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Prostate cancer SRT+ADT combo for how long post biochemical recurrence after RP

Pathfinder
Posts: 55
Joined: Jun 2016

 

There is a previous thread that begins this journey. For full backstory please see the following:

 

https://csn.cancer.org/node/303384?

 

Current status:

 

Diagnosed Pca in 2016, PSA 23, Gleason 5+3=8, no metastasis to lymph node and bones.

 

Neoadjuvant ADT for 1.5 months then underwent Radical Prostatectomy: "Pathology: 4+4=8, invasion of nerves, tumour extends to the prostatic capsule, negative surgical margin, negative lymph node metastases."

 

Then continued ADT for another 9 months, before stopping for observation. PSA gradually increased to 0.25 over the course of one year, indicating biochemical recurrence. PSMA-Pet scan couldn't find recurrent lesions.

 

Underwent Salvage RT for pelvic 70gy/35 times. ADT continued to be administered during the RT (the doctor wanted to do SRT without ADT to see the effectiveness, but after consulting for a second opinion, we decided to continue ADT alongside the SRT).    

 

PSA situation: PSA continued to rise to 0.33 during SRT, and only began to decrease after ADT (down to 0.24). One month after SRT completion PSA measured 0.06, 0.03, 0.02 , 0.02, 0.01, 0.01 (PSA test every two months) while concurrent with ADT.

 

TODAY & QUERY:

 

It's been 13th months on ADT now, PSA stable at 0.01 since January. Should we stop ADT in this situation? Or is it recommended to use ADT up to two years? I read on EAU guideline says 'In patients with high-risk localised disease, use RT in combination with long-term ADT (two to three years). BUT that's for the initial treatment! Our doc originally suggested SRT+6 months ADT.

 

Is it time to stop ADT to see what happens to the PSA, or just continue for another 11 months?

 

Thank you for your advice.

Georges Calvez
Posts: 221
Joined: Sep 2018

Hi there,

This is a tricky question to answer as no one knows.
Some cancers do respond to ADT faster than others and the cells stop growing and start to die quicker, they are more dependent on a good supply of androgens of which testosterone is the principle compound.
Two to three years was the standard but some doctors are beginning to experiment with eighteen months or less on the grounds that most of the good effects are achieved in the early part of ADT but they tail off and the bad effects begin to predominate.
Some men find themselves in a situation where one doctor will be advising three years and another is happy with eighteen months.
You have to consider your case with your doctors and see, no one wants to stop too early but no one wants to stay on ADT one day longer than needed.

Best wishes,

Georges

Pathfinder
Posts: 55
Joined: Jun 2016

Thank you for your reply Georges,

Yes it's an impossible question to answer, I was just hoping to hear from some other people's experiences. Maybe someone with a similar prognosis had a good outcome with only 6 months of ADT. 

The doctor who performed the surgery for us suggested SRT + 6 months ADT, which seemed short to us based on some of the information we read up on, which is why it's 13 months to now.

We're just unsure if we should stop ADT and check the PSA movement or continue on now for another 1 or 2 years. Is there any negative ramifications to stopping and restarting ADT as far as ADT losing it's effectiveness is concerned?

 

Thank you all!

Georges Calvez
Posts: 221
Joined: Sep 2018

Hi there,

I am looking at stopping Firmagon in September which will give me 19 months on the stuff.
By some lights I am a high risk case, by others I am less so.
You can follow my story here.
https://csn.cancer.org/node/318066
You can search the case histories here to find cases similar to yours and get some kind of idea on a reasonable length of time according to several different doctors.
https://www.yananow.org/Experiences.shtml

Best wishes,

Georges

Pathfinder
Posts: 55
Joined: Jun 2016

Again, thank you Georges for your reply. I understand cancer is treated on a case by case basis and it's always difficult to ascertain what to do with treatment. It's just very perplexing as we don't know which doctor's advice is correct. It's all conflicting.

Georges Calvez
Posts: 221
Joined: Sep 2018

Hi Pathfinder,

I doubt that there is a scientific method but these are some pointers that I am taking into account in my case;

Gleason score, a five is a lot more aggressive than a four and signs of neural invasion, cribriform, etc tend to indicate more aggressive forms that may need longer treatment. Mine was a four with none of the above so I think it is less aggressive than some.

Speed of decline of PSA when beginning hormone treatment, PSA is a poor marker for prostate cancer activity but some men do decline slowly while mine fell like a stone, rapid declines to an undetectable nadir are a good sign. The quicker the decline the more susceptible the cancer is to hormone treatment and the more cells die because of androgen deprivation.

Decrease in the percentage PSA, my PSA was very high with a tumour that had taken over about 40% of the gland, it fell to a very low level after the operation, to me this indicates that almost all of the bulk of the tumour was in the prostate. I hope that any residue was in the prostate bed and I do not have any hot spots in pelvic lymph nodes, see below.

In my case there is no indication of any involvement with pelvic lymph nodes by MRI or the lymph nodes removed in surgery. It is a big maybe but the residual tumour could have been associated with the urethra, prostate bed, etc and we got it all with the surgery and radiation.

Level of testosterone, my testosterone is below the limit of detection and because of the fact that I am on Firmagon it is likely that I have not had  any micro surges which can happen with GnRH agonists, the beast will have been starved for 19 months at the end of October. I hope that this will be enough.

Negative effects, I have suffered strong negative effects of ADT of which the most marked was a strong rise in blood pressure to near lethal levels 220/190. My urologist was not a lot of help in treating this so I cooked something up with my friendly personal physician that requires irbesartan 300mg and amlodipine 10mg per day. It is now controllled but still above the normal range. It is still nasty and represents a significant health risk, maybe more than a recurrence of the prostate cancer in the short term.
In summary, I will have had 18 months of Firmagon at the end of October when the next injection should come due. My urologist would like to continue to two years with an option for three but I have had enough. We have agreed that if my PSA is below the limit of detection at the beginning of October then I will begin an indefinite ADT holiday.
There are various things that can happen, my testosterone may not recover and I will remain castrate despite halting the GnRH antagonist, my testosterone could recover and the cancer could come back immediately or in two, five, ten or more years, maybe never, etc. No one knows.
The likelihood is that I will recur but there is not a lot of good evidence that three years is better than eighteen months in stopping this, although six months is too short in advanced cases and maybe in some SRT cases with PSA levels less than mine. No one knows, really, everybody can read the trial results, doctors can claim medical knowledge but the raw statistics are equivocal.
I am young, only fifty seven next October, and I am willing to gamble a little on a return to something approaching normal life.  The return of some testosterone would have health benefits as well as in terms of QoL.
Firstly, I want to live my remaining life to the full and having a working skeleton is part of that and secondly I still have an active mental libido although my body has now shut down completely but I would like to sweep the wife's chimney again and get the spiders out if I can in the future! I might need to inject myself in my penis to do it but that is not going to stop me.
I hope that this gives you some idea of my personal thinking at the moment.

Best wishes,

Georges

Pathfinder
Posts: 55
Joined: Jun 2016

Ha ha, thank you Georges for the lengthy reply! Apologies for my slow response.

It's of great interest to hear your experiences with ADT and your experiences in general. Thank you for taking the time to share it with me. We're doing our best to collect as much info as possible and try to make some kind of decision based on that. 

I wish you the best of luck for the future and hope you'll proudly be sweeping the chimney for years to come! :)

 

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