Adjuvant therapy? ~ The data continues to gain momentum.

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Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 8/5/2010 2:11 PM (GMT -6)   
Post at the InfoLink today on the use of adjuvant therapy...

tinyurl.com/2ekqw2a

I commented there as well.

The folks that this post applies to are stage 3 and/or lymph node positive cases. Some early stage 3 cases do have improved results, but better results are seen in cases where seminal vesicle invasion is present or larger disease. These results are regardless of Gleason grade. In fact those older studies shown in Strums book, and Walsh's book that show that adjuvant therapies are not clearly effective, have indeed been trumped by many studies since the 5-6 year period since those books were written. Both of these oncologists have gone on record as stating so in recent times.

This particular study focusses on ADT with a local therapy. I take the liberty to state that ADT with any combination will show improved results.

I hope so. I know I'm not complaining...

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino

Post Edited (TC-LasVegas) : 8/5/2010 1:15:20 PM (GMT-6)


Magaboo
Veteran Member


Date Joined Oct 2006
Total Posts : 1210
   Posted 8/5/2010 4:28 PM (GMT -6)   
Hi Tony,
 
Thanks for the URL to an interesting article. It maybe of great benefit to newly diagnosed brothers. To bad that it is a little to later for me.
Hope you're well. Keep up the good numbers.
All the best to you.
 
Mag

Born Sept 1936
PSA 7.9
-ve DRE
Gleason's Score 3+4=7, 2 of 8 positive
open RP 28 Nov 06 (nerve sparing), Post op staging T3a
Gleasons still 3+4=7
Seminal vesicles and lymph nodes clear
Catheter out 15 Dec 06, Dry since 11 Feb 07
All PSA tests in 2007 (4) <.04
PSA tests in 2008: Mar.=.04; Jun.=.05; Sept.=.08; 3 days before Rad Start=0.1
Salvage RT completed (33 days - 66 Grays) on the 19th Dec., 08.
PSA in Jan., 09=0.05; July 09 <0.04; JAN 10 <0.04; Jul 10 <.04

don826
Veteran Member


Date Joined May 2008
Total Posts : 1010
   Posted 8/5/2010 4:31 PM (GMT -6)   
Hi Tony,
 
When I was researching alternatives for treatment after my diagnosis I gave heavier weight to more recent studies. I found several that supported ADT with radiation as an accepatable and effective therapy for locally advanced PCa. Most said the best results were radiation and a two year duration of ADT. On the ADT there did not seem to be a large difference in whether it was single, double or triple blockade when looking at OAS. So far, I am satisfied with my choice and my last PSA was a 0.10. Hoping that was not an error and will repeat it in a few weeks.
 
Best to you.
Don
Diagnosed 04/10/08 Age 58 at the time
Gleason 4 + 3
DRE palpable tumor on left side
100% of 12 cores positive for PCa range 35% to 85%
Bone scan clear and chest x ray clear
CT scan shows potential lymph node involvement in pelvic region
Started Casodex on May 2 and stopped on June 1, 2008
Two years on Lupron completed 01/2010.
Started IMRT/IGRT on July 10, 2008. 45 treatments scheduled
First 25 were full pelvic for a total dose of 45 Gray to lymph nodes.
Last 20 to prostate only. Total dose to prostate 81 Gray.
Completed IMRT/IGRT 09/11/08.
PSA 02/08 21.5 at diagnosis
PSA 07/08 .82 after 8 wks of hormones
PSA 10/08 .642 one month after completion of IMRT, 6 months hormone
PSA 03/09 .38 six months post radiation and nine months into hormones
PSA 06/09 .36 or .30 depending on who did the test
PSA 09/09 .33 one year after IMRT and 16 months into hormone
PSA 03/10 .32 18 months after IMRT Still on hormones
PSA 05/10 .42 Rising a little as the lupron wears off. Last lupron shot 01/10.
PSA 06/10 .322 Maybe the .42 reported in May was in error?
PSA 07/14/2010 0.1

