When is Hormone Therapy recommended in addition to Brachytherapy

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MacroMan
Regular Member


Date Joined Aug 2017
Total Posts : 29
   Posted 10/31/2017 12:24 PM (GMT -7)   
While waiting for an appointment with a radiation oncologist, this one question may determine which treatment I decide on.

My urologist suggests that if I choose radiation that Hormone Therapy would be needed.

Although only one of 13 cores was positive, it showed 40% of a 10mm core with GS (4+4) 8.

I suspect that any gleason grade 4 cancer triggers a bone scan, which I'm getting on Friday.

Does this High Risk cancer also require ADT?
DOB: Oct 1955
Greater Vancouver

PSA 4.4 May'16
5.79 Oct'16
5.0 Jan '17
7.1 Apr'17
6.1 Sept'17

MRI Jun'17
Prostate Biopsy late Sept'17
Prostate Size 36cc

Dx Oct. 16, 2017
1 core (Right Side -Mid medial) of 13 showed cancer (adenocarcinoma) GS 8 4+4 40%
PIN - High Grade 1 core (Right Side - Base Lateral)
Low Tier - High Risk

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3558
   Posted 10/31/2017 1:34 PM (GMT -7)   
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..
Age now 75 . Diagnosed G-9 6/2010. RALP, Radiation failed
Lupron, Zytiga, PSA <0.1 10/16 no change <0.1 5/17 PSA 1.6 Chemo or Provenge next..Sept '17, PSA now 9.2. ADT including Zytiga has failed. Will investigate treatment options. 11/17 PET/CT clear, but 4 new bone mets..Going to try Xtandi and see how I respond to that..

Tall Allen
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Date Joined Jul 2012
Total Posts : 8827
   Posted 10/31/2017 1:50 PM (GMT -7)   
In the ASCENDE-RT study, all patients received 12 months of ADT, but it was started 8 months before radiation began. They did this so that all patients would be treated exactly the same. Because some guys have prostates too large for seeds, they shrink the prostate first in those cases with ADT. It's possible that your prostate doesn't require pre-shrinking. But that would still leave 4 months of ADT. I would assume they follow the ASCENDE-RT protocol, but they may make allowances for individual cases now. You would have to ask them.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

Philmire
Regular Member


Date Joined Oct 2017
Total Posts : 54
   Posted 11/3/2017 5:55 AM (GMT -7)   
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.

MacroMan
Regular Member


Date Joined Aug 2017
Total Posts : 29
   Posted 11/9/2017 7:32 AM (GMT -7)   
My visit with a RO said my prostate felt more like 25cc.

He also said that since my GS8 (4mm) is so small that he'd do brachytherapy on me without HT.
DOB: Oct 1955
Greater Vancouver

PSA 4.4 May'16
5.79 Oct'16
5.0 Jan '17
7.1 Apr'17
6.1 Sept'17

MRI Jun'17
Prostate Biopsy late Sept'17
Prostate Size 36cc

Dx Oct. 16, 2017
1 core (Right Side -Mid medial) of 13 showed cancer (adenocarcinoma) GS 8 4+4 40%
PIN - High Grade 1 core (Right Side - Base Lateral)
Low Tier - High Risk

Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 8827
   Posted 11/9/2017 11:21 AM (GMT -7)   
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.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

MacroMan
Regular Member


Date Joined Aug 2017
Total Posts : 29
   Posted 11/9/2017 11:49 AM (GMT -7)   
Thanks for your input Tall Allen.

Here's a publication given to me by Dr. Tom Pickle himself regarding the need for ADT.

http://www.brachyjournal.com/article/S1538-4721(17)30425-7/abstract
DOB: Oct 1955
Greater Vancouver

PSA 4.4 May'16
5.79 Oct'16
5.0 Jan '17
7.1 Apr'17
6.1 Sept'17

MRI Jun'17
Prostate Biopsy late Sept'17
Prostate Size 36cc

Dx Oct. 16, 2017
1 core (Right Side -Mid medial) of 13 showed cancer (adenocarcinoma) GS 8 4+4 40%
PIN - High Grade 1 core (Right Side - Base Lateral)
Low Tier - High Risk

Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 8827
   Posted 11/9/2017 12:38 PM (GMT -7)   
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.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

Michael_T
Veteran Member


Date Joined Sep 2012
Total Posts : 2512
   Posted 11/9/2017 12:46 PM (GMT -7)   
MacroMan...were you contemplating brachy as a mono therapy, or in conjunction with IMRT?
Age 56, Diagnosed at 51
PSA 9.6, Gleason: 9 (5+4), three 7s (3+4)
Chose triple play of HDR brachy, IMRT and HT (Casodex, Lupron and Zytiga)
Completed HT (18 months) in April 2014
3/17: T = 167, PSA = 0.13

MacroMan
Regular Member


Date Joined Aug 2017
Total Posts : 29
   Posted 11/9/2017 5:04 PM (GMT -7)   
Michael_T, I'm contemplating brachytherapy as a mono therapy.
DOB: Oct 1955
Greater Vancouver

PSA 4.4 May'16
5.79 Oct'16
5.0 Jan '17
7.1 Apr'17
6.1 Sept'17

MRI Jun'17
Prostate Biopsy late Sept'17
Prostate Size 36cc

Dx Oct. 16, 2017
1 core (Right Side -Mid medial) of 13 showed cancer (adenocarcinoma) GS 8 4+4 40%
PIN - High Grade 1 core (Right Side - Base Lateral)
Low Tier - High Risk

Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 8827
   Posted 11/9/2017 5:38 PM (GMT -7)   
MacroMan-

You are talking about low dose rate brachytherapy (seeds), right? I just assumed you were getting a brachy boost since you are being treated at the place that proved its effectiveness. When you said you were considering forgoing ADT, I thought, risky but at least you are getting dose escalation. Forgoing both decreases your odds of success considerably. Is this something your doctor recommends?

