Is ADT Always Advised with ART In Localized High Risk Cancers?

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Zlife
New Member


Date Joined Jan 2018
Total Posts : 5
   Posted 3/7/2018 9:37 AM (GMT -6)   
I have a post-surgery consult with a radiation oncologist scheduled to discuss adjuvant radiation therapy in early April.

Based on my surgical pathology, the radiation oncologist believes that adjuvant radiation therapy is warranted but wants to wait until my first post-surgery PSA in May before deciding on use of ADT with ART.

If the initial PSA is undetectable that is presumably a good sign; however, if it rises later, that correlates with poorer outcomes.

I would rather hit hard at the beginning rather than fight a defensive battle later on.

From what I have read here and elsewhere, I thought that ADT always accompanied ART. I gather I was mistaken.

Any views on advocating for ADT even if the initial post-surgery PSA @ 3-months comes back undetectable?

Reasoning: Adverse pathology findings (single 3-mm positive margin with Gleason 8 score) plus extraprostatic extension (perhaps with capsular inclusion)

If ADT is advised, any views on advocating for adding Zytiga based on STAMPEDE and given my high risk cancer?

Following are my particulars to-date.

Thanks for being such a terrific source of information - It helps all of us on our respective journeys.

=============
Age 61
PSA 4.06 on 9/19/2017
Bx on 12/2017 - 4/12 cores pos - 1 core G 7, 3 cores G 8
RALP on 2/12/2018 @ Johns Hopkins
Surg Path
" SV and Nodes neg
" Stage - pT3a: Extraprostatic extension or microscopic bladder neck invasion
" G Score - Dominant Nod: 4+4=8 Grade Group: 4 (Tert Patrn 5)
" G Score - Secondary Nod - 3+4=7, Grade Group: 2 10% Patrn 4
" Tumor dimension (max): 20.0 mm
" Local Extent:
o Extraprostatic extension.
o location/extent of extraprostatic extension Rt posterolateral mid, focal.
o Margins Pos
o Pos in an area where it is difficult to distinguish extraprostatic extension vs capsular incision.
o Summed length of positive margin: 3 mm
o Highest grade at margin = 4+4=8

Progressing
Regular Member


Date Joined Aug 2017
Total Posts : 219
   Posted 3/7/2018 10:06 AM (GMT -6)   
I’m seeing an RO at MSKCC. After another bone scan and MRI, maybe psma, if all goes well he will start me on 6 months of ADT, with RT in the middle two months. Technically I’m “early salvage” rather than “adjuvant,” don’t know if that makes a difference. My EPE was focal and margins all negative, G4+3.
Age 76, excellent health except PCa
Psa 7/13=8 with BPH, 9/17=20.44
7/20/17, Biopsy, 5/12 cores PCa all right side, Gleason 4+3, PNI
MRI and CT no evidence of metastases
Laparoscopic surgery MSKCC 10/31/17, left nerves spared, pathology T3aN0, G4+3, focal EPE, negative margins, no multicentricity, BPH
Continent but ED
12/14/17-psa 0.10; 1/25/18-0.11, 3/5/18 - 0.12.

Saipan Paradise
Veteran Member


Date Joined Sep 2017
Total Posts : 632
   Posted 3/7/2018 10:27 AM (GMT -6)   
Welcome, Zlife!
Our pathologies are similar. I consulted three ROs post-RP, all wanted to add ADH, only question for how long. I start early salvage Monday with an RO who wants me on the juice 9-12 months.
Age 60 at dx
Dx July 2017 after biopsy G8 (4+4), 5/13 cores, bone scan clear
RARP Aug 11, 2017 (Dr Patel)
Post surgery pathology: pT3a, tumor 30% of gland; EPE+, SV- and 3 lymph nodes clear
PSA 1/2016, 2.9; 4/2017, 7.2; 9/2017 (first post-RARP), 0.13; 10/2017, <0.05, 1/9/2018, 0.09, 1/31/2018, 0.10, 2/9/2018, <0.05(!?), 2/23/2018, 0.08.

Hardlyrob
Regular Member


Date Joined Sep 2017
Total Posts : 98
   Posted 3/7/2018 11:43 AM (GMT -6)   
Welcome zlife!

