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  • An update - plus ADT + IMRT question

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    Old 06-05-2021, 03:15 PM   #1
    music4ever
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    An update - plus ADT + IMRT question

    Hi All – Have a question about when to do ADT + IMRT in my case…

    A recap: I was diagnosed with prostate cancer Jan 2021. I'm 53 years old my primary doctor found a nodule on my right side during DRE for physical exam last fall. My PSA was 3.9 (3.51 in 2019, 2.55 in 2017), he suggested I go to a urologist that he recommended who did a biopsy in Dec 2020. Biopsy showed 6 of 12 cores all on right side of prostate positive. I am Gleason 7. All 6 cores are 3 + 4, Two cores are 70% involvement the rest are 35-50% inolv. Prolaris report says I'm "unfavorable intermediate" NCCN risk.

    An update: I opted for RP in March. It went well but some more bad news. Post RP pathology showed a focal positive margin on that right side, some PRI, but no lymph node or seminal vessel involvement. Gleason is still 7 but was upgraded to (4 (70%) + 3). Also, my Decipher score shows high risk (.97 out of 1 which is top of the scale for high). My PSA at 6 weeks was 0.08. At 12 weeks (a few days ago) it is 0.06.

    I talked to two highly respected ROs who specialize in prostate cancer for their opinions. Both basically want to wait for another PSA test in 3 months before offering further guidance. However, one of them said to wait until PSA hits 0.2, then do a PSMA scan and start ADT + IMRT RT. Neither of them suggested going on ADT right now since PSA is low. I am still healing from surgery and it's going well but a bit slower than I expected. Neither suggested doing any RT until healed from surgery (which makes sense to me).

    My question is this: After I’m healed from surgery (probably 3-4 more months) should I jump right into ADT + IMRT RT treatment regardless of where my PSA is at since I am high risk. Or should I wait until my PSA goes up to .2 and then start treatment?

    Also, since my PSA was only 3.9 at it’s peak – is waiting for it to rise really the best indicator that cancer might be spreading or could it be spreading with a low PSA? Are there other factors/tests to consider?

    My conflicts are that I have positive margin, high risk genomic test, but have always had relatively low PSA.

    I'm interested in your thoughts since mine seems to be a more complicated case.

    Thanks
    John

     
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    Old 06-05-2021, 05:52 PM   #2
    Insanus
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    Re: An update - plus ADT + IMRT question

    In the end, it may not make any difference.

    I think I would chosen adjuvant RT with at least 6 months, maybe 24 months, ADT first because of the positive margin. If you then recur wait on the PSA to increase for a scan.

    The counter argument is why would you radiate the pelvis until you know where the cancer is.

     
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    Old 06-06-2021, 05:10 AM   #3
    Prostatefree
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    Re: An update - plus ADT + IMRT question

    You have time to decide. However, you will have more time to decide when considering detailed information about what is actually happening if you go forward using an ultra sensitive PSA test. Preferably a 3 digit test: 0.000. Two digit tests also are used for this, 0.00.

    You will detect any movement sooner and have time to plan and react. While there may be some testing anxiety around each test date, you will not be burden with the long term anxiety wondering what's it doing until it reaches 0.2. More options are available with the ultra sensitive testing.

    The one digit test is used for screening men with a prostate. It is often used for post RP men who are at low risk. I'm not a fan using it for post RP men with intermediate or high risk cancer.

    There is a whole other conversation about early vs waiting to 0.20. It depends on your specific profile/risk. But first, set up the best testing strategy for you.

     
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    Old 06-06-2021, 06:28 AM   #4
    DjinTonic
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    Re: An update - plus ADT + IMRT question

    Hi Music.

    With (4+3), a positive margin, and sky-high Decipher score, I think adjuvant RT after the healing period is wise, regardless of your PSA after healing.

    As I see it, your #1 is goal to prevent distant mets rather than deal with them. Being proactive beats waiting.

    A scan can be done at any point your PSA becomes high enough for it. Having RT soon may make a scan unnecessary in your future. But how would you feel if you get to the point of revealing distant mets only to regret you could have done something that might have prevented them?

    A PSA of 0.06 is low, but a nadir of 0.03 and above post RP has been shown to mean BCR (a climb to 0.2 in the future) is more likely than a nadir below 0.3.

    Djin, a pianist
    __________________
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3-
    7-05-13 TURP for BPH (90→30 g) path neg. for PCa, then 6-mo. checks
    6-06-17 Nodule on R + PSA rise on finasteride: 3.6→4.3
    6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
    Nodule negative for PCa. Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, negative frozen sections, Duke Regional Hosp.
    SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
    pT2c pN0 pMX, G9 (4+5) 5% of prostate (4.5x5x4 cm, 64 g)
    Dry; ED OK with sildenafil
    Decipher 0.37 (Low Risk), uPSA: 0.010 (3 mo.)...0.020 (3 yr. 7 mo.)

     
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    Old 06-06-2021, 06:23 PM   #5
    guitarhillbilly
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    Re: An update - plus ADT + IMRT question

    I would be surprised if a MD UR or RT MD does not recommend ADT after you heal from surgery and BEFORE you start RT.
    I guess in different parts of the Country / World protocols are handled differently.
    __________________
    T2a / Gleason Score 8 / PSA at Diagnosis 6.9 /
    1-5 aggressive score : 4
    12 cores= 4 positive
    NBS = Negative
    Pelvic CT= Negative
    Pelvic MRI= Negative
    Age at Diagnosis= 60-65 age group
    Completed 42 IMRT Sessions
    Lupron scheduled for 2 years [Started DEC 2019]

     
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