What is best next treatment after 20 years of active surveillance?

What is BRCA2

@asolidrock
A genetic problem where the genes cause your body to be unable to correct errors in your DNA. They actually make a drug called a PARP inhibitor to enable your body to correct those errors if you have BRCA2.

Wow that's awesome. They did genetic testing on me but don't know what it says

@asolidrock
You need to ask whoever did it what the results were. They probably found nothing so they didn’t mention it, but you want to know for sure.

I'll ask my oncologist when u see him.

I don't have anything to add, @michaelcharles said, you have a variety of choices.

You are 87, describe a generally good health and lifestyle...

So, like the rest of us, do we treat, if so, what's the clinical data supporting that, when, with what and for how long..?

I have seen where a PSADT of greater than 12 months is a clinical data piece indicating you can consider continuing to actively monitor and decide later if the clinical data changes.

There is also the "no ADT" option, MDT only to the locations you've identified. There is some data that says it can push back the need for systemic therapy. From my foxhole, it's like the active surveillance option, you can do something later, repeat MDT, go on systemic therapy, heck as @jeffmarc says, there is mono systemic therapy using ARIs which may not have the same annoying side effects as Lupron, Orgovyx...

You could choose to be aggressive and combine systemic therapy, short term, 6 months say with MDT.

Choosing options 1 or 2 may buy you time for new treatment choices brought on by medical research to come ino play in any decision you and your medical team may (if you even do) need to make in the future.

The clinical data you describe does not put you in high risk so the third option may not be a fit.

As to @heavyphil comment about SRT and @jeffmarc response, got it, think we all understood the intent was to include radiation to the prostate bed based on the clinical data. It does speak to the importance though of terminology and their definitions so that when we are using terms, there is clarity, precision and common understanding of what we are saying.

As to radiation and concerns about "side effects." I may not be the best example. I've done SRT, WPLN and SBRT. That equates to 69 times on the table, 155 Gya total. Side effects, nada, zip, zilch, why, who knows, but I have a great radiologist, she has a great team, she has high standards, and the planning software and delivery systems are advanced. She showed me the 3D software planning tool, when I was doing WPLN she took my wife into the control room to show her the process, Star Wars...As an aside, before the anesthesiologist put me out for my cardio ablation, I looked around the operating room, same, a dazzling array of medical technology!

There are varying systems so discuss with your radiologist.

Kevin

@qldodge Thank you for the additional information.

I’ve had radiation of the pelvic bed area after a recurrence. I do not presently have any side effects and my PSA is < 0.01. However, I had tbe radiation treatment less than 5 years ago and everyone really is different with so many variables. If you and your medical team decide that this treatment makes sense for you, I would recommend basing your side effect decision on any recent studies (< 3 years old) of patients having salvage radiation treatment with a large enough study population to provide meaningful side effect data for 5 years after treatment.

As commented by others, I would not envision salvage radiation now. Only because salvage radiation to the pelvic bed is typically only conducted when PCa is believed to be only in the prostate bed. Once PCa has spread beyond the prostate bed, the treatment is more typically systematic (ADT/ARSI) and in some cases, spot radiation for tumors which are PSMA scan identified and possible to be successfully treated with radiation.

Why? Once PCa shows up in a lymph node on a scan, you know that PCa cells are traveling in your blood stream. You see the tumor sites on a scan, but do not see the locations of all PCa cells.

Your historical PSADT is indicative of slow growing PCa. If you present PSADT remains unchanged (last 12 months), it is possible that your PCa has not mutated to a more aggressive form and you can make a decision based upon the time based probability of bones or vital organs being affected.

More typically, treatments focus at this stage of PCa progression on minimizing the probability of affecting quality of life, and more specifically on reducing the probability of spread to bones and vital organs.

Your health and specially your fitness provides you with an advantage, if you choose a systematic ADT/ARSI treatment, as all recent studies show a correlation between those patients with a higher level of cardio /strength fitness and lower side effects. Many in this forum can provide you with details of their diets and fitness programs while undergoing ADT/ARSI therapy.

You are exceptional in your health and likely your genes, so I’m not sure that any statistics or “convention” applies to you!

Best wishes for continued great health.

If the prostate cancer goes out of the prostate to 3 pelvic & 1 para-aortic lymph nodes per CT, and leuprolide is started right away, without a recent biopsy or MRI, can a man ever go back on AS? A CT was done < 2mos later and showed "Lymph nodes: normal" and "No evidence of metastatic disease". Efforts to have more confirmation of metastasis were thwarted by about 5 different oncologists & urologists. They all just wanted to continue the same treatment indefinitely. Is it okay to go back on AS after Possible metastasis? Has anyone been able to do that? ADT w/undetectable PSA for almost 5yrs I know has taken some toll!

@jonesfit65 if you don’t get a reply from @jeffmarc, I recommend reposting your question as a standalone topic. Many can comment on this topic.

If you are near Albuquerque, I recommend getting an appointment at the UNM Cancer Center with one of their Genitourinary Oncologists, who can walk you through their protocol for ADT treatment “holidays.”

I believe that the specifics will depend upon your specific pathology and treatment history.

@jonesfit65
When you say “go back on active surveillance” do you mean just stay on ADT? If you are on ADT, you are not on AS. You’re just suppressing the currently active cancer.

A PSE test could prove that you either have cancer or do not. It’s at least 94% accurate. If it finds you have cancer, then you need a biopsy. If it doesn’t, then you could stay on “active surveillance”

If you’re talking about going back on AS without ADT Then you need to get PSA test pretty regularly, I’d want one monthly for at least three or four months, then quarterly.

You don’t mention what your PSA got up to before they put you on Lupron. It must’ve been pretty low.

Prostate cancer never really goes out of the prostate. It may shrink due to ADT, but it’s still there. Same thing with your Lymph nodes. ADT can shrink the cancer so it doesn’t show up, But you stop ADT and it is likely to rise up again.

Staying on ADT alone, for as long as you are, can make you castrate resistant and can make the whole thing worse in the future. Median survival once you become castrate resistant is two years.

The thing is ADT does not eliminate prostate cancer. It suppresses it, reduces it in size stops it from spreading, but it’s still there.

Have you been to a center of excellence to be checked out? It just sounds like the right people are not treating you if you are on ADT for five years and have nothing else done. A real strange situation these doctors have put you in.