Our surgical outcomes are similar, but your Gleason scores are somewhat worse. My uro was recommending ADT / ART (SRT) even before the first post surgery PSA was done.

I believe the studies show that SRT is more effective with ADT - the big question seems to be how long to keep people on ADT. The current bets are 6 months, 12 months, 18 months, 24 months. I recall a study that showed there was no improvement from 24 months to 36 months - so that's good.

I start salvage next Wednesday. Started Lupron in December '17 for 18 months.

Good luck, and let us know what happens.

Rob
5/2017 PSA 34.2 age 53
6/2017 Dx by biopsy - 9 of 14 positive; Gleason 7 (4+3) 5% to 90% cancer
8/24/2017 RARP, Dr. Canes - Lahey Burlington (MA)
4/8 lymph nodes positive
Extraprostatic extension
Positive margin 5 MM
Seminal vesicle invasion
pT3b; pN1; M0
10/24/17 PSA 0.13
12/11/17 Started 18 months of Lupron
1/18 PSA <0.1; T=31
SRT 3/14 - 5/7/18 - 39 fractions

RobLee
Veteran Member


Date Joined Apr 2017
Total Posts : 708
   Posted 3/7/2018 3:27 PM (GMT -6)   
Hey Rob, other Rob here... It looks like I'm just a year and a decade ahead of you. My first biopsy was at age 63, RP was 8/30/16 with SVI but neg SM & neg nodes. Started Lupron Jan 2017 for 18 months. Good luck with your adjuvant RT.
2014-15: PSA's 9, 12, 20, 25... Neg DRE's, false neg TRUS biopsy
6/16: MRI Fusion biopsy, Right Base, 2x40%+2x100% all G8 (4+4)
8/16: DaVinci RP, PNI, 6mm EPE, 11 LN-, 53g 25% involved Grp 4, BL SVI, T3b n0m0
1/17: started 18 months Lupron ADT, PSA's ~.03
5/17: AMS800 AUS implanted, revised 6/17
8/17: RapidArc IMRT 39 tx (70 Gy) Aug-Oct 2017
1/18: PSA 0.00, Now test every 3 months for a trend

Zlife
New Member


Date Joined Jan 2018
Total Posts : 5
   Posted 3/7/2018 5:13 PM (GMT -6)   
Thanks All.

Very helpful.

It had not occurred to me that the radiation oncologist may be waiting for the initial PSA to determine the nature and duration of ADT as opposed to no ADT at all (which is what I had assumed).

Good luck to all with your treatment and monitoring plans.

Skypilot56
Veteran Member


Date Joined Mar 2017
Total Posts : 647
   Posted 3/7/2018 5:22 PM (GMT -6)   
Zlife if you go over to the ADT and SRT thread there are lots of guys there telling their stories and experiences with both ADT and SRT

Larry
Male 62 DX @ 60
Dad had PC
2002. Psa. .08 Enlarged Prostrate
2014. Psa. 3.8
2016. Psa. 19
3-08-17 RP Mayo, Mn
Gleason 9, pt3b, SV + 1 nerve, N-Margins 35 LN removed clear
Prostrate 45 grams
4-20-17 Incarcerated Umbilical Hernia
6-13-17 psa 0.13
7-19-17 psa 0.12 3TMRI with coil - clear
10-11-17 psa 0.16
10-12-17 Lupron
12-13-17 psa <0.10
12-18-17 SRT
2-7-18 SRT done 72gy

Zlife
New Member


Date Joined Jan 2018
Total Posts : 5
   Posted 3/7/2018 5:39 PM (GMT -6)   
Thanks for the tip! Lots of good info there.

InTheShop
Veteran Member


Date Joined Jan 2012
Total Posts : 8618
   Posted 3/7/2018 6:30 PM (GMT -6)   
ADT isn't always given. Depends on the risk factors. The other open question is duration - I've seen that all over the map up to two years.

If you want to be agressive, then opt for the longer time, but understand it will have an effect on your quality of life during that time.

