Posted 5/29/2020 6:05 PM (GMT -6)
I checked back with my urologist via email 2 days ago to get an update of when I might expect to get the 2nd opinion back from JH. Turns out it hadn't been sent yet! He informed me that my biopsy had been reviewed at conference by 7 pathologists (who all agreed on the readings) and asked if I was sure I wanted that 2nd opinion, because the cost wouldn't be covered. I told him yes, please do send that! In the meantime, six days were wasted from this lack of communication. So hopefully it's on its way to them.
I received a written summary of my phone visit with the RO from last week, and thought I'd post it here for anyone's opinions and for future reference. He makes the case for ADT, some of the members here have thoughtfully expressed their reasons for declining that treatment in addition to SBRT. Truth be told, I'm now finding myself on the fence. I'm of course motivated to do this the "right" way, but don't want to enter the realm of over-treatment either.
The copy of my RO's statement follows:
We had a detailed PARQ conference today.
We discussed the natural history of prostate cancer, as well as the risks of both local and distant progression. Given the intermediate-risk nature of his disease, treatment is usually recommended. Such treatment typically consists of either radiotherapy in combination with androgen deprivation therapy versus radical prostatectomy with pelvic lymph node dissection, potentially followed by risk-adapted radiotherapy.
As an alternative to treatment, some patients may opt for active surveillance, consisting of serial monitoring of PSA serum levels as well as periodic biopsy of the prostate itself, followed by treatment at disease progression. However, the largest study of active surveillance in men with intermediate risk prostate cancer found that the risk of developing metastases at 15 years was 16% in patients with Gleason score 7 (3+4) disease and 37% in men with Gleason score 7 (4+3) disease. This is in contrast to a 6% risk in men with Gleason score 6 disease with a PSA less than 20 ng/ml (Musunuru et al. J Urol 2016).
With regard to treatment, dose-escalated radiotherapy is typically administered over multiple weeks using external beam, intensity modulation and image guidance. External beam radiotherapy alone achieves excellent results in terms of disease control. For instance, in an analysis of 849 men with intermediate risk disease treated with this technique at Memorial Sloan Kettering, the seven-year PSA relapse-free survival rate was 72 percent. The distant metastasis-free and cause-specific survival rates at seven years for men with intermediate-risk disease were 92 and 94%, respectively (Zelefsky et al. IJROBP 2008).
Additionaly, as demonstrated by the randomized RTOG 0232 trial, brachytherapy alone may be an appropriate treatment for men with intermediate risk disease who fall into one of the following categories: A) Gleason Score 6 and PSA >10 but <20 or B) Gleason Score 7 and PSA <10. However, brachytherapy comes with an increased risk of urinary toxicity compared to external beam radiotherapy alone, and requires a prostate volume of less than 60 cc and an IPSS of < 16 (Prestidge et al. ASTRO 2016).
The use of concomitant, short-term androgen deprivation therapy is controversial for men receiving radiotherapy for intermediate-risk prostate cancer. However, an evidence based approach was proposed by Memorial Sloan Kettering and involves the use of androgen deprivation therapy in men with unfavorable intermediate risk disease (those men with either more than one intermediate risk factor, primary Gleason pattern 4, or 50% or greater biopsy core positivity), while omitting it in those men with favorable disease that does not meet the above criteria (Zumsteg et al. Lancet Oncology 2012).
In the EORTC 22991 trial, 819 patients were randomly assigned to radiotherapy with or without six months of androgen deprivation therapy; 75 percent had intermediate-risk disease, and 25 percent had high-risk disease (Bolla et al. J Clin Oncol. 2016). At a median follow-up of 7.2 years, biochemical disease-free survival was significantly improved with the use of androgen deprivation therapy (five-year rate, 83 versus 70 percent). Similarly, the clinical progression-free survival was significantly improved with the use of a six-month course of ADT (five-year rate, 88.7 versus 80.8 percent).
With regard to the optimal duration of androgen deprivation therapy, the DART 01/05 trial randomized 355 men to radiotherapy with either 4 months or 28 months of goserelin. Men with intermediate risk cancer did not benefit from longer testosterone suppression and these patients experienced nearly identical rates of biochemical failure between the two arms (Zapatero et al. Lancet Oncol 2015). This is consistent with the findings from RTOG 92-02, which on subgroup analysis found that long-term androgen deprivation therapy did not benefit those with intermediate risk disease (Horwitz et al. JCO 2008).
Finally, stereotactic body radiotherapy (also known as ultra-hypofractionation) offers excellent biochemical control and a favorable side effect profile, both comparable to more conventionally fractionated radiotherapy but accomplished in fewer treatments (Kishan et al. Seminars in Radiation Oncology 2017). However, the technical aspects of this technique are more involved and require both implantation of fiducial markers as well MRI simulation. The use of stereotactic radiotherapy has been endorsed by ASCO, ASTRO, and the AUA as an appropriate option for men with low or intermediate risk prostate cancer (Morgan et al. JCO 2018). It equivalency in terms of disease control and side effect profile has been proven in recent randomized trials, such as PACE-B.
With regard to external beam radiotherapy, I explained the treatment planning process, including simulation and treatment planning. I explained the daily treatment itself as well as the expected duration of treatment.
We reviewed the potential short and long-term side effects of radiotherapy. Acutely, side effects can include fatigue, cystitis (manifested by increasing urinary symptoms such as frequency, urgency, nocturia, and dysuria), proctitis (with possible symptoms of diarrhea, tenesmus, and/or bleeding), and mild dermatitis. Long-term complications can potentially include but are not limited to symptomatic bowel or bladder sequelae, such as increased frequency, urgency, discomfort, or bleeding. We discussed the small risk of requiring surgical intervention for complication, including a remote chance of necessary colostomy or urostomy. We also discussed the risk of impotence, decreased ejaculate, urethral stricture, incontinence, fracture, arthritic changes in the hips, and second malignancy (such as rectal cancer). All of these risks were placed in their appropriate perspectives.
We also discussed the risks of androgen deprivation therapy including but not limited to decreased libido, erectile dysfunction, hot flashes, weight gain, gynecomastia, reduction in penile and testicular size, fatigue, and depression. There may also be an increased risk of cardiovascular events, kidney injury, and cognitive dysfunction. Finally, there is increased risk of osteoporosis and subsequent bone fractures, for which it is recommended that the all men receiving androgen deprivation therapy achieve a dietary calcium intake (food and supplements) of 1000 to 1200 mg daily and supplemental vitamin D 800 to 1000 international units daily. It is also recommended that such men perform weight bearing exercise, decrease alcohol consumption, and cease smoking.
The risks and benefits of treatment were placed in the context of the patient's other primary option, which is to forgo treatment at this time and instead follow his PSA closely with serial measurements.
The patient would like to roceed with leuprolide now, for atotal duration 4 months, then tentatively plan for stereotactic body radiotherapy in approximately 2 months, barring any changes in pathological review
I will contact Urology to arrange carbon marker placement and leuprolide.
CT and MRI simulations ordered for at least 10 days after fiducial marker placement and after he has been on leuprolide for a minimum of 6 weeks.
He had an opportunity to express his concerns and ask questions, which I answered to his satisfaction.
This consultation consisted of approximately 90 minutes spent with the patient, more than half of which consisted of counseling.