New Action Plan....not what I expected?

Chask

The 68 Ga PSMA PET, in my opinion, will be a game changer. I am scheduled to have it at UCSF, later in July.
As far as I know, only way to have it is via a study, as not approved by FDA. Some insurances will not cover it, my request is still pending, but will have it regardless.

If he is radiating bone mets then it is only palliative as the cancer is already in the blood system. However, from what I have been reading if it is Oligometastatic disease the radiation could be curative.

The ultimate treatment decision is up to you.

Bobby Mac

Oh, Australia, you guy's, along with Germany, have had the PSMA scan for years. In fact, until I was accepted into the US Study, I was going to Germany to have it.

Bobby Mac

Allen, thanks again for your wise counsel.

And you have added strength to one of my concerns, participating in a trial which has questionable results, but more importantly, delays resumption of known palliative treatment which could have significant longevity outcomes. It really is problematic, gamble on a cure against palliative treatment.

Another not insignificant factor for me, is that the SABR trial is being run in Melbourne and requires 3 monthly follow ups for 2 years. Melbourne is a good 8 to 9 hour drive from Canberra where I live so there is a fair bit of disruption/cost involved. Wouldn't be an issue if the result was known to be positive, but in this case??

As it happens I am seeing my radiation oncologist next week and will discuss with him now that I am better armed with a bit more info. Was really taken aback a bit yesterday with the Uro as I wasn't expecting anything like this option. I did have the Lancet report with me to give to him, after you referenced it in another thread, but in all the kerfuffle, I forgot to give it to him. Will do that at our next meeting in 6 months.

Gee Halbert, that is a perspective I had never considered, but I guess we all collectively add to the pool of knowledge with our posts, both successes and failures.

Ironically, I have been feeling a tad guilty lately, because most of my posts are seeking help and advice, whereas many of the contributors, particularly those like Tall Allen, are on the other side of the ledger, providing wisdom and/or succour. My problem is that I know so little, that I can't offer much other than encouragement and sympathy.

Appreciate your kind words and I will keep them in mind, though to be honest, whatever treatment path I take will be selfishly oriented towards my own wellbeing. If it happens to break some new ground, and help others, that would be fantastic.

Chas

I'm not convinced early ADT is always the way to go?

Here are some UCSF MD's takes on the Aussie study Allen cited above.

"There is no consensus as to whether it is better to treat immediately or to delay androgen-deprivation therapy in patients with a rising prostate-specific antigen (PSA) level (“biochemical relapse”) after curative therapy for prostate cancer. A phase III study, selected for the Best of ASCO® 2015, found that immediate androgen-deprivation therapy improved overall survival and time to clinical disease progression, but the results were not definitive.

This trial has several issues that make it difficult to walk away with a firm conclusion, according to Terence W. Friedlander, MD, of the University of California, San Francisco, who reviewed this trial and its implications at the Best of ASCO 2015.

Study Details

about 20% to 50% of patients will relapse following definitive therapy for prostate cancer. The Timing of Androgen-Deprivation Therapy in Prostate Cancer Patients With a Rising PSA (TOAD) study sought to address the optimal timing of androgen-deprivation therapy in this setting. Men were eligible for the trial if they had a PSA doubling time of less than 12 months following curative therapy or metastasis or symptoms.

Only one-third of the planned accrual occurred, with 293 patients enrolled from September 2004 to July 2012. Median follow-up was 5 years. Most patients had slowly progressing disease, and about two-thirds of each arm went on intermittent therapy.

Patients were randomized in a 1:1 ratio to receive immediate intervention with androgen-deprivation therapy (arm B) or delayed therapy (arm A). about one-third of patients in arm A initiated androgen-deprivation therapy within 2 years, whereas 49% started therapy later than 4 years on trial or had not yet begun therapy.

The mean age was about 70 years at trial initiation. about two-thirds of patients had curative radiation therapy, and about one-third underwent surgery plus radiation as curative therapy. The relapse-free interval was less than 10 months in about one-third of patients and 10 months or longer in two-thirds.

Survival Data and Toxicity

At 5 years, overall survival was about 10% higher if androgen-deprivation therapy was started immediately: 86% vs 76%, respectively; 6-year overall survival was 81% vs 65.4%, respectively (P = .05). Nonsignificant reductions were also observed in prostate cancer–specific deaths and deaths due to all causes.

Overall, 46 deaths were reported, including 30 deaths in the delayed-therapy arm and 16 deaths in the immediate-therapy arm. “There were only 18 prostate cancer deaths in this study—6 of these deaths were in the immediate [androgen-deprivation therapy] arm and 10 were in the delayed arm. It is difficult to interpret these data to know if this is a real difference,” Dr. Friedlander commented.

Progression-free survival (both distant and local) was improved with immediate therapy (P = .001) compared with delayed therapy. However, time to castration resistance did not differ between the two study arms.

A subgroup analysis suggested that intermittent androgen-deprivation therapy might be superior to continuous androgen-deprivation therapy. However, due to poor accrual, the study was underpowered to detect a difference in this and other secondary endpoints.

Adverse events related to androgen-deprivation therapy were more common in the immediate-therapy arm than in the delayed-therapy arm: 80% vs 50%.

‘Not Practice-Changing’

“This was a challenging trial to conduct, and accrual was disappointing. It appears that overall survival may be improved by immediate vs delayed initiation of androgen-deprivation therapy, but the benefits are likely to be modest and have to be balanced with the considerable side effects of hormonal treatment,” stated Dr. Friedlander.

“This study is not practice-changing. When faced with a patient with a rising PSA following curative therapy, the physician should discuss therapeutic options incorporating the risks of treatment,” he said. The way forward will depend on finding better ways to identify which patients need androgen-deprivation therapy upfront and which ones can safely delay it.
Disclosure: Dr. Friedlander reported no potential conflicts of interest."


"Interpreted With Caution
In an accompanying editorial, Michael S. Leapman, MD, and Peter R. Carroll, MD, both from the University of California, San Francisco, explain that this finding does not mean that immediate androgen deprivation should become standard treatment for all patients with biochemical recurrence.

Selecting optimal management for patients with prostate cancer who relapse after surgery or radiotherapy as assessed by PSA levels has been the subject of much debate, they point out, and the current study "provides clinicians and their patients with much improved estimates of the potential value of such therapy as well as its trade-offs (ie, reduced quality of life)."

In addition, not all research has identified a survival benefit from immediate treatment and patients are increasingly worried about adverse effects of therapy.

"I do think the results provide more granular information about benefits/risks," explained Dr Carroll. "However, I think the results need to be interpreted with some caution as the patient population may not represent well all those who present with a rising PSA after primary treatment.

"Some of these men may be at a low risk of metastatic relapse and not benefit form ADT, but be exposed to its side effects which are increasingly being recognized as significant," he told Medscape Medical News.

Another factor to consider is that new technology and therapy will refine the timing and type of treatment for this patient population. "I also think that technology is racing into this space to better assess risk, such as circulating cell-free DNA," Dr Carroll said."

Bobby Mac