ADT first then Radiation? Or Surgery?

There have been studies looking into whether it’s preferable to front-load ADT with radiation treatment or backload it.

This is a paper titled - “In Prostate Cancer, ADT After RT Better Than Before RT” - that was presented at the American Society for Radiation Oncology (ASTRO) 2020 Annual Meeting —> http://www.medscape.com/viewarticle/940049)

It discusses whether (and why) ADT with (and after) RT leads to better outcomes than ADT well before RT (which is how it is usually given).

It then explains the details of how this mechanism works, and follows with “… radiation damage to DNA can continue long after the radiotherapy itself has been completed. So by keeping the androgen receptor inhibited or suppressed by hormone therapy, you can suppress that DNA repair mechanism for months, and this is why [I think] adjuvant ADT is a very important component to kill prostate cancer cell…”

The study’s conclusion favors “an adjuvant rather than neoadjuvant-based approach,” and it has to do with ADT’s continued suppressive effects after radiotherapy to help radiation kill prostate cancer cells.

(Hormone therapy can also shrink the prostate, allowing radiotherapy to be delivered to a smaller gland; it can also help alleviate symptoms if the tumor is pushing on the urethra.)

If you had one, Gleeson grade group 3, you are a great group 3 the other cores are not considered relevant.

ADT First to shrink metastasis is commonly used, If you are getting Radiation instead of surgery, though it’s used for surgery sometimes too. How old you are is a factor in surgery.

Radiation and surgery do you have the same overall results of time? The side effects are different. If you get surgery, you can have radiation later if you need it, If you get radiation that may be limited.

Thx guys, I will be 65 in August 2025. Good info when I meet with radio guy and my urologist.

I can see why the ADT before treatment would be helpful; it would serve to shrink the prostate cells encroaching on the bladder wall and give more separation for whatever will be done.
At age 65, surgery is a good first choice IMO. A very skilled surgeon can dissect the cancerous tissue away from the bladder and if you need SRT down the road it should not be a problem.
However, radiation therapy, although extremely precise, does involve a margin of anywhere from 2-5 mms depending on the machine used (Cyberknife vs MRI
Guided. So bladder damage might be inevitable if all the cancer is to be eradicated. And if treatment fails, your options become limited.
I chose surgery at age 64 (kicking and screaming) purely to get a second chance if needed…and it was.
Phil

Gleason 9, stage IVa. I had prostate removed. ADT for 4 months followed by pelvic radiation (38 treatments). I've continued on ADT (Orgovyx) for 2 years since then. All is well so far. PSA < 0.01

What I found as I was reviewing resources back in 2019/2020 (for my 2021 proton radiation treatments) was that if the treatment failed, all the options were still available (depending on the nature of the recurrence) —> focal therapy, brachytherapy, SBRT, and sometimes even re-radiation (depending on how well the rectum was protected during initial radiation),

Then, at the 2023 PCRI mid-year conference, I heard Dr. Rossi say pretty much the same thing in his presentation: starting at 4:53:00 (Re-radiation) at https://www.youtube.com/live/WTqPnSRYtW4?feature=share

Oh sure, We’ve heard some members talk about retreatment with radiation after initial RT…but this cancer abutting the bladder doesn’t give much room for error - even with proton beam therapy.
Protons may not pass thru the targeted area as readily as photons but the targeted area (in this case) is the bladder and a double dose might not be favorable.
Dr Rossi has treated many patients successfully so I believe he knows what he’s talking about.