Results From Mayo

Woody,

I think this is a very good recommendation by Dr. Sartor. It will avoid pain from the bone met later on and should provide good control for any microscopic lymph node mets you may have.

As an alternative you could also just use SBRT for both mets in one go and treat possible micromets in the pelvis with ADT. Due to your bone met you will have to do ADT sooner or hopefully later anyway.

George

Bobby,

the study by Gundem showed that metastases do metastasize. He writes: "Metastasis-to-metastasis spread was found to be common". But I think this question is still controversial. On the basis of the Gundem study the cancer spread would slow down if you destroy visible mets since these cannot cause new metastases any more.

However, the cancer has probably already spread and there are micrometastases somewhere in your body. You cannot tell how many there are and how long it takes for them to grow to a visible size. While you are on ADT though, these should not grow but rather shrink.

In the case of Mel for example, after SBRT the treating physician will determine that the PSA is very low, no metastases are detectable with the best imaging tools available so why not extend the vacation? The patient also will not understand why he should continue ADT when he is in this situation.

George

George -

It seems others, including Dr. Walsh, as seen below, don't believe hormones stop the clock on advancing prostate cancer. Sorry TA, I am using an outdated book, but still I do not believe Walsh's position has changed and there is no high level proof that hormone treatment delays prostate cancer progression.

I hope Dr. Walsh is wrong!!

“WHEN SHOULD YOU BEGIN HORMONAL THERAPY? First, if you have metastases to bone, bone pain, or a large mass of cancer that is obstructing your kidneys or bladder, you need to start hormonal therapy now. In this situation, hormonal therapy is the right course of action— one that can make a huge difference in your quality of life and can protect your body from the ravages of cancer. But what if you have no cancer in your bones and no sign that anything is wrong except a rising PSA level after surgery or radiation, or the presence of cancer in your lymph nodes, and you feel fine? Many doctors would advise you to start hormonal therapy as soon as possible. Others— and I’m in this group— believe that there is no evidence that starting hormonal therapy immediately, as opposed to later, will prolong life. But doesn’t early hormonal therapy delay the progression of cancer? The answer is yes and no. It delays your knowledge of progression. Hormonal therapy does two things. It stops cells from making PSA, and it shrinks the hormone-sensitive cell population; a man’s PSA falls, and it takes longer for his bone scan to become positive for metastases. But it doesn’t stop the clock; the hormone-insensitive cells keep right on growing silently, and you may need additional treatments to help keep them in check."

Dr. Walsh does approve of hormone treatment in conjunction with radiation therapy.

Bobby Mac

Mel,

there were studies that showed no overall survival benefit whether you did start ADT immediately or delay the start until symptoms appeared. The PSA value did rise, however, if you had delayed ADT. E.g. this one: www.ncbi.nlm.nih.gov/pubmed/15310999

Allen recently presented a study which concludes that it is better to start ADT as early as possible and he recommends this now.

Bobby Mac and I have a different opinion regarding this study:
www.healingwell.com/community/default.aspx?f=35&m=3662656&g=3666449#m3666449
www.healingwell.com/community/default.aspx?f=35&m=3711322&p=2

George

Post Edited (George_) : 10/15/2016 8:07:08 AM (GMT-6)

George:

True, but the reality for me is that I started feeling much better within 2 months. You feel better as your T rises.

During my first HT vacation, I fully recovered in 3 months -- totally back to normal.

During my 2nd HT vacation, I seemed to largely recover in 3 months, but a few months later my HT-type memory issues seemed to suddenly return for about 4 months. It has recently improved. Not sure why that happened. Maybe old age?

Anyway, I hope to enjoy being HT free for the next 2 months!

Mel

compiler said...
... I asked him about how much time I would need to be in the area and he indicated 2 weeks. Not sure if that means anything in terms of tx. plans.
Mel

Mel, I was able to qualify for financial assistance on the travel portion. The PAN foundation also helps with co-pay assistance but mine was entirely covered by Medicare/AARP Plan-F. I think you chose Medicare Advantage and may have some co-pay, but you can change that at this year's annual enrollment if the co-pay avoidance numbers show that to more than offset the Medicare Supplement Plan-F premium increase.

