Prostate cancer metastacized to the Iliac lymph node

The recommendation from my radiologist, who seems quite competent, is to do one of the following:

Radiate the lymph node for five days and take an ADL for six months.
OR
Radiate lymph node and pelvic are for 33 days and take an ADL for six months

He showed me lots of data indicating the second choice has better five year outcomes, but he emphasized no case is the same and it completely my choice as to treatment.

Seeing my oncologist, also very competent, tomorrow, but have to make a decision.
Support and advice and information appreciated! Thanks, Jim

@monahanirvingjames My feeling on this has always been that where there’s smoke, there’s fire.
If you have a visible lesion in a node, might there not be many many more that have not reached the critical mass necessary to light up?
Since you did ask, personally I would zap the node with SBRT and do full pelvic with IMRT and ADT. Better safe than sorry down the road. Best,
Phil

I had both as a treatment in IMRT. It was a 6 month ADT dose. This after a prostatectemy that looked promising but had BCR 13 months later and salvage radiation to the pelvic area that too looked promising. But the reason your Docs are recommending both IMRT is that the ADT helps in the killing of the cancer cells the radiation hits. They call it "sensetzing" them. There's disagreement on how it helps exactly with some postulating it jams the dying cells' repair mechanisms.
But in addition it kills or lames up the micro cancer cells that even the PSMA Pet scan can't detect.
I'm very athletic and my Doc said that's a major reason my side effects from ADT were relatively mild - some night sweats no loss in libido, etc. Full recovery of testosterone in about 2 months.
The procedure dropped my PSA undetectable for a 4 month period. This was in 2021. Still being treated for oligometastatic lymphtropic pc with a PSA that's never gone above 6. Classified as an indolent oligometastatic metachronous lymphtropic hormone-sensitive pc which means I'll probablybe fighting rear guard actions with it till I die. But if I keep those up I'll probably die with the disease and not of it. I'm 78 and survived rocket attacks and an ambush in Vietnam where I probably picked it up via Agent Orange. So no complaints here.
Talk to your Docs about this- but the key is to avoid as much of the ADT as possible to avoid or forestall becoming castration resistant. But as I understand it takes about 2 years of continous ADT for that to occur. So 6 month dose now isn't likely to even contribute to that issue even if there's more intermittent doses down the road. But you might ask you Docs about using an ARPI like enzalutimide instead of the ADT.
In any case good luck
Jim

@icorps
While Enzalutamide Can be a good choice for some people it does cause many serious side effects. On the other hand Darolutamide Has no side effects for most people that works really well as a standalone ARPI. I know Many people using it as they’re only drug, Some very advanced case cases which are kept under control by it.

If you have to be on ADT, including an ARPI has been shown to extend the amount of time it takes to become castrate resistant.

@heavyphil
This sounds like the treatment I received for pc in the prostate and in two adjacent lymph nodes. The prostate and nodes rec'd full radiation each day w/SBRT and the pelvic region was given a smaller dose.

@cadaddy SBRT for how many days? It’s usually just five (5) if it’s all SBRT.

Welcome to the world of indecisiveness...
Is there a "right" decision...no...
Are there "good" decisions...yes

There is data that points to MDT by itself delaying the need for systemic therapy.

There is also data that points to the combination of MDT + systemic therapy increasing PFS and RPFS. Though, a question to ask is, how long is that difference and is it worth the side effects of systemic treatment...?

I am not sure about differences in OS, in part, the data on that is sparse and is difficult given the length of time involved in collecting and determining that. Also, given he rate of change brought about by medical research, irrelevant to decision making...

Age is a factor, I was 57 when diagnosed, some on this and other forums are in their late 70s, early 80s...they may be looking at decision through a different lens

If the decision involves one or the other, questions still remain, which agents -Lupron, Orgovyx, duration...6-36 months systemic therapy, which ADT, which ARI. Will doing ARI monotherapy work, what about the PATCH trial and estrogen...

As to the side effects of systemic therapy, well, again, well known. A question is what side effects would you experience and the severity? Again, not known. In part, the agents and duration of systemic therapy play a role as do mitigating strategies - diet, exercise, managing stress...I never experienced loss of libido, statistics say 80% do while on systemic therapy. I did the Bataan Memorial March 15 months into systemic therapy. I did not experience depression...

So, what are we to do?

The decision you are trying to make can be one of several, each a good decision...

MDT only
MDT + systemic therapy
Playing the long game, aka, do nothing but continue o monitor, decide ,later.

In part, that answer lays in your clinical data, GS, GG, PSADT, PSAV, an genomic testing...

Keep in mind, even today's most sensitive imaging can't see micro metastatic PCa...

I am high risk, so, generally have been "aggressive" in my treatment decisions. That has worked for me, 12+ years, only three on treatment. Life on versus off treatment, the only difference has generally been not what I do but how I feel doing it. I may be an outlier, in both cases I have done less than the SOC time for systemic therapy, have not included an ARI, T has recovered quickly and the vacations have been lengthy, five ears and going on two plus currently...
https://www.urotoday.com/recent-abstracts/urologic-oncology/prostate-cancer/168250-natural-history-of-untreated-prostate-cancer-a-comprehensive-review-of-long-term-progression-patterns-and-survival-outcomes-beyond-the-abstract.html
https://ancan.org/playing-the-long-game-does-your-recurrent-advanced-prostate-cancer-need-treating-nci-seminar/
Kevin

Why not just try it? Taking it for a short period does no permanent damage, & you could see what the effects are on YOU. Individuals have different reactions (& perceptions).

I was on Lupron for 2.5 years, & the side effects were so mild, that when my oncologist wanted to take me off of it after 2.5 years, I initially declined.

After 2 years off Lupron, I'm now back on Orgovyx. I chose Orgovyx only because it's quicker to see the effects, both going on & going off. Lupron has the advantage of one shot every three months over a daily pill.

It's good to come here for information, but in my opinion (& practice), I generally take a doctor's informed opinions over stories (which are not statistically balanced). After all, specialists (like oncologists) spend a lifetime studying research, which beats several weeks on an Internet forum.

I know this is a little negative but based on my own experience you may want to add into your discussions with your doctors as where it might move to next. Proactive approach is new to some of these guys but more are thinking ahead. My research and personal experience indicates the next stop is the pelvic area and or vertebras or continue onto the next lymph nodes. The only way you will know about ADT is to try it. My advice is to avoid Lupron. Once you take that shot you are in for the long ride and if you bad reactions you have no way out. I have only been on Lupron but refuse it now. If I were to I would chose Orgovyx now . I have had 80 radiation treatments over the last 14 years and continue to prefer SBRT over ADT.

@kujhawk1978 Thank-you. Very helpful.