G9 Triple Play/Chemo

I know we've been chided for having too many cooks in the kitchen (probably true), and at the risk of being scolded for that again, I'm looking for some info here on Chemo and how it may or may not impact the length of time necessary on ADT.

My husband has 9 treatments of IMRT remaining...we'll be done in 2 weeks. He's tolerating it remarkably well so far, so that's great.

We then have the length of HT up in the air still (a few docs involved have recommended anywhere from 12-36 months).

Chemo has been offered, and we've been told it will increase his chance of cure by 5% above and beyond where the triple play alone (HDRBT+IMRT+HT) will get him...so it's quite a bit of toxicity for that 5%.

My question is with respect to the chemo and HT. As far as I can tell, the HT is to Prostate cancer sort of like penicillin is to strep throat. You take half the antibiotic, you feel fine, and now your throat culture is negative, but if you go off the penicillin too early, you end up with a worse case of strep than you had in the first place.

So we're grappling with how to know when enough is enough, AND...since part of the job of ADT is to sort of clean up remaining cancer cells post-radiation, could the chemo boost help that along and maybe render the choice in length of ADT slightly less risky?

With G-9, G-10, you hit it as hard as you can with everything that's available to you..Buy themselves, neither the ADT, the radiation or the chemo can kill all the cancer cells...But combined, the combined effect has a much better chance of getting it all..You are only going to get one shot at this so I would leave no stone unturned....

• Chemo: That "extra 5%" is based on receiving IMRT only. There is absolutely no indication of any benefit when used with a brachy boost. High pain for no gain.

• ADT: To some extent, longer ADT can correct for lower radiation doses. But he had the boost dose - so longer duration of ADT adds more toxicity than oncological effectiveness. Moreover, several ROs who deliver extreme hypofractionation (HDR-BT or SBRT) have remarked that ADT doesn't seem to add anything. Dr King,in his high risk SBRT protocol allows up to 9 months, at the patient's option. If there is any benefit, just how much to add is certainly a matter of judgment - but whose judgment? Clearly, Demanes, who has more experience with this than just about anybody in the world, is the only doctor in your mix that I would give any credence too. How would the others know? I understand that you don't want to undertreat, but you don't want to overtreat either. His experience should count for a lot. But it is ultimately up to your husband.

Thank you everyone.

Tall Allen-Demanes is one of the docs who did NOT weigh in on duration of ADT. Perhaps we should ask him again in a follow up. I really liked him a lot, but he seemed pretty focused on the brachytherapy boost only. Dr. King recommended a year of ADT, but we ended up choosing a different RO (we liked King so much, but he was just too far...). The current doc doing IMRT doesn't administer ADT and is deferring as well. I hate the MO, who was totally cavalier about side effects and toxicity...

You're absolutely right that we don't want to undertreat OR overtreat. It's finding that perfect, elusive "sweet spot"...

Annie88 thanks for the study. I think we're waffling between 12-18 months...maybe we will just reevaluate each month after a year, but I feel like it would be good for us mentally to have an end date in mind. The MO talked with my husband about Zytiga at his last visit (I wasn't there for that visit), so it's on the radar, especially based on the new info that has recently come about, but our doc wasn't sure about insurance coverage.

PeterDA-your comment about chemo and ADT...if we do the chemo, it will likely be this Fall, so there would still be several months of ADT remaining, but (and I hope this isn't a dumb question), why would there need to be ADT remaining post-chemo? To clean up remaining chemo and radiation resistant cancer cells?