When is Hormone Therapy recommended in addition to Brachytherapy

The Urologist is now working outside his area of expertise..You should replace him with a Medical Oncologist....

In most high-risk cancers, ADT is recommended as an adjunct to the radiation as it increases its effectiveness..G-8 warrants aggressive treatment..

If your prostate is only 36cc you are a perfect candidate for brachy, the one therapy that is done in one painless session with a high success rate. I tried to do it but my prostate was too large (62cc). Most people I know that had brachy are fine and some had ADT and some didn't. As Tall Allen said it was used to shrink, which you don't need. If you do have ADT your psa after the brachy won't be accurate so it will be a while before you'll get a true psa and know if the cancer is gone.

While I don't think one can assume that just because only one core of Gleason 8 was detected in 13 cores sampled that that is all there is, although it does suggest that there's not a lot of it. It may be true that you don't need it, especially since you will be receiving so much radiation from both the external beam and the brachy boost to the prostate.

Current SCO/CCO guidelines call for hormone therapy with brachy boost therapy for high risk cases, but I think there is room for judgment.

/pcnrv.blogspot.com/2017/03/revised-ascocco-brachytherapy-guidelines.html

I think that it's your decision to make.

Thanks. But that retrospective study doesn't apply to your case. It's about adjuvant ADT in unfavorable intermediate risk men, not high risk men. (I noticed that those treated with ADT had higher volume but lower Gleason score - the opposite of your situation). Also, none of the men in that study had external beam with their brachytherapy. I think that patients with unfavorable intermediate risk and high risk men should be offered multimodal therapy. Whether they take it or not should be based on shared decision making.

Michael_T, I'm contemplating brachytherapy as a mono therapy.

I agree with Allen. I would not risk a high risk cancer with monotherapy. I would say that Tom Pickle is one of the best. Did he recommend monotherapy?

Paul

I'm sorry, but it doesn't work the way you imagine. You can't "dilute" a Gleason 4+4 tumor by including all the rest of Gleason pattern 3 within your prostate. The Gleason scoring system has proved to be highly prognostic. When your pathologist diagnosed it as Gleason score 8, that means that 95% of the single tumor sampled in that core was Gleason pattern 4. It means that you have at least one Gleason 8 tumor within your prostate.

That also does not mean it's the only Gleason 8 tumor. mpMRIs can't find any tumors smaller than about 4 mm. That doesn't mean they're not there - just that they are probably too small for the MRI. It also makes them easy to miss on biopsies. Prostate cancer is almost always multifocal - that means that there are most likely small tumors distributed throughout the prostate.

Unfortunately for you, the volume of cancer within the prostate is less prognostic than Gleason score, PSA or stage. Volume of cancer is not used in most risk stratification systems, other than to help with sub-classification.

www.redjournal.org/article/S0360-3016(01)02670-0/fulltext

This is why prostate cancer is characterized by only the highest Gleason score. It has been found that only the highest Gleason score is prognostic for risk.

There is no amount of convoluted reasoning that can get you out of this. Your risk level is "high risk" according to every risk stratification system that is used. The whole point of risk stratification is to help find the most appropriate therapies. But that doesn't mean incurable - 83% of high risk patients seem to have been permanently cured with brachy boost.

I give your RO a lot of credit in accommodating your wishes. However, that puts more responsibility on you to really understand this stuff before making a decision.

All of this is very interesting and informative but wouldn't SBRT be more effective and easier ?

Thanks for all your insightful comments.

I have a lot to consider.