Brachytherapy with or without neoadjuvant ADT?

This question only applies to guys in the intermediate risk category. Patients at low risk definitely do not need to begin with ADT (unless they have huge honking prostates and nevertheless desperately want to have seeds). Patients at high risk almost certainly should have ADT (and EBRT too).

What the researchers found in this data analysis was that it depends on whether you're "favorable intermediate risk" (who don't benefit from ADT) or "unfavorable intermediate risk" (who do benefit from ADT). For the unfavorable group, they didn't find any extra benefit for adding just EBRT over adding just ADT, but in light of the recent ASCENDE-RT trial results, a randomized controlled trial, I'd be reluctant to write-off the EBRT without better quality evidence.

This applies only to LDR brachy (seeds) and not to HDR brachy (temporary implants). ADT has not been found to be beneficial with HDR brachy in any risk group.

Here's an article about the study:
Optimal brachytherapy pre-treatment for intermediate-risk patients depends on “favorable” or “unfavorable” status

- Allen

Tall Allen said...
This question only applies to guys in the intermediate risk category. Patients at low risk definitely do not need to begin with ADT (unless they have huge honking prostates and nevertheless desperately want to have seeds). Patients at high risk almost certainly should have ADT (and EBRT too).

What the researchers found in this data analysis was that it depends on whether you're "favorable intermediate risk" (who don't benefit from ADT) or "unfavorable intermediate risk" (who do benefit from ADT). For the unfavorable group, they didn't find any extra benefit for adding just EBRT over adding just ADT, but in light of the recent ASCENDE-RT trial results, a randomized controlled trial, I'd be reluctant to write-off the EBRT without better quality evidence.

This applies only to LDR brachy (seeds) and not to HDR brachy (temporary implants). ADT has not been found to be beneficial with HDR brachy in any risk group.

Here's an article about the study:
Optimal brachytherapy pre-treatment for intermediate-risk patients depends on “favorable” or “unfavorable” status

- Allen

So it all boils down to favorable vs unfavorable condition and of course that other factor, let's not take any chances here and do whatever it takes to increase the odds in winning this battle.

Favorable Intermediate Risk: NCCN intermediate risk, as defined above, but only those with
Predominant Gleason grade 3 (i.e., Gleason score 3 + 4 = 7), and
Percentage of positive biopsy cores < 50 percent, and
No more than one NCCN intermediate risk factor

Unfavorable Intermediate Risk: NCCN intermediate risk, as defined above, plus
Predominant Gleason grade 4 (i.e., Gleason score 4 + 3 = 7), or
Percentage of positive biopsy cores ≥ 50 percent, or
Multiple NCCN intermediate-risk factors

Michael_T said...
Then I guess I'm glad I stopped my HT after 18 months than going longer if it's not helpful for HDR brachy.

But...that's a significant fact if HT isn't needed at with HDR brachy but can be beneficial with some cases of LDR brachy--doesn't that make a strong case for HDR brachy in higher risk cases? While the two flavors of brachy are not exactly the same, I've always thought of them as more similar than different. Am I mis-understanding something?

Hey Michael,
How are you doing these days? I didn't know that you had cut your HT sentence short.

Glenn

Michael_T said...
Hey Glenn,

I've been off the sauce for about a year now. And I actually had always planned for 18 months (and even 12 months was on the table), although I know a lot of guys are in for 3 years. I'm doing well in terms of my PSA, although my T hasn't fully recovered. It's recovered enough that I don't get hot flashes and have the worst SEs, but I have zero libido.

I know my total recovery took a lot longer(8-10 months or more) than I had imagined and I can only assume that there is a relationship between the length of time on ADT and the T recovery time. Have you consulted with anyone on your T level recovery and are you active in any form of exercise?

Michael_T said...
But...that's a significant fact if HT isn't needed at with HDR brachy but can be beneficial with some cases of LDR brachy--doesn't that make a strong case for HDR brachy in higher risk cases? While the two flavors of brachy are not exactly the same, I've always thought of them as more similar than different. Am I mis-understanding something?

They kill the cancer in different ways. LDR, as the name implies, has a very low dose rate, but it kills the cancer with a slow, continuous onslaught of radiation. The higher grade cancers - Gleason grade 4 and 5 - are less efficiently killed by the low dose rates compared to Gleason 3s. The ADT is thought to radiosensitize those cancers to increase the net cell kill.

HDR, as the name implies, kills with a few strokes of very high intensity radiation, possibly so high that the G4s and G5s cannot survive it, even without the help of ADT. However, in actual practice, most ROs include ADT in the mix anyway "just in case."

They both work very well in combination therapy for high risk patients - two strategies that get you to the same place.

On the external beam side, IMRT is closely related to LDR in the way it kills the cancer, while SBRT is bio-radiologically identical to HDR brachy.

- Allen

Hi all, this is my first post. I was just diagnosed with PC in Dec. Since then I have already started ADT and am almost halfway through a 5 week session of IMRT. Approximately 3 weeks later I am scheduled to have LDR brachy. My question is how long should I continue my ADT treatment ? My urologist is recommending 2-3 years, but I cant find any study/data that shows ADT helps after IMRT and LDR. There seems to be lots of positive studies for ADT when paired with one radiation treatment, but cant find anything for my specific treatment plan.

DaysBetween, welcome to HW.

Here's an article that addresses your concerns:

/pcnrv.blogspot.com/2017/12/is-adt-still-needed-for-high-risk.html

/pcnrv.blogspot.com/2017/12/is-adt-still-needed-for-high-risk.html

I'm in the unfavorable intermediate category of D'Amico and looking at dose escalated ldrbt of McLaughlin where the blogspot reference above gives a basis for not using ADT.

How does this new article on "Optimal Brachytherapy pre-treatment" interact with that one above especially with dose-escalated ldrbt + ebrt (a la McLaughlin).

I'm also wanting to explore the HDR and the SBRT more with this valuable statement of yours: "On the external beam side, IMRT is closely related to LDR in the way it kills the cancer, while SBRT is bio-radiologically identical to HDR brachy."

[Sorry, I haven't learned how to quote in the small print in boxes yet. I'm happy to learn.]
Manticore

Please do not fear the side effects of ADT or convince yourself they will be bad.

Many of us made it through with not much more than inconvenience. Some have more problems, but that is not most.

Our wives, mothers, sisters all go though menopause and never stop. For us the male version of menopause is most always very limited. And I understand the worst side effects of ADT are nothing like the side effects of advanced PCa.

Get yourself ready. Improve your diet by reducing fats, sugar, caffeine, carbonated drinks. Eat less meat but understand you need the iron and Vitamin D. Drink much more water and green tea. Exercise and lose weight. The continued exercise will be one of your best weapons against both radiation treatment fatigue and the longer term effects of ADT. I felt the worst when I was sedentary. Felt the best when I was busy and active. Do what it takes to sleep well and practice stress reduction including meditation.

Start these behaviors today. They will make a difference.