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How long on adjuvant ADT?

David_R
Posts: 3
Joined: Aug 2014

I was diagnosed Oct 18, 2013 with PCa stage T1c. My PSA was 3.2, low but slowly rising over the past 5 years. DRE showed an enlarged but otherwise normal prostate. The ultrasound didn't reveal anything but my urologist recommended a biopsy for peace of mind. We were both surprised when 3 of 12 cores were positive, Gleason 4+3=7 in 40% of one and Gleason 3+4=7 in 5% of the other two. I decided on RP to get rid of the cancer while it was small and contained because at age 51 and in good health, I had many years to live.

The nerve-sparing open RP was done Dec 24, 2013 but the quick 3hr operation became 5.5hrs. I came to in recovery to excruciating pain and stayed in hospital for three days. The night after I was discharged, I returned to Emerg with a blocked catheter which was quickly flushed. All together a terrible ordeal since I live an hour away. 17 days later my wife and I returned for the catheter removal and post op report. Pathology showed ECE, seminal vesicle invasion, PNI, and 2 positive surgical margins. The Gleason was 4+3=7 with tertiary 5 and a 0.2mm tumour was found in one lymph node. I was staged T3bN1M0 and we were devastated.

8 weeks after surgery my PSA was 0.03, a good number but not classed as undetectable, so off I went to the radiation oncologist. The doctor proposed 33 daily treatments for a total 66Gy to the prostate bed and 45Gy to the pelvic lymph nodes and 2 years of ADT. This is where we disagreed. I asked if this was neccesary because I had read there was no conclusive evidence to the right lenght of adjuvant ADT. The oncologist said he had a study I could join which would randomize me to either 6 months or 2 years. I suggested I would do 6 months and when the time came we would discuss going further. I was concerned about side effects of hormone deprivation and becoming hormone-resistant if staying on it for long periods. I was also concerned if my hormones would return to normal after 2 years. I had read that after prolonged ADT some side effects may never go away. He seemed a little annoyed that I would question his judgement but we agreed to start treatment.

Feb 26, 2014 I started bicalutamide for 30 days and March 12 received my first 3 month injection of Trelstar. May 8 radiation treatments began and finished on June 24. I had mild immediate side effects from the radiation, burning on urination, some diarhea and my incontinence returned. The ADT side effects were/are much worse: flushing, night sweats, skeletel pain, muscle aches, fatigue, brain fog, no libido and emotional instability. On August 20, 2014 I returned to the radiation oncologist for the post radiation check and my third Trelstar injection. My PSA was <0.2 and Test <50, he considered this undetectable which I found surprising since I was sent to him with a PSA of 0.03.He said congratulations I was in remission. He asked if I was going to do 2 years of ADT and I asked about just doing 6 months more. I wanted to know if there was a real benefit to 2 years, considering that the side effects were ongoing and preventing me from working. At this point he said if I changed my mind, I should get my PCP to give the injection and otherwise he would see me in 6 months for a PSA test. And then he left.

My question is how long on adjuvant ADT? Does anyone have any information or experience with this? I'm going to have the third injection this week and probably the fourth injection. I have seen reports that ADT prior to radiation and 12 months after gives very good results.

Old Salt
Posts: 806
Joined: Aug 2014

Your history is not only painful to read, but also quite complex. Perhaps that's the reason there have been no responses so far. Not being a medical professional, I am reluctant to give advice. But I can give you a link to a 'recent' development that might be of interest. Actually the presentation dates back over a year, but was given a lot of press (not that that means much).

http://www.ascopost.com/issues/july-25,-2013/shorter-duration-of-hormone-therapy-feasible-in-localized-high-risk-prostate-cancer.aspx

(Sorry, I don't know how to make this a clickable link)

I hope that some discussion will follow that will be helpful to you.

 

VascodaGama's picture
VascodaGama
Posts: 3369
Joined: Nov 2010

 

David

 

Thanks for sharing your story with us. I can see that you know well about your options and that you are aware of what to expect. Old Salt has given you the link from ASCO with the information you were looking for. I also believe that long term adjuvant ADT does not add any particular benefit to the combo treatment (HT plus RT) you are planning to follow. In any case, researchers comment that for patients with high-risk prostate cancer, using hormone therapy for just a short while is not effective.

 

As far as I come across in my researches, the neoadjuvant hormonal treatment portion will sensitize cell’s ARs helping the purposes of the radiation treatment, in damaging cell’s DNA. The high energy waves damage the DNA which causes the destruction of the cells that may “try” to divide prior to repairing the DNA. Since cancerous cells divide quicker than healthy ones, these (damaged cells) cannot divide and will die. The significance of the adjuvant HT in the combo is reduced and seen as effective during the mitosis period when a cell divides. It keeps them on the “canvas” not allowing a perfect duplication to occur. (PCa cell to another PCa cell). Proteins help to regulate the cycle of mitosis so that taking antioxidants (pills, etc) should be avoided during the treatment to keep the “environment” as much toxic as possible to the PCa cells.

