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I am 76 y/o 11 years left, obese. G9 80% core in one peripheral zone lesion DNI only, two others 5, 15% core G7 in another zone. Decipher and ArterraAI INTERMEDIATE risk level and no need for abiraterone. Orgovyx for 5 months. preparing for RT. Size of gland 120 before. Presumably 35% less ( 77% ) now. Before ADT PSA 6.0 (PSAV 0.05) MRI & PPSMA PET CT scan negative for any outside of gland. 1st lesion SUV 15, the other 2 SUV about 3, 4,
ArterraAI, (if NCCN protocol) 10 year risk of DM (distal mets) 3%, There is 1.4% 10 year risk of PCSM (prostate specific cancer mortality), this 94% better than everyone else on this reference scale.
Question ONE:
Does recommended "preventive" pelvic lymph node (PLN) radiation added to RT make any sense?
Pre widespread use of MRI, certainly pre PSMA PET CT scans G9 discovered post RAPR concluded that the chance of extra glandular disease (mets) would be about 20% over 5 years, or 80% NO METS. [ BTW If mets 60% one pelvic lymph node, =12% 1/8th, 20% 2 pelvic lymph nodes =4% 1/25 overall,. Spot SBRT would reset the cure clock for the 80% of the escaped cancer cells. Add that 16% (80% of 20 %) of initial non mets 80 we are approaching 96% This is in the context that "prevented" RT only benefitted biochemical resistance (BCR) in those with a starting PSA >40. [OS, PCSM, and DM were unaffected]
Question TWO:
It appears that 6 months of short term (ST-ADT [STADT]) is about 82% as effective as the 88% who have long term ADT (LT-ADT, [LTADT]). High dose (gy)?
Replies to "I am 76 y/o 11 years left, obese. G9 80% core in one peripheral zone lesion..."
You are a Gleeson nine which is a very aggressive prostate cancer. It appears your doctors are treating it like it’s not aggressive. Any other Gleason numbers are irrelevant, the highest number is your Gleason .
It would be useful to know exactly what the decipher score was.
Radiating anything that does not have cancer Has to be done carefully. That is what salvage radiation does as well as initial RT.. It would prevent you from radiating the lymph nodes again if Cancer appears. They frequently do radiate some lymph nodes, Discuss this with the doctors.
The NCCN standard for ADT is 24 months with a Gleason nine. The latest ASCO guidelines say that you should also have an ARSI (Zytiga or a lutamide) If you want the best long-term survival.
Combinations of ADT with ARSI and/or DOC (docetaxel have been a consensus guideline recommendation from ASCO and the American Urological Association since 2018 (2020 and 2023 for triplet combinations). These guidelines are based on phase III clinical trial findings demonstrating improved clinical outcomes, including progression-free survival and overall survival, with ADT combination therapy compared with ADT alone.
There is no cure clock. You can get remission you never can get a cure with Gleason nine. I know people with Gleason nine that have come back 30 years and 20 years later with recurrence.
Are you going to a center of excellence for treatment? It sounds like you really need to get a second opinion from a center of excellence or a Genito Urinary Oncologist. With a Gleason nine you need to be very careful.
Are you sure the biopsy didn’t find any of these things? Intraductal, cribriform, Seminal vesicle invasion or ECE. If any of these were found it makes your cancer much more aggressive
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If you are having IMRT you might as well treat the nodes as well. NO scan can pick up a single cell or clump of cells which may be outside the gland.
I mean, you’re already on the table - there’s no extra treatment days involved and you really won’t notice any difference. Just my opinion, you really should ask your RO - and another one to be sure.