Andrew
I'll be in the shop.
Age 58, 52 at DX
PSA:
4.2 10/11, 1.9 6/12, 1.2 12/12, 1.0 5/13, .6 11/13,
.7 5/14, .5 10/14, .5 4/15, .3 10/15, .3 4/16, .4 10/16, .4 5/17, .3 10/17
G 3+4
Stage T1C
2 out of 14 cores positive
Treatment IGRT - 2/2012
My latest blog post

Tall Allen
Elite Member


Date Joined Jul 2012
Total Posts : 10121
   Posted 3/7/2018 7:04 PM (GMT -6)   
I don't think there's much risk in waiting for a 3-month PSA. (Maybe move it to 2 months). And maybe you'll be surprised by a very low uPSA, which may indicate that you can just monitor it. But any PSA over 0.03 for your case should be a trigger for early SRT. I notice that your pre-treatment PSA was low compared to what was discovered at your pathology. Some ROs use a rule of thumb that if the PSA <0.5, ADT can be withheld. But with your GS 4+4 (tert.5) at the margin and your lowish PSA, maybe a lower bar should be used for you. Please share your May (or April) uPSA when you get it and let's discuss it further then.
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

Zlife
New Member


Date Joined Jan 2018
Total Posts : 5
   Posted 3/8/2018 10:10 AM (GMT -6)   
Thanks very much Tall Allen.

I was unaware of the availability of the ultra-sensitive PSA (uPSA) until you mentioned it.

I had read that some high risk cancers become so highly-differentiated that they can produce unusually low levels of PSA. So, setting a flag of uPSA > 0.03 makes sense.

I will ask for a uPSA script when I see my RO in April.

Also, I checked out your excellent blog. What a terrific resource. I will be using your "Questions for a Adjuvant or Salvage Radiation Interview" when I see my RO. Thanks very much for all you do for all of us.

Zlife
New Member


Date Joined Jan 2018
Total Posts : 5
   Posted 5/1/2018 12:33 PM (GMT -6)   
Update -
I had my first (3-month) post-RALP uPSA test result. It came in as <0.006. Good news indeed.

I also had another look at my surgical pathology report and noticed a finding that I had overlooked: “Focal duct adenocarcinoma features.”

From what I have read, that may explain why I had a relatively modest screening PSA of 4.06 but a Gleason 8 (4+4, tert 5) scoring. Apparently focal duct adenocarcoma tissue produces comparatively less PSA. All the more reason to use uPSA vs a conventional PSA in my case so thanks again for the uPSA recommendation.

Prior to my 3-month uPSA, I had a consult with my radiation oncologist at Johns Hopkins. He advised adjuvant radiation therapy because of my adverse pathology findings (3mm positive margin Gleason 8 + EPE). He said, however, that if my 3-month uPSA was undetectable he would not advise androgen deprivation therapy. Unless I hear otherwise from him, my plan is to undergo adjuvant RT (38 treatments) beginning in June.

Thanks to everyone for your helpful comments and for this terrific informational resource.

Saipan Paradise
Veteran Member


Date Joined Sep 2017
Total Posts : 632
   Posted 5/1/2018 2:38 PM (GMT -6)   
Super uPSA news! Thanks for sharing.
Age 60 at dx 7/2017 biopsy G8 (4+4), 5/13 cores
RARP 8/2017 (Patel), pT3a N0 M0, 30% tumor; EPE+, SV-
PSA 1/2016, 2.9; 4/2017, 7.2; 9/2017 (post-RARP), 0.13; 10/2017, <0.05, 1/9/2018, 0.09, 1/31/2018, 0.10, 2/9/2018, <0.05(!?), 2/23/2018, 0.08.
Eligard started 3/2/2018. SRT started 3/12/2018, 72Gy
Caution: I’m not an MD and don’t know what I’m talking about.

fiddlecanoe
Regular Member


Date Joined Oct 2016
Total Posts : 323
   Posted 5/1/2018 5:07 PM (GMT -6)   
How are you doing with the side effects? That might affect how soon you start the ART.
Age: 62
Diagnosed in July 2016 with G7 (4+3) PC & PNI
Bone & CT scans clear
Surgery at Lenox Hill Hospital in NYC, 9/12/2016
Post-surgery pathology showed G7 (3+4), with SVI and PSM
Lymph nodes clear
First post-surgery PSA October, 2016: <.008
Second post-surgery PSA December, 2016: 0.01
Third post-surgery PSA June 2017: 0.05
IMRT begun: July 18, 2017 (35 fractions)
Post-SRT PSA, 11/17: <.008
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