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4237
   Posted 8/5/2010 6:56 PM (GMT -6)   
It's not hard to belive that adjuvant therapy works with the higher gleason grades. HT works best when the tumor volume is still low. If surgery or radiation removes the bulk of the tumor then HT will kill the remaining cells that are still in the blood stream or in the margins. These are what usually cause a reoccurrance. It doesn't make much sense for the lower grades contained PC as the primary treatment has a very high probability of getting it all.
JT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 8/5/2010 6:59 PM (GMT -6)   
No this isn't for the T1/T2 guys unless they are N1 or M1 confirmed. There is some knowledge that the G8-10 guys with T1c may reap benefit in those stages, but you are really adding morbidity with smaller return. The best benefits I am seeing consistently are the clearly defined T3 and up guys.

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino

Post Edited (TC-LasVegas) : 8/5/2010 6:10:06 PM (GMT-6)


livinadream
Veteran Member


Date Joined Apr 2008
Total Posts : 1382
   Posted 8/5/2010 7:27 PM (GMT -6)   
Great article Tony and thanks for sharing it. I read your reply and I think it was accurate.

peace to you my brother

Dale
My PSA at diagnosis was 16.3
age 47 (current)

http://www.caringbridge.org/visit/dalechildress

My gleason score from prostate was 4+5=9 and from the lymph nodes (3 positive) was 4+4=8
I had 44 IMRT's
I was on Lupron, Casodex, and Avodart for two years with my last shot March 2009. I am currently (7-22-2010) not on any medication.
My Oncology hospital is The Cancer Treatment Center of America in Zion IL
PSA July of 2007 was 16.4
PSA May of 2008 was.11
PSA July 24th, 2008 is 0.04
PSA Dec 16th, 2008 is .016
PSA Mar 30th, 2009 is .02
PSA July 28th 2009 is .01
PSA OCt 15th 2009 is .11
PSA Jan 15th 2010 is .13
PSA April 16th of 2010 is .16
PSA July 22nd of 2010 is .71
Testosterone keeps rising, the current number is 156, up from 57 in May

T level dropped to 37 Mar 30th, 2009
cancer in 4 of 6 cores
92%
80%
37%
28%

zufus
Veteran Member


Date Joined Dec 2008
Total Posts : 3149
   Posted 8/5/2010 9:09 PM (GMT -6)   
Now maybe they will eventually compare various other drugs to use prior or with primary treatments....well wishful thinking anyway.
Youth is wasted on the Young-(W.C. Fields)

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 8/6/2010 12:02 AM (GMT -6)   
It's up to the people manufacturing and providing the various drugs, Bob. They certainly can start using study protocols to get statistical data. The problem is that many of the doctors using the numerous and various options use case study and not stringent study criteria. That's not to say that they are not on to something, it just makes it harder to report on their efficacy or for people to trust reported results.

Just a thought...

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino

zufus
Veteran Member


Date Joined Dec 2008
Total Posts : 3149
   Posted 8/6/2010 7:41 AM (GMT -6)   
Just my own bizarre ideas I would think prior treatment with estrogenics(maybe even Keto, Leukine and a few select other drugs) might have even better results, because they work on hrpca and Lupron or LHRH and even casodex are found inferior on that level. I think early refractive or risker patients could have an even better chance either for possible cure (I know bizarre thought) or longer remissions and survival times. But, there is no money or incentive for these money people to get excited about to work on such (except for the Journal Article from Nov. 2003 on DES, very objective findings and the docs commentary on it was priceless), I would say keep your eyes pealed to further findings that are outside what we call the norm.

Tony do you know how to get Dr. Premoli's published results on estradiol patches, he published it in his country I had heard from him about that directly, naturally our Journal publications were not interested even in mentioning his patient studies and results (yeah if it isn't done here it has no value???). I have read what UsToo.org had on this and some of that comes from Dr. Premoli, I am talking about either an abstract or Journal article from him, I would love to read it.
Youth is wasted on the Young-(W.C. Fields)

don826
Veteran Member


Date Joined May 2008
Total Posts : 1010
   Posted 8/6/2010 10:35 AM (GMT -6)   
On the subject of sequence of treatments there was an interesting article on Science Daily a few months back that related information from a small study where the patient received IMRT first followed shortly by surgery before the radiation damage set in. It appeared to be successful. I questioned my oncologist about this and he was not aware of the study and left me with a "no comment" sort of reply.