Your qualification would depend on how much income you took when you retired this year. Since you are looking at early 2017, perhaps you can qualify by only providing your monthly income intent in retirement. They do not take total assets into consideration, just the income stream

/panfoundation.org/index.php/en/patients/assistance-programs/metastatic-prostate-cancer

I initially qualified for a $2,500 travel grant based n combined income at the time of less than their $60,000 limit for 2 people. When i exceeded that, they provided a second $2,500 pre-paid debit card.

So if like I did, you choose to live with a nearby relative rather than a hotel, that's okay. in my case it was $75 SW Air flights back and forth to San Jose. There were no side effect issues on same day travel before and after the SBRT itself to avoid LA Hotel costs.

I have also heard good things about the lower ( a relative term) cost nearby university housing, but meals in LA add up.

I did Provenge and SBRT concurrently. I actually learned about PAN foundation through Provenge financial assistance help desk so not sure if SBRT only also qualifies.

Have you excluded Provenge? I viewed it as can't hurt, might help and no out of pocket cost with potential "abscopal effect" benefits.

pcri.org/the-abscopal-effect/

Now would be the time to apply for Provenge while you have the mets and the 2 requisite PSA increases at least 14 days apart.

Using Tall Allen's advice and counsel I did one Provenge cycle before SBRT, then 2 weeks later the second concurrent with SBRT and the third 2 weekends later after SBRT. That of course led to more travel and living expenses in LA area.

You may be able to have your Provenge administered locally in Michigan but in my remote area of west central FL, I chose to have Prostate Oncology in Marina del Rey oversee if with the lukapharesis in Van Nuys approved Provenge faciiity 15350 Sherman Way #380, Van Nuys, CA on Fridays and the reinfusion at Dr. Scholz/Lam/Turner Marina del Rey offices on Mondays.

So that's why my airfare, Uber/car rental, meals etc were so high.

Bobby Mac-

Yes, Walsh's book is outdated.

What changed the standard practice, at least for many oncologists, was a major randomized clinical trial this year (May 2016) called TOAD. They randomized men who had PSA progression after treatments had failed to either immediate or delayed hormone therapy. The death rate in the first 5 years was cut in half by beginning ADT earlier. This is the only level 1 evidence we have.

www.thelancet.com/journals/lanonc/article/PIIS1470-2045(16)00107-8/abstract

The authors also made the following points:

• Early start increased both prostate-cancer survival and survival from other causes (for some unknown reason)
• Health-related quality of life was not impacted by starting early, at least not in the first 2 years
• Intermittent ADT was used by ⅔ of all men in the study
• The highest survival rates were noted in men who started immediate intermittent ADT
• Castration resistance set in sooner among men who waited. It was delayed in men who used immediate ADT probably because it prevented the evolution of castration-resistant cancer cells. Many hypothesized that the opposite would happen because earlier ADT would exert selective evolutionary pressure for castration-resistant cancer cells to predominate.

Because of this, we now know that waiting for PSA to rise in order to go on a wild goose chase for mets will compromise a patient's survival. There may be other valid reason to delay, but certainly not to wait until more mets become visible.

This has nothing to do with Mel's situation. He is already on intermittent hormone therapy, so he is not delaying anything. He is only hoping to increase his vacation time, and he is hoping to avoid treating all his pelvic LNs.

Nomar:

I'm confused. You posted a quote from me and then got into cost. I was not asking about that. I am, however, making the tacit assumption that my MediCare Advantage Plan will cover a good deal of the cost. In fact, that is a good reminder for me: check with King's staff and/or my insurance regarding coverage!

I plan to do the snowbird thing. We did it for the first time last February, and loved it. Given my current situation, it looks like Santa Monica will be the February location (last year it was Palm Desert). So, the travel expense would be an expense anyway. Also, with our MediCare Advantage, there is a maximum OOP. I may hit this in 2017!

