Choosing initial therapy for high-risk PCa

Newly diagnosed (details below) and investigating initial therapies.
Have read very widely and deeply (beyond the rookie stage).
Comfortable with detailed and complex subject matter.

I observe that the AUA 2017 guidelines suggest
1. radical prostatectomy
2. radiation therapy with ADT
on equal footing, and discourage focal therapies outside clinical trials.

If going with AUA guidelines, I am inclined to prefer radiation.
Judging from things I have read in my research,
the favored method would be EBRT + brachy + ADT.

I expect to need to travel to get the best treatment, and would like to hear opinions.

Question 1: Who are the best doctors nationwide for EBRT + brachy + ADT?

Question 2: Who are the best doctors on the west coast for EBRT + brachy + ADT?

I have read about, and had a conversation with Dr. Gary Onik.
Based on verbal description of my case, he thinks I am a candidate for focal therapy.
His evaluation starts with a "3D mapping biopsy" (core every 5mm of prostate extent).
After pathology report and analysis, if no adverse findings,
focal ablation is performed using cryo or IRE to kill local cancer.
A typical 6 months of hormone therapy is used to arrest cancer systemically,
sometimes before, sometimes after ablation, based on tumor characteristics.
The appeal is predicted reduced negative effects compared to surgery or radiation.

Question 3: What argues against this focal approach (aside from cost)?

Question 4: Are there better approaches for my case than the ones mentioned?

Dr. Demanes at UCLA for HDRBT.
I started with Casodex for couple of weeks, then HDRBT, then EBRT.
Also on Zytiga with Prednisone. Eligard shot every three months.
I do not have recommendation for EBRT, mine wasn’t what i feel was the best out there.

Gleason 9 and cT3 is not just high risk, it is "very high risk". Risk of what? Recurrence after treatment. You have all 3 NCCN high risk criteria (Gleason 8-10, PSA>20, and T>3), and the linked study calls that "Very High Risk" due to the multiple factors.

The problem is that those type 5 cells are readily metastatic, no longer requiring the host environment of the prostate to survive. Their presence, even in minute quantities, kick the risk up. So much so that now they even mention it if the declared Gleason score is lower, say a 3+4. If they find some small amount of type 5 cells (like <5%), they'll call it a 3+4 with tertiary 5. It's that important.

I won't claim the breadth of knowledge some of our forum's cognoscenti have, but I don't recall in the last 4+ years on this forum ever hearing of focal ablation for a high risk case. There's just too much chance of missing tumor tissue scattered elsewhere within the prostate. Or, worse, as a cT3 with local advancement, it may be progressing beyond the immediate prostate and missed entirely. Others may have more information about that, but I'm just sharing my humble perspective. I chose radiation because of a similar scenario.

I've added you to the G9 Crew roster, a thread meant as a gathering place for those of us sharing this diagnosis. You may find it informative to look at the signatures and threads of many other G9 & G10 cases there. I've placed links to the first posts of many. It may provide some perspective on the diagnoses and treatment decisions of folks on this forum. Here's a link to that thread, the third in a series:

The Gleason 9 (and 10) Crew - Welcome and how ya doin'? (Part 3, continued thread)

All the best Bob, as you do your research.

Welcome to HW.

The big problem with focal treatment is that PC tends to be non-focal. You have an agressive case, best to treat aggressively. In your place I'd go with the triple play of AT, Brachy with ERBT.

If you're head south, check out UCSF and UCLA, both have good programs and great doctors.

Andrew

JNF said...
very high risk status rules out surgery

This view has changed and today, according to the EUA and AUA guidelines, RP is a viable treatment for selected patients with cT3a, GS 8-10 or PSA >20. It is recommended that patients with adverse tumor characteristics benefit from extended pelvic lymphadenectomy as lymph node involvement is often found in these patients.

Sorry about your diagnosis. I'm not a doctor, but focal treatment certainly isn't common for high risk diagnoses. Logically, it seems to me to be riskier as a G9 in that those cells are likelier to spread. (That's my non-scientific opinion. Take that for what it's worth.)

Regarding the IMRT + HDR brachy + HT combo, I had that done at UCLA. Demanes at UCLA is one of the HDR brachy pioneers. If you do go this route, you might want to consider traveling to LA for the HDR brachy and having the IMRT done locally.

Good luck to you and hope we can help you get through your next steps!

Allen,
how come this study ascopubs.org/doi/abs/10.1200/JCO.2017.35.15_suppl.5082

came to the opposite conclusion:

"Compared to RT, initial treatment of men under 60 with high risk PCa with RP results in a large, statistically significant improvement in overall survival that remains consistent over time and remains significant in a multivariable model adjusting for known prognostic variables."

Dr. David Samadi made his commentary on this link
www.prweb.com/releases/2017/06/prweb14418339.htm

For combo therapy, aka "Triple play: try Dattoli in Sarasota FL, a self contained stand alone facility, all testing and treatment equipment onsite. Very professional staff. He's been treating nothing but prostate cancer since the late 80' it's been five years however, but worth investigating. Free consults over the phone. Worth hearing his opinion.

I can't comment on west coast treatment but regarding radiation and brachytherppy, one of the best known, men travel to him from other countries is Dr. Dattoli in Sarasota, Florida. He has pioneered so much in this area and continues to conduct studies and research around prostate cancer. My dad just started here and his team is top notch and the communication is amazing!

Dattoli is not well known for brachy boost. For IMRT, it's pretty much the same wherever you go. I would stick with one of the expert practitioners for brachy. There are several nearby.