 

You can read about the purposes, cells’ grow and division, and the whole concept in these links;
http://mct.aacrjournals.org/content/6/7/1920.long

 

http://www.cancer.org/acs/groups/cid/documents/webcontent/003019-pdf.pdf

 

http://www.sciencemuseum.org.uk/whoami/findoutmore/yourbody/whatdoyourcellsdo/howoftenareyourcellsreplaced/howdocellsgrowanddivide.aspx

 

http://science.education.nih.gov/supplements/nih1/cancer/videos/act2/transcript-act2-anim.htm#video5

 

The pathological stage sets you at the high risk group. Your description of your status is pretty bad with seminal invasion and positive lymph nodes. The Gleason grade 4 is for an aggressive type of cancer that is producing fewer PSA. With this in mind maybe it would be better that you plan an aggressive attack on the bandit.

 

It seems that the radiation oncologist laboratory has no ultra sensitive assays. The PSA <0.2 and Testosterone <50 is the LLD of their assays, not practical for a case of cancer producing low levels of the serum. The 0.2 ng/ml could mean 0.03 or lower. The castration level is best at <20 ng/dL.

 

Surely the side effects are of concern and they will superimpose. The hypogonadism (kind of menopause symptoms) you are experiencing from the hormonal manipulations can be treated with tactics and a change in the life style (naps and earlier dinners, etc). Physical exercises help me a lot to counter the effects and gain back lost muscle mass. Some guys use over the counter drugs too.

 

There is a good book with advice on supplements and nutrition for HT patients;
“Beating Prostate Cancer: Hormonal Therapy & Diet” by Dr. Charles “Snuffy” Myers.

 

UCSF got a publication on Nutrition & Prostate Cancer, which copy I highly recommend you to get.
http://cancer.ucsf.edu/_docs/crc/nutrition_prostate.pdf

 

I would recommend you to consult a medical oncologist for a second opinion in the treatment protocol and advice in treating the symptoms.

 

Best wishes for successful outcomes.

 

VGama

 

David_R
Posts: 3
Joined: Aug 2014

V Gama

Thank you for your reply, yes my status is poor. I went ahead with the Trelstar injection on August 28 which will bring me to 9 months of HT of which almost 3 were prior to the start of RT. I am trying to balance the benefit of adjuvant ADT with my quality of life. I was actually feeling quite good prior to the cancer diagnosis. All of my troubles now are the result of treatment.

September 3 I met with my urologist who was kind enough to be blunt. He is knowledgeable and not reluctant to refer my case to others. He did his fellowship with Dr Paul Lange. He feels my pathology was the worse he has seen without bone metastasis but sees no reason to give up hope. He asked that I continue HT as long as I can, but admits that there are no definitive studies to rely on. My cancer is aggressive with low PSA so we will use ultra sensitive tests to track it. There is a small chance that the treatments have killed the Bandit, but if not he feels that it has been knocked back at least 5 years. He would like more PSA and testosterone tests before going to the medical oncologist. He doesn't believe this is a fast cancer, more likely slow with low PSA and we were fortunate to find it before it had spread to more lymph nodes.

Having said all of that, I am in danger because of my age. At 52 I have many more years left for this cancer to grow, not that it isn't a tragedy at any age. My urologist's prognosis is 2-3 years before it returns and another 2-3 years before I become symptomatic.. His advice is to live life now and we will attack it when it shows up. He seems very optimistic for future prostate cancer treatments.

Any thoughts?

David

VascodaGama's picture
VascodaGama
Posts: 3369
Joined: Nov 2010

I wonder if your descriptions are in fact what your doctor said or if it has some “arrangements” by you. There is not much sense to me to talk about Dr. Paul Lange if it wasn’t him diagnosing you. Your urologist is not that experienced in his own words “…pathology was the worse he has seen without bone metastasis but sees no reason to give up hope…”. It all means that he is not prepared to follow your case. All his comments cannot be taken serious. You need to find another specialist that has seen and treated worse cases (as he set you). His advice in “…live life now and we will attack it when it shows up…” does not seem good to me because you got confirmed metastases.

SRT+HT protocol probably established by the radiation oncologist seems to be extensive. Particularly in regards to the total Gy (66Gy plus 45Gy) you commented above. It does not surprise me that the QoL deteriorated. Regarding the side effects from hormonal manipulations (you are experiencing) may get better if you use some tactics and change the way you do things. Hypogonadism condition is similar to women’s typical menopause symptoms so that your mother may teach you some tricks. Usually, two years on castration is acceptable in regards to the worries that you have on the effects that “may never go away” or “becoming hormone-resistant”. In fact your cancer could be of the type that is not that dependent on testosterone to progress.
You can follow the story of Radiation Hopeful, a G9 survivor that did successfully adjuvant HT during two years, though with the prostate in place, so that you can compare only symptoms. Here is one of his threads but you should goggle his name to read more about his long journey events; http://csn.cancer.org/node/210934

The PSA results will be under the effects of the hormonal manipulations so that they cannot be used to judge outcomes of the radiation portion in the therapy. The progress is going to be difficult to ascertain but one should think that the PSA will be lower than the usual. Doubling (PSADT) is a better reference mark to follow if you get an increase. Testosterone is important to verify if castration is set. Typically less than 30 ng/dL is good (<20 ng/dL is better).

You may also get now a dexa scan to look for any bone loss. HT may affect any existing osteopenia and PCa “loves” to spread on weak bone.

I wish you luck in your journey and improvements on the side effects.

VGama

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