Mel

I would not be at all surprised if Hussain has changed her opinion - I know I have. Until the TOAD study, the best info we had (from retrospective analysis of datasets) was that it didn't matter when HT started. Now we know different.

Dr King will have to answer your question about how much to treat and repeatability. Individual anatomy differs greatly. It depends on where the organs are, and visceral fat. Also, the lymphatics are networked. Attempts at sentinel node removal has not been found to be useful for prostate cancer, the way it is for breast cancer. Similarly, ePLND (trying to surgically remove all the pelvic LNs) seems to delay progression, whereas PLND does not. I understand you are not trying to delay progression, but only to lengthen your vacations. I mention it only because it points to the unpredictability of where the next LN met will become visible. If it is far from a treated met, you may be able to zap it. If it is nearby, you may not be able to.

Bobby Mac-

That's the power of randomization. It's like flipping a coin - the odds of getting "heads" 32 times in a row is 1 in 2^32. I'm sure that data is in the full text and would have been discussed if abnormal. This was a top notch, well designed and executed clinical trial conducted at 29 centers in Australia, New Zealand, and Canada.

Even if a little back-and-forth happens, this is a most useful and interesting discussion. You guys have put a lot of thought into it, and that's appreciated. I may be facing this at some point, and I'm going to bookmark this one.

This example always blows people's minds:

Tall Allen said...
It's like flipping a coin - the odds of getting "heads" 32 times in a row is 1 in 2^32.

Just wanted to pitch in that I love this one. And yet the odds of heads on the 33rd coin flip? Still 50/50! Counterintuitive, and usually produces an argument. They're independent events, which is critical.

Bobby Mac said...
George - where did you get the 2-3 years from? It seems to me the majority of men go way past 3 years.

What I meant was the time from the start of ADT to the start of castration resistance, when you have to start with a secondary hormonal therapy.

Two to three years are often mentioned in the studies I read. However, patients in forums often report much longer periods.

So I looked again now where I could find references for this period. This is what I found:

Loriot: Prior long response to androgen deprivation predicts response to next-generation androgen receptor axis targeted drugs in castration resistant prostate cancer:

„The study cohort consisted of 173 patients. Median duration of response to initial androgen deprivation therapy (ADT) (time to castration resistance, TTCRPC) was 17.8 months. “

Kratiras: A review of continuous vs intermittent androgen deprivation therapy.....

In table 1 the time to progression for several studies are listed both for intermittent and continous ADT. It varies from one to two and a half years.

A very detailed review is the following study:

Mark Pomerantz and Philip Kantoff: Clinical Progression to Castration-Recurrent Prostate Cancer

A few citations from this study:

„the median time to PSA progression from the start of ADT was 23.7 months (Ross et al. 2008)“

and reporting from a different study:
„Median time to CRPC was only 15 months in the nonmetastatic subgroup and 10 months in the metastatic subgroup.......shorter time to CRPC is related to the extent of disease at the start of ADT.“

Further:
„A particularly intriguing finding from the DFCI study suggests that prior ADT for local disease affects the development of CRPC.The median duration of neoadjuvant and adjuvant ADT was 8 months, and the median duration between completion of ADT as a part of local therapy and the beginning ADT for recurrence was about 22 months. Prior therapy was associated with shorter time to CRPC in metastatic and nonmetastatic patients...“

So the neoadjuvant and adjuvant ADT for radiation, even when about two years ago, also shorten the time to castration resistence in a following ADT.

I also want to mention that Pomerantz and Kantoff do not advocate early start of ADT: „As a result of starting ADT early in the course of disease, a considerable number of patients develop CRPC before the onset of clinical progression“

All these studies show that the time from the start of ADT to castration resistance is limited. I would try to delay the time to castration resistance if possible. Therefore I would not start with ADT as early as possible and also destroy my mets TRYING to extend the period ADT is working before castration resistance occurs.

George