Hormone Therapy (ADT) when ArteraAI Test says it's not necessary

What interested me when I was concerned about what treatment I should choose given my trepidation about the side effects of ADT was brachytherapy. I'm cT3b GGIII "at least high risk", according to my RO, so clearly I'm much higher risk than you. A standard treatment often prescribed for cases like mine is some sort of external beam with 2 years of ADT. This was the initial prescription my RO sentenced me to.

I looked into brachytherapy. One of its virtues is that the radiation source is placed inside the prostate, so the full power doesn't pass through any other tissue to get to the cancer. Another virtue is that in many cases, less ADT is required.

My research concentrated on therapies involving external beam plus brachytherapy boost, because my cancer has gone outside my prostate to the seminal vesicles and possibly although not proven beyond. External beam plus brachy delivers a higher dose than is possible with any other therapy, which results in data showing a longer disease free recurrence. The TRIP study showed no improvement with 30 months of ADT compared to 6 months. The highest risk patients were pT3a, not 3b as is the case with me, but I decided on brachy.

Nelson Stone gave a lecture at the 2024 SouthWest Prostate Cancer Symposium about this.
https://grandroundsinurology.com/radiation-dose-and-hormone-therapy-how-much-is-enough/

@climateguy
A mayo Radiation oncologist gave the speech on April 6 at the monthly meeting.

He said they had four proton machines in Rochester and were adding two more.

He personally has only used it four times. I guess he also feels that there’s not a big difference between proton and photon when it comes to prostate cancer treatment.

There are those who hesitate about attaching decisive weight to ArteraAI results. Quoting from one study that is underway:

"Androgen deprivation therapy (ADT) improves outcomes in men undergoing definitive radiotherapy for prostate cancer but carries significant toxicities. Clinical parameters alone are insufficient to accurately identify patients who will derive the most benefit, highlighting the need for improved patient selection tools to minimize unnecessary exposure to ADT’s side effects while ensuring optimal oncological outcomes. The ArteraAI Prostate Test, incorporating a multimodal artificial intelligence (MMAI)-driven digital histopathology-based biomarker, offers prognostic and predictive information to aid in this selection. However, its clinical utility in real-world settings has yet to be measured prospectively."
https://pmc.ncbi.nlm.nih.gov/articles/PMC11827432/

@jeffmarc The description of what Mayo Rochester has given by Davis was they have one proton source that can supply four treatment rooms. He said they are adding another source.

One thing that interested me about the presentation by Davis is he said Mayo Jacksonville is adding a carbon therapy facility, the first of its kind in North America. Carbon ions are said to provide a more biologically effective dose to kill cancer tissue than protons.

@climateguy My UofMD doctors are also including a one-time brachytherapy after the proton therapy. Under general anesthesia they will insert a certain number of seeds for a period then remove them in the same procedure. So, this was another aspect that I wondered if anyone had input on. It could leave me with a catheter for a couple of days, they said. Is it worth it?

I am also scheduled to have a spacer and fiducial markers placed before proton therapy begins. I'm all for the spacer, for obvious reasons, but even they admitted that the markers don't really improve accuracy of the proton beams. It can be done as accurately without them, just needs some additional setup before each proton treatment. So do I opt for the spacer but not the fiducial markers?

@climateguy The Jacksonville facility will have all treatment rooms (including Carbon) from a single synchrotron. The carbon room is a fixed beam with the patient strapped in standing and designed to treat upper body (head, neck). Will need to wait a little longer for Carbon prostate treatment.

@climateguy
That would make a lot more sense to them having four proton machines.

I did hear him saying they are going to add more, maybe that will include two treatment rooms, not two proton machines. I know they did get the funding to add another machine.

@tjnoffy The markers will improve the ability of therapists using photons to detect if your prostate has moved during the treatment. If Proton people use a scanning system during treatment to show them if the prostate has moved that is different than the usual for photon therapy, then they might say not to use them. I don't understand the ambiguity about maybe. I'd leave it up to them. How can they expect a patient to understand what they need for the most accurate aim of their beam?

I just had HDR, i.e. high dose rate brachytherapy. Everyone except the patient leaves the procedure room. The radiation source is sent by a machine into the prostate anywhere their plan says, lingering a very short time in each spot, i.e. seconds, then is moved to the next planned spot, etc., and then is withdrawn, and everyone comes back into the room.

They don't call it a "certain number of seeds" that are later withdrawn. Talk of seeds might be LDR, low dose brachytherapy, but the small radioactive "seeds" are permanently left in place.

HDR side effects tend to peak earlier than LDR. I didn't need a catheter. My LUTS are worse now than prior, but I look forward to slow improvement. I've heard the side effects might persist until patients believe they will never go away, i.e. months, then subside. I can easily live with what is happening right now. I need to get up every 2 hours at night to piss, when before it was twice a night. My stream is weaker than it was. Your mileage may vary. I was working out in the gym 3 days after the procedure.

@tjnoffy You will probably need to ask for Decipher and Prostox Std tests if you want them. Decipher specifically estimates the probability of recurrence. It is covered by Medicare and uses biopsy tissue. With the ArteraAI risk being so low it might not add much. The Prostox Std test is designed to separate those at high risk of having long term (occur 8 months to years after treatment and are more permanent) GU effects from radiation such as ED, urethra constriction, etc. If high on Prostox risk is 75% of having 1 or more long term GU effects. If in the 86% not high the risk is 7%. The quoted risk is usually 15% so the test knocks out those at highest risk. