Radical AND Hormones?

garyfoote · Regular Joined: 25 Jan 2008 Posts: 16 Location: Vermont

My initial PSA was 24.8 January 15th. Next PSA 17.8 in mid-Feb. Mar 11th PSA 18.8 plus 12 core biopsy. Six cores on left side positive one core on right side positive. Gleason 8. Negative on bonescan. Negative on CT scan. Urologist says Brachytherapy not an option. Beam radiation possible. I chose radical prostatectomy. Get it out and look at it and the lymph glands to confirm no spread there. My surprise in all this is my doc seems adamant about two years of hormone therapy to suppress testosterone post surgically. This is the first time I've heard of this combination. Anyone else out there with similar pathology and similar recommendations/experience?

Surgery is scheduled for April 29th.
_________________
Gary

Initial PSA 24.8. Jan 08
Second PSA 18.8. Feb 08
Biopsy Mar 08. 12 cores. 7 positive.
Gleason 8 [4+4]
Radical Retro Pubic Prostatectomy 04/29/08
Diagnosed mucinous adenocarcinoma
PSA 0.0 8 weeks after surgery

Replicant · Moderator Joined: 01 Nov 2006 Posts: 163

Hi Gary.

There is a large trial starting to look at whether adjuvant hormonal therapy, with or without chemotherapy, is beneficial for patients with high risk factors (like Gleason higher than 7, very high PSA, positive margins, positive lymph or sem. vesicles, PSA rising 2 ng/ml or more in one year). It's run by researcher Mario Eisenberger. There's quite a bit of information about this on the web, including a podcast on Urotoday. The trial is TAX 3501. It will try to recruit more than 2,000 patients. Walsh talks about this on pages 503 and 504 of his book.

Adjuvant treatment is when a secondary treatment is started without waiting for signs of recurrence.

Note that this trial is being run because *it is not known whether this approach is beneficial* compared to waiting for PSA to rise and then starting androgen deprivation and/or chemo.

Best wishes.
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T3a, N0M0, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 <0.1, 12/07 <0.1, 4/08 <0.1
http://pcabefore50.blogspot.com

johnw100 · Posted: Fri Mar 28, 2008 6:52 pm Post subject: Re: Radical AND Hormones?

For anyone considering hormone treatment, I always suggest reading Dr Myers' book on the subject.

Dr Myers used radiation and hormone treatment for his own high risk PC.

He mentioned that there are a number papers on the results of surgery with hormone treatment in cases of lymph node involvement.
Dr Zincke has treated men in this way with extremely good results.

Some men can experience acute side effects with hormone treatment, but when it's used for a relatively short period, hormone levels usually return to normal when the treatment is discontinued.

garyfoote · Regular Joined: 25 Jan 2008 Posts: 16 Location: Vermont

To be honest I am at a loss for the reason for such a protocol. It is my understanding that if the cancer is localized there is no need for ADT if RP is performed. ADT makes no sense to me with no spread of cancer outside the prostate.
_________________
Gary

Initial PSA 24.8. Jan 08
Second PSA 18.8. Feb 08
Biopsy Mar 08. 12 cores. 7 positive.
Gleason 8 [4+4]
Radical Retro Pubic Prostatectomy 04/29/08
Diagnosed mucinous adenocarcinoma
PSA 0.0 8 weeks after surgery

Replicant · Moderator Joined: 01 Nov 2006 Posts: 163

Gary, I think the reasoning goes like this: A certain percentage of men will have recurrences. It's roughly 1/3 of all men who have prostatectomies. It is not possible to determine exactly who will have a recurrence, but there are certain risk factors that put a man at a greater than average risk. Some of those men will not only have recurrences, they will have metastatic disease and high probability of dying from PCa. Why not get going with ADT on all high risk patients right away? (I'm not agreeing with this--just laying out the way I understand his logic)

Your doctor seems to be saying that he believes that you are at high enough risk based on Gleason and PSA that there is (in his view) a significant probability of recurrence. If you put in your stats at nomograms.org, you'll see that you have a pretty high statistical chance of having extracapsular extension, a significant risk of seminal vesicle invasion, and a slight risk of lymph node involvement.

You didn't say what your DRE was, but assuming it's normal and you have a 4+4 Gleason, PSA of 18.8 and a stage of T1c (not palpable, found only by PSA and biopsy):

Chance of extracapsular extension: 50%
Seminal vesicle invasion: 40%
Lymph node involvement: 9%

5 year progression free probability: 72%
10 year PFP: 61%

You can experiment putting in different numbers--for example, if your next PSA is back to the January level by the time of surgery, the outcomes look a little worse.

Local, early spreads will not usually show up on CT scans. Therefore he is hedging his bets. Hopefully surgery will take care of it, but if not, he wants to be ahead of the game.

The problem with this logic is that very often, recurrences after prostatectomy are NOT systemic--they are still localized and therefore potentially curable by salvage radiation. I would--from a layperson's perspective--worry that being on ADT automatically after surgery would suppress PSA and hide a local recurrence until it was no longer local.

My question, as a patient, would be "if you think I need adjuvant treatment, why ADT and not radiation?"

My urologist seemed to be on a pretty straight and narrow path with recommendations that sounded exactly according to protocol to me UNTIL my PSA rose after surgery. Then the first thing he suggested was chemo! I was stunned and told him I thought I would be going for radiation. "Well, there's that too, but I've seen great results with early chemo" he said! The medical oncologist did not agree--he agreed with me that I should have radiation. So did the radiologist. And that SEEMS to have worked.

I won't say "cured" for another 35 or 40 years, but at this point my PSA is right where it should be.

