doctors. I don't have any answers, but I do have a lot of questions:

Age

A major randomized clinical trial found "postoperative irradiation might improve clinical progression-free survival in patients younger than 70 years and in those with positive surgical margins, but could have a detrimental effect in patients aged 70 years or older."

There are urinary and rectal side effects of salvage radiation, and there may be no survival benefit. Only you can decide if that is something you want to put yourself through.

Radiation Dose

The most current learning is that the dose of radiation makes a big difference in outcomes. It now seems that at least 70 Gy is required. With modern, highly conformal linacs, this dose can be delivered without increased toxicity. To some extent, radiation dose and hormone treatment are probably interchangeable.

Hormone Therapy

There's been one randomized clinical trial that showed a clear benefit to 2 years of Casodex in terms of preventing clinical progression and metastases. It has not yet shown a survival benefit, however. Other studies show mixed results. Most studies used lower doses of radiation.

The open questions are:

  • Is there a survival benefit to hormone therapy with salvage radiation?
  • If so, is there a benefit when the radiation dose is 70 Gy?
  • Is there a benefit to starting hormone therapy 2 months before radiation?
  • Is there a benefit to hormone therapy with and after radiation?
  • If so, how long should hormone therapy be continued afterwards?
  • Which hormones should be used? Casodex only? GnRH agonist or antagonist only? Both?
Posted 5/11/2014 8:04 PM (GMT 0)
TA, those are great questions. I wonder when or if we'll ever know the answers?
Posted 5/11/2014 8:39 PM (GMT 0)
Redwing,

There's a big randomized clinical trial that's still recruiting designed specifically to answer those questions. It's called "Radiotherapy and Androgen Deprivation In Combination After Local Surgery" (RADICALS). They are doing it in the UK, Canada, Ireland & Denmark. If you're interested, you can read more about it: www.radicals-trial.org/
Posted 5/11/2014 9:32 PM (GMT 0)
Doodle,
I read TA's post and the study he quoted regarding age and ADT. All I can say is that a member of my support group is 78 or 79 and has completed primary imrt and is on lupron & casodex and has stated he has no I'll effects; he had a psa of 150 with a Gleason of 9. Another member is in his late 70's and has been on lupron for 10 years after surgery & radiation failed; he runs half marathon's and finishes.
Please realize that many of my support group members are hardy outdoor Scandavian types;
I believe in firepower so went with the recommended nccn treatment at the time which includes hormones; I'm still standing!
Bill idea
Posted 5/12/2014 12:09 AM (GMT 0)
Bill
I'm half Finnish; does that qualify?
Bob
Posted 5/12/2014 12:57 AM (GMT 0)
TA, those are great questions. I wonder when or if we'll ever know the answers?

not in the time the OP has to make a decision. you have to go with your gut and when I look at the OP's numbers my gut yells "kitchen sink!".

ed
Posted 5/12/2014 1:18 AM (GMT 0)
Bob,
Gyrene you qualify 100%!! Still trying to figure out how you wound up in "the heart of Dixie". Most are in WI or Mn. I wouldn't be surprised if you were related to Yoop! OK, so I'm "racially profiling", but they do seem to live forever.
I wish you success with your treatment and a long life.
Bill
Posted 5/12/2014 3:23 AM (GMT 0)
Doodlebugger,

While it varies from doctor to doctor I think the consensus would be that ADT will probably make the radiation more effective. But that advantage may be small and it comes with potential side effects in bone density and muscle strength that must be balanced against it.

Ed,

Research does a bang up job of revealing the poor decisions made by our dad's doctors a generation ago but are much less clear about what to do today. The main value of a lot of this research for patients is that it gives you stuff to talk to your doctor about so he can give you some "why"s along with his "what"s.
Posted 5/12/2014 8:45 AM (GMT 0)
The advice I received is that Solodex (Lupron?) starves the cancer of Testosterone, leaving it more susceptible to the radiation. Bicultamide (excuse spelling - not sure of that one) was given 2 weeks prior to 1st Solodex shot to prevent a flare - can't remember if that was of Testosterone or PSA. So I will have been on the hormone treatments for 3 months prior to the radiation, and will be on it for 2 years in total.
Not a lot of fun, but if it does kill the cancer, I figure it is a very small price wiorth paying
Posted 5/14/2014 1:47 AM (GMT 0)
Met with rad oncologist today and decided on one month lupron shot to see how I react and beginning SRT starting May 20. Because of slow rise in PSA he thinks it's still in prostate bed and with pos margin he knows where to concentrate. So I'm off to the races!
Bob
Posted 5/14/2014 2:11 AM (GMT 0)
Bob,
Excellent decision! You might want to consider another 6 months of lupron-- you can handle it! All the best to you.
Bill idea
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