Decision Time RP or ADT/HDR/EBRT

Multimodal therapy

CM,

I think you doing well in investigating multimodal approaches. Many guys with Gleason score 9 are doing well with protocols involving combination therapies. There have been reports on aggressive surgeries followed by radiation in voluminous cancer treatment in young guys, dissecting the whole gland for the solo intent in diminishing the burden of the cancer. Surely more therapies means more risks and side effects to which you should give consideration (some consequences cannot be avoided). Your present quality of life will be affected. Get your family involved in all decisions.

I hope that you get good news from the scans but the previous MRI can already provide you details on closer malignancies. In your next meeting with the radiotherapist try obtaining details of the extent of RT protocol he proposes to a voluminous Gleason score 9 cases.

Will wait to read your next update.

Best,

VG 

CMO2021 said:

VG and Eonore,

VG and Eonore,

Thanks you for your comments.  My CT scans and Bone Scans did not show any metastatic disease.  I know that there are likely micro mets hanging out somewhere but will take the positive new that gross mets were not seen.  I spoke with RO at MSK today and his approach would be HDR- Brachy then IG-IMRT for 5 weeks and ADT for 18 months.  He was very informative but not pushy just trying to give me a balanced view of the treatment.  I meet with the Medical Oncologist this coming Tuesday and then the Surgeon the last week in April. I will keep you all posted and I appreciate you insight and your support.

CMO

Aggregate

CMO, it seems that you have numerous particulars going for you:  You are well-informed, realistic, calm, and in excellent medical hands.  The Brach with long-term IGRT/IMRT is potentially curative, with the HT helping the radiation do its thing.   I hope all goes well, and that you decide to continue sharing your interesting but challanging case,

Give a chance to the quality of life in the decision process

CM,

The approach involving HDR + IMRT covers a wider area than a single surgery (RP) and it is less invasive than an approach involving RP + IMRT, both typicalin Gleason 9 therapies. I believe that the medical oncologist has informed you on the side effects attached to each treatment. 

I recommend you to decide on a option only after clearing all doubts and discussing the details (pros and cons) with your family.  This is a difficult moment in your life so that take all the time you need to reach to a conclusion. 

I would like to know the results of the "impact test" but you need to consider that these nomograms are informative only. These are based on data collected from cases with similar characteristics not exactly your situation.  They do not consider the age of the patient (life expectancy) or the deterioration of the quality of life.

You doing well in gathering the needed details.

Best wishes. 

VG 

 

RP + ADT + RT

Hi there,

You could go down the route that I took which was a prostatectomy to remove the gland plus the lymph nodes, etc then ADT plus radiotherapy to clean up any last bits in the prostate bed, etc.
It is possible with your diagnosis that you will have a measurable PSA post RP, so you could well face salvage radiation with ADT immediately post RP, so you will effectively face what I voluntarily signed up for.
Initial treatment has three possible outcomes; you could be cured, this is unlikely but possible, you could go into remission, you will be free of prostate cancer for some years, this is quite possible, you will need further treatment for life, this is possible and maybe more probable than an outright cure.
You are a sample size of one so don't read too much into nomograms and the like.

Best wishes,

Georges

Taking the right step

Hi again, 

I do not know what lead you to decide in the combi treatment ADT/HDR/RT but this doesn't make part in the Ascend-RT trial you mentioned above.

The combination of HDR brachy plus IMRT has been a typical treatment in risky voluminous PCa cases showing high successful outcomes,  but it is connected to higher RT side-effects, similar to the results obtained in the Ascend trial. In other words, brachy assures better outcomes (longer period of free survival) but at the cost of higher genitourinary, gastrointestinal and erection dysfunction consequences (also typical in RP/RT/ADT combi treatment). In fact,  this is probably what the surgeon told you in your consultation.

Ascend trial shows that EBRT, in terms of the killing process, is better if delivered in higher radiation doses (81 Gy) than if delivered at lower doses (50Gy). This fact can be extended to the typical radiation volume used in RT protocols (68 Gy) in the combi RP/RT or in SRT.

The quality of life is in jeopardy. One can try to eliminate the bandit for good in one goal risking the cumulative side effects  or try to eliminate it setp by step in a sequential type of treatment. 

Probably one more consultation with the MO is advisable to discuss about the details  of your chosen option. I think that you doing well in investigating the details involved to reach to that final decision. 

I wish you the best. 

VGama

Experiences
Hi there,
You can read about my experiences here;
https://csn.cancer.org/node/318066
I doubt that you are looking at RP and RT plus ADT somewhere down the road. I suspect that you will have a significant PSA reading after the RP so they will swing you straight onto ADT, eighteen months worth at least, plus 66 Gy of radiation.
So your choice is RT/HDR/ADT or RP/RT/ADT.
One of the things about radiation is that it has significant cumulative effects, the first week or two is OK, then gradually you notice the effects of being toasted.
I was quite lucky but by the end of the 66 Gy I could feel that the inside of my bowel had significant irritation and my urine was ever so slightly pink if I put a few drops on some toilet paper.
You really do not know how you will respond in terms of effects, you might breeze through it relatively speaking, or it might turn into what will seem to be a medieval trial.
RP is not a picnic either, in your case I would guess that you are looking at erectile dysfunction, the chance of incontinence is higher when you couple RP with RT.
I was lucky insofar as I have the first but dodged the second.

Best wishes,

Georges

Update

I have been following your discussion here following your doctor imputs.   Impressionistically, I would think that surgery would not add much curatively, but imposes significant recovery.   I am not familiar with the trial protocols Vasco discussed, but in general, Trials are a good way to secure the newest treatmens, with excellent follow-up.  Old School, a case like yours would receive IMRT and HT, almost every time.