Gary, if I were you, I would seek out a second opinion in regards to the automatic ADT. You're right--at least here in late March 2008, the course of treatment recommended seems outside standard protocol. Maybe after the trial I mentioned, things will be different, but right now what your doctor is recommending sounds surprising. I've been on a few PCa discussion boards for the past 2 years, and this is the first time I've heard of such a recommendation.

Best wishes.
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T3a, N0M0, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 <0.1, 12/07 <0.1, 4/08 <0.1
http://pcabefore50.blogspot.com

garyfoote · Regular Joined: 25 Jan 2008 Posts: 16 Location: Vermont

I'm definitely going to get a second opinion. Your question of Why ADT and not Radiation is one I hadn't thought of. Its an obvious question so I must not be thinking too clearly about this right now.

Thanks Rep. You've given me more than one question to add to my list when I talk with doc - hopefully by phone today.
_________________
Gary

Initial PSA 24.8. Jan 08
Second PSA 18.8. Feb 08
Biopsy Mar 08. 12 cores. 7 positive.
Gleason 8 [4+4]
Radical Retro Pubic Prostatectomy 04/29/08
Diagnosed mucinous adenocarcinoma
PSA 0.0 8 weeks after surgery

sequoiaranger · Posted: Mon Apr 07, 2008 10:05 am Post subject: Similar Pathology

Hi Garyfoote,

I had Gleason 9, T3 tumor (forgot what my pre-operative PSA was--in the high teens I think) and had the radical prostatectomy Feb 2007. The surgeon did a "wide sweep" to make sure he got out as much as possible. The preliminary examination of lymph nodes didn't find any cancer so the prostatectomy proceeded. Post-operative detailed analysis detected minute cancer cells in the lymph nodes, so metastasis had started.

;-(

I have been on "Eligard" (leuprolide) and have had success in supressing testosterone production and my PSA has been "imperceptible" for awhile now. I have full urinary function (no incontinence) but absolutely no libido, and the lack of testosterone is weakening my muscles and bones (taking pils for THAT now, too!)

However, I'm otherwise doing fine, campervanning through New Zealand for several weeks, and substitute-teaching at my local high school.

I am a little surprised that your doctor recommended ADT immediately after surgery. It seems to help the diagnosis and prognosis if one waits for the surgery to settle down for a few months, and take some baseline PSA's thereafter to see if there is still any active cancer going on. Depending on what the surgeon finds after prostatectomy, you may not need ADT at all.

I can certainly get on board with the position of aggressively attacking the cancer so it doesn't run away. Maybe the doctor's recommendations are just the preliminary game plan assuming metastasis, and can be modified when the results of the prostatectomy are in.

Good Luck.
_________________
T-3, Gleason 9+
RRP 2-26-07
Using Eligard Hormone Therapy--
working Sometimes!!

garyfoote · Regular Joined: 25 Jan 2008 Posts: 16 Location: Vermont

I have a phone conference with my urologist tomorrow night. Much of what he said to me at our last meeting was blanked out by the Gleason and Stage points. After that it was a bit like a foreign language. He may well be waiting to begin ADT until after a 6 week PSA, or pending pathology as you suggest.

It sounds like you have had a great outcome. I hope for the same. I'm just waiting for surgery right now - and I really hate this waiting and waiting.

What pills are you taking for bone loss? Calcium supplements or something more?
_________________
Gary

Initial PSA 24.8. Jan 08
Second PSA 18.8. Feb 08
Biopsy Mar 08. 12 cores. 7 positive.
Gleason 8 [4+4]
Radical Retro Pubic Prostatectomy 04/29/08
Diagnosed mucinous adenocarcinoma
PSA 0.0 8 weeks after surgery

sequoiaranger · Posted: Mon Apr 07, 2008 4:25 pm Post subject: Bone(r) Loss

>What pills are you taking for bone loss? Calcium supplements or something more?<

I've been told to take three 500mg Calcium tablets a day, plus "Fosamax", a drug that will put a limit on the resorption of bone (there is an equilibrium between bone deposition and resorption, but my resorption rate is too high right now). I don't have "Osteoporosis" but "Osteopenia", which is a mineral bone density less than I should have, but not critical. We are not sure if it is strictly due to the leuprolide, or a combination of an anti-heartburn medicine that also upsets the deposition/resorption dynamic.

>It sounds like you have had a great outcome. I hope for the same. I'm just waiting for surgery right now - and I really hate this waiting and waiting.<

Make merry while you wait!

Without trying to be crude, make love like there is no tomorrow, because there won't be once the prostatectomy is done. I mean, the thought just doesn't enter my head, and even if it did, I could do nothing about it. Frankly, I do get a little envious when I see media images of couples making love, etc. and knowing that, for me, that is a thing strictly of the past. I also know, however, that had I retained my innards, testosterone, and accompanying libido, I wouldn't be here to write this. Becoming a eunuch is sad, but a worthwhile tradeoff, methinks!!

Cheers!
_________________
T-3, Gleason 9+
RRP 2-26-07
Using Eligard Hormone Therapy--
working Sometimes!!

garyfoote · Regular Joined: 25 Jan 2008 Posts: 16 Location: Vermont

Hahaaaa... We are definitely making merry while waiting. I hope my surgeon is able to salvage one ED nerve so I may have some post-surgical luck in that area too.
_________________
Gary

Initial PSA 24.8. Jan 08
Second PSA 18.8. Feb 08
Biopsy Mar 08. 12 cores. 7 positive.
Gleason 8 [4+4]
Radical Retro Pubic Prostatectomy 04/29/08
Diagnosed mucinous adenocarcinoma
PSA 0.0 8 weeks after surgery

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