Don
Diagnosed 04/10/08 Age 58 at the time
Gleason 4 + 3
DRE palpable tumor on left side
100% of 12 cores positive for PCa range 35% to 85%
Bone scan clear and chest x ray clear
CT scan shows potential lymph node involvement in pelvic region
Started Casodex on May 2 and stopped on June 1, 2008
Two years on Lupron completed 01/2010.
Started IMRT/IGRT on July 10, 2008. 45 treatments scheduled
First 25 were full pelvic for a total dose of 45 Gray to lymph nodes.
Last 20 to prostate only. Total dose to prostate 81 Gray.
Completed IMRT/IGRT 09/11/08.
PSA 02/08 21.5 at diagnosis
PSA 07/08 .82 after 8 wks of hormones
PSA 10/08 .642 one month after completion of IMRT, 6 months hormone
PSA 03/09 .38 six months post radiation and nine months into hormones
PSA 06/09 .36 or .30 depending on who did the test
PSA 09/09 .33 one year after IMRT and 16 months into hormone
PSA 03/10 .32 18 months after IMRT Still on hormones
PSA 05/10 .42 Rising a little as the lupron wears off. Last lupron shot 01/10.
PSA 06/10 .322 Maybe the .42 reported in May was in error?
PSA 07/14/2010 0.1

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 8/6/2010 11:09 AM (GMT -6)   
Here is one such study:
www.pcainaz.com/Pages/ETE_eng.pdf

They acknowledge that this is not a controlled study, but the results are decent. I am a gluten for punishment every time I mention that I don't like non-controlled studies here. But I am firm there and I think for good reason. But I don't turn the acceptance of data off, I just remain skeptical.

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 8/6/2010 11:14 AM (GMT -6)   
Don,
That again is a single case study. Few doctors will jump all over it. Most surgeons will stay away from that type of surgery. i understand that Mayo has the best salvage RP program, but it's relegated to extreme cases. They call it tumor debulking and it does work for those patients who are in absolute need of it. And by "work" it has been known to extend survival...

One HW member here whose husband had that surgery was "divo"... She live in Connecticut. She is a well known artist, her husband a scientist. I haven't heard from her in a while, but I have her contact information...

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino

goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2691
   Posted 8/7/2010 8:06 PM (GMT -6)   
My question is probably one more of odds and statistics than studies that show the potential value of adjuvant radiation.
 
It comes down to the potential risks of radiation without a clear diagnosis versus the odds of having a surgical cure without the adjuvant therapy.  Probably even a third dimension to this dilema is the odds that the PC is systemic, and that the adjuvant will not get it either.
 
In my case with a T3 G9, this study would imply that I was a potential gainer by undergoing adjuvant therapy.  However with incontinence, and with excellent post-op PSA's, I chose to follow the surgeon's advice who said that more current thinking was to wait for rises in PSA before undergoing salvage.
 
So, now at 15 months and PSA < .01, I am getting cautiously optimistic that the surgeon may have gotten it.  In another 10 years I will be a little more certain.  But my question still remains unanswered.  Should I have underone adjuvant based on some of these studies that showed a 40 to 50 % chance of a curative treatment vs a 30 to 40 % with slavage treatment, and a 1 1/2 % chance of radiation tumors, and permanent incontinence, and potentially permanent ED.
 
I guess I am playing the odds here.  For a 10 % better chance of a cure, with potential or worse QOL issues, and the potential for radiation induced tumors, and rectal damge, etc., etc., I decided that the numbers weren't there.  I am waiting for PSA increases. 
 