In the ASCENDE-RT trial, they reported "Among those with high-risk prostate cancer, 9-year bPFS was 83% for the brachy boost cohort vs. 62% for EBRT-only." (all had ADT too.)

/pcnrv.blogspot.com/2017/03/brachy-boost-gold-standard-for.html

There hasn't yet been a trial of brachy boost vs. brachy monotherapy in high risk men. But you can see in the following that brachy monotherapy (at Cleveland Clinic) had a 5-yr bRFS of 68% (undoubtedly, it would be somewhat lower at 10 years). That compares to a 9-yr bRFS for brachy boost in the ASCENDE-RT of 83% and an 8-yr bRFS of 86% at UMich/Schiffler.

/pcnrv.blogspot.com/2016/08/ldr-brachytherapy-ldrbt-monotherapy.html

Most of the high risk men in all of those studies were Gleason 8.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

PDL17
Regular Member


Date Joined Oct 2011
Total Posts : 464
   Posted 11/9/2017 8:33 PM (GMT -7)   
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
Gleason 3+4; 5/16 positive cores; average volume 30%; PSA prior to tx 4.8
TX-IMRT + brachytherapy; IMRT Nov. 2011; Brachytherapy Feb. 2012
PSA April 2012--3.6
PSA May 2012--2.5
PSA Aug 2012--2.2
PSA Nov 2012--2.9
PSA Feb 2013--2.8
PSA May 2013--2.1
PSA Aug 2013--2.3
PSA Nov 2013--2.5
PSA May 2014--1.1
PSA Dec 2014--0.8
PSA Jun 2015--0.5
PSA Jan. 2016--0.4
PSA Aug. 2016--0.4
PSA Mar. 2017--0.3

MacroMan
Regular Member


Date Joined Aug 2017
Total Posts : 29
   Posted 11/9/2017 9:27 PM (GMT -7)   
My fusion (MRI guided) biopsy found one core of GS8 totalling 4mm of cancer.

If I was to magically add lots of Gleason Grade 3 cancer to this core as well as the other 12 cores I wouldn't be high risk, instead I'd be classified as intermediate risk.

My RO knows I don't want HT and he's willing to treat me as IR.
DOB: Oct 1955
Greater Vancouver

PSA 4.4 May'16
5.79 Oct'16
5.0 Jan '17
7.1 Apr'17
6.1 Sept'17

MRI Jun'17
Prostate Biopsy late Sept'17
Prostate Size 36cc

Dx Oct. 16, 2017
1 core (Right Side -Mid medial) of 13 showed cancer (adenocarcinoma) GS 8 4+4 40%
PIN - High Grade 1 core (Right Side - Base Lateral)
Low Tier - High Risk

Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 8827
   Posted 11/9/2017 10:05 PM (GMT -7)   
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.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

Post Edited (Tall Allen) : 11/10/2017 6:12:49 AM (GMT-7)


Philmire
Regular Member


Date Joined Oct 2017
Total Posts : 54
   Posted 11/10/2017 7:18 AM (GMT -7)   
Dumb question, can seeds be recharged with IMRT?

Philmire
Regular Member


Date Joined Oct 2017
Total Posts : 54
   Posted 11/10/2017 7:24 AM (GMT -7)   
All of this is very interesting and informative but wouldn't SBRT be more effective and easier ?

Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 8827
   Posted 11/10/2017 11:09 AM (GMT -7)   
Philmire-

No - seeds can't be recharged. They are made of a radioactive isotope of Iodine (sometimes Palladium or Cesium), called Iodine 125, encased in titanium. The Iodine 125 emits X-rays through a process called "electron capture," which also changes one of its protons into a neutron. After that radioactive decay, it becomes Tellurium 125, which is no longer radioactive. Throwing more X-rays at Tellurium 125 won't reverse the process.

You're right that SBRT can deliver a very high biologically effective dose that may be capable of killing GS 8-10 tumors. For that reason, SBRT is being tried experimentally for high risk cases, but there isn't yet enough long-term data for it to become standard of care. The OP is fortunate that some of the top brachytherapy doctors are in Vancouver near where he lives .
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

MacroMan
Regular Member


Date Joined Aug 2017
Total Posts : 29
   Posted 11/10/2017 11:49 AM (GMT -7)   
Thanks for all your insightful comments.

I have a lot to consider.
DOB: Oct 1955
Greater Vancouver

PSA 4.4 May'16
5.79 Oct'16
5.0 Jan '17
7.1 Apr'17
6.1 Sept'17

MRI Jun'17
Prostate Biopsy late Sept'17
Prostate Size 36cc

Dx Oct. 16, 2017
1 core (Right Side -Mid medial) of 13 showed cancer (adenocarcinoma) GS 8 4+4 40%
PIN - High Grade 1 core (Right Side - Base Lateral)
Low Tier - High Risk
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