advice for locally advanced Pca

getalloseal

Hi
My father is 71 years old, and recently diagnosed with Pca. PSA = 28, 7/12 core positive (gleason score 4+4) from biopsy, one lymph node enlarged (2cmx3.4cm) and a gross extraprostate extension from MRI. The only good news is no bone or other distant metastasis found (I really hope that is true).

Our urologist recommends no surgery but the radiation therapy (RT) + ADT. I think that is the standard treatment for locally advanced Pca. We also get a second opinion from an experienced urologist, who but only recommend ADT for my father.

1. I have done a lot of research, and it seems RT + ADT can extend the patient’s life much longer than solely ADT. I personally think my father should get RT regardless of the side effects. What do you guys think? See the following link:
https://prostatecancerinfolink.net/2015/05/16/adt-and-radiation-for-first-line-treatment-of-node-positive-n1-prostate-cancer/

2. It is heard that prostate cancerous cell loses the energy to grow as the man aging. But is it still true for the more aggressive cancer as with gleason score 8?

3. We are in NYC. The doctor has referred us to the radiation oncologist, Dr. Richard F. Cohen, at NYU Langone medical center. Any one in NYC has experience with NYU Perlmutter Cancer Center? How is the radiation oncology there? I see they have the equipment of 4D CT to guide the radiation treatment, which seems more advanced than 3D CT. See the following link:
http://meddb.eznetpublish.ihealthspot.com/Demos/MedicalLibrary/Ophthalmology/tabid/2588/ctl/View/mid/4503/ContentPubID/419/dnnprintmodule/true/Default.aspx?SkinSrc=[G]Skins/_default/No Skin&ContainerSrc=[G]Containers/_default/No Container
However, I found that the best cancer center in NYC, Memorial Sloan kettering Cancer center, still use 3D CT. Is it still premature for 4D CT in EBRT? Finally, anyone could share some comment on Dr. Cohen?

4. I see some members on the forum received ADT for several months before RT, with the hope to shrink the prostate and better for rediation treatment. Our medical oncologist said that the shrinking may happen for certain patients. Should my father just wait for several months (taking ADT now) to see if prostate is shrunk or just go to radiation therapy immediately now?

Thank you all and best wishes to your health.

Tang

GeorgeG

I do not know the doctors or

I do not know the doctors or treatment center that you reference but I have been to MSK and they are outstanding. I would not hesitate to use them. They are on the cutting edge for radiation treatment using for instance seeds and photon beam at the upper limits of total dose with impressive results. They have also developed the predictive tools used worldwide to help guide treatment choices. As to if radiation is appropriate you will probably get differing opinions on this even from top centers so you will need to listen to multiple qualified opinions and see what sounds best. Depending on how strong the patient is I would lean into radiation plus at least 6 months of neo adjuvant ADT but I would want to MSK nomogram prediction for my exact situation to make sure that radiation has the probability of moving the needle enough to be worth the downside risk. I have had surgery and am currently undergoing radiation and ADT. For me, ADT has had worse side effects than the other two so far but everyone is different and not all treatment centers have the same level of competence.

Be thinking benefit vs risk and consider any competing mortality risk. In other words is it worth the downside risk and if left untreated, will PCA take the patient. Most 80 something's die with but not of Prostate cancer. 

George

 

VascodaGama

It all starts from reliable diagnosis

Tang,

Welcome to the board. I think you're doing well in researching before any decision. In any case the basic data in hand, serving in the judgment must be reliable. Confirming the diagnosis should be your first step, in particular if you opt for RT in a setting of apparent extraprostatic extensions, inspite of the experienced urologist's recommendation for ADT as solo therapy (what may be his reasoning?). In other words, you need to locate those metastases that will become the targets for radiation.

The article of your link refers to cases where radiation only has debulked cancer (shrinking the whole volume) therefore extending the life of patients. This is typical occurrences in patients with extraprostatic disease (including salvage treatments for RP) where the treatment is usually done on guessing (no precise targets to aim). 
RT works very well when the cancer is contained or when it is localized so that the radiologists can use reference data from traditional image exams (CT, MRI, Bonescan) to decide on the field of attack. They imagine the whole gland as a tumor and the surrounding area that would be zipped at the prostate bed, iliac lymph nodes and bone. Far metastases are subjected to spot radiation and must be located at convenient locations to avoid superimposing rads in areas already radiated. This is a difficult treatment that needs particular attention in isodose planning, but it could eliminate the bandit successfully.
As you can think, a reliable image exam is crucial in the decision (your dad's case). The best at present times is the PSMA PET scan which, if in your shoes I would do it before advancing with anything.

The info you share above classifies your dad with a T3b but the "gross extraprostatic extensions" could include invaded seminal vesicles (T3c) or even more extensions at the levator muscles and pelvic wall, turning his case into a T4. I do not know why but Gleason score 8 (4+4) cases have the history for being difficult to treat. My lay opinion on 4+4 cases is that they represent micrometastases of an aggressive type of cancer. In my researches I found that typically these (4+4) produce low levels of PSA serum when at soft tissue but high levels when at bone or LN. Your dad got a PSA of 28 ng/ml and an apparent LN metastasis (N1 2cmx3.4cm) that, in my lay opinion, could justify the high PSA. This is considered a High Risk case
The missing info regards distant metastases (M0) and in such respect I would be suspicious of the bone scan results. M0 could be guessed as M1b, and that leads to the conclusion of his doctor in recommending ADT. A better nuclear image specific for PCa in bone (PET FDG) could give you a better understanding on the extent of the disease.

Unfortunately, treatments for PCa cases with metastases not localized are considered systemic and to such extent palliative (extending the life of the patient with the prime goal in the quality of life). Most doctors recommend ADT and chemo, however there are some cases where the patient has a fewer number of metastases that can be treated with intent of cure with a combination of ADT+ Chemo plus spot RT. This is called oligometastatic treatment.

I had a look into  Dr. Richard F. Cohen past experiences and found several papers on head RT issues. Did not find any about PCa but surely as an experienced radiologist he (or his team) can do the job properly. The machine delivering the rays and the equipment for IGRT is important in terms of delivery accuracy (lesser risk for collateral damage). 4D CT may be better than 3D CT but it would not change the results regarding the elimination of the cancer. I would chose a radiologist experienced in PCa cases working at modern facilities.

ADT main role in the combination therapy of RT+ADT is to sensitize the cells into absorbing the radiation. It affects cells AR and also provides a stable cell's life cycle preferred for the success of radiation in destroying its DNA. From clinical studies one knows that it improves the RT by approximately 35%.
In such regards, ADT is best if started two month in advance of RT and continued at least six month after RT (the typical period of cell's life cycle). Some doctors prefer longer periods after RT, lasting two years in high risk cases. In my lay opinion six month is sufficient for therapy efficacy. ADT will also mask the PSA so that one needs to wait till it looses its effects to verify the success of the treatment.
In my case of SRT I did radiation alone (clean environment) so that I could certify the outcome the soonest. Once failure was confirmed I started ADT.

Here are links regarding the image studies;

http://emedicine.medscape.com/article/387840-overview

https://link.springer.com/chapter/10.1007/978-0-387-48902-5_32/fulltext.html

https://www.ncbi.nlm.nih.gov/pubmed/25738559

Your dad could try involvement in a clinical trial, free of charge, for a PSMA PET scan that would give you a conclusive posture to a final decision. You can discuss to access possibilities with his doctor. Here is the link;

https://clinicaltrials.gov/ct2/show/NCT02282137

Best wishes and luck in his journey.

VGama 

Max Former Hodgkins Stage 3

RT

Tang,

Vasco wrote you as detailed an analysis of combining RT and HT  for metastatic PCa of uncertain locale as you will ever get. Probably more detailed and accurate than what most medical oncologists would ever give you.

Very generally, studies are saying that EBRT with ADT are improving odds, compared to ADT alone.  That data might be skewed by the particulars of which men had RT added.  Statistics are always to some degree science, but to some degree a crapshoot out on the sidewalk.  Driving through Brooklyn and watching the card games teaches a man as much about odds as a degree from MIT.

I would use both EBRT and ADT, and I would go with SKCC.  My subjective take on your particulars,

max

Disclaimer: I've had no medical training, just every medical thing.