I suppose my age plays a part here as well.  I guess my entire point of this post is that this is not a simple decsion that is easily arrived at, and nothing but upside.  There is a rather complex decsion tree here.
Goodlife
 
Age 58, PSA 4.47 Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09   Nerves spared, but carved up a little.
0/23 lymph nodes involved  pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks .
Neg Margins, bladder neck negative
Living the Good Life, cancer free  6 week PSA  <.03
3 month PSA <.01 (different lab)
5 month PSA <.03 (undetectable)
6 Month PSA <.01
1 pad a day, no progress on ED.  Trimix injection
No pads, 1/1/10,  9 month PSA < .01
1 year psa (364 days) .01
15 month PSA <.01

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 8/7/2010 10:06 PM (GMT -6)   
Goodlife, we are the same age, but on paper, your stats are more serious, but then I have all the velocity issues. It's hard sometimes to know what to do with a post surgery secondary treatment. There are always gambles and tradeoffs, which was why I was hoping I didn't need to jump into SRT. In my case, I had pretty good reason from past experience that any radiation again would do a lot of damage to me, and it has proven to be the case. Your PSA numbers are outstanding when you consider your overall stats. So sometimes. we jump the gun, and sometimes, we miss the best shot, just not way of being certain. That's the hard part of PC to me, regardless of how educated one is with the facts, figures, treatment options, it still comes down to an educated guess at best in my opinion. And we all hope we are guessing correctly. In my case, and the jury is still out, but if my SRT fails to halt the PC, I will always be angry at myself for given in to SRT against my gut feeling. If I knew it wasn't going to work long term, I would have never put my body through the hell it has been and still is all these months later. Not a fair disease by any means, but we all have to do what we feel we have to do, and hope for the best. I hope your numbers stay good for a long, long time, and that you stay on the good side of the percentages.

David in SC
Age: 58, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin

Incontinence: 1 Month ED: Non issue at any point post surgery, no problem post SRT
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16

Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 3
Latest: 7/9 cath #6 - 41 days, 8/9 2nd corr surgery, 8/9 cath #7 - 38 days, mapped 9/9, 10/1 - 3rd corr. surgery - SP cath, 10/5 - 11/27 IMRT SRT 39 sess/72 gys ,cath #8 33 days, Cath #9 35 days, Cath #10 43 days, 1/19 - Corr Surgery #4, Caths #11 and #12 ,Cath #11 - 21 days, Cath #12 - 41 days, 3/2- Corr Surgery #5, Cath #13 - 4 days, Cath #14- 27 days, Cath #15 - 26 days, Cath #16 - 31 days, Cath #17 - 39 days, 7/2 - Corr Surgery #6, Cath #18 - 13 days, Cath #19 - 17 days, Total Blockage, Cath # 20 - 7/19

goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2691
   Posted 8/8/2010 5:56 PM (GMT -6)   
David,

I thought of you as I wrote my post. If you had done adjuvant radiation and didn't need it, all of your trials for the last year would have been needless.

Since your stats necessitated SRT, then you paid your money and took your chances. You only had statisically a 25 to 35 percent chance once you started, so the odds weren't with you.

I would/will do exactly as you have done. I will go a step further and say that in all likelihood I will do HT as well if I think I can maintain a good QOL for a few more years. I see guys like Dale and others who have had some good years on HT. I see no real reason not to.

The point of my post was that SRT is a better gamble than Adjuvent. At this point it is a gamble.

Wishing you the best in the coming months. You have fought as good a fight as any on here. I think that if you can get the catheter situation under control, that your attitudes may change about HT if you are feeling well, and able to function like a normal guy. Life is good, and if HT can give us a few more years of good life, then there isn't a lot of downside.
Goodlife
 
Age 58, PSA 4.47 Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09   Nerves spared, but carved up a little.
0/23 lymph nodes involved  pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks .
Neg Margins, bladder neck negative
Living the Good Life, cancer free  6 week PSA  <.03
3 month PSA <.01 (different lab)
5 month PSA <.03 (undetectable)
6 Month PSA <.01
1 pad a day, no progress on ED.  Trimix injection
No pads, 1/1/10,  9 month PSA < .01
1 year psa (364 days) .01
15 month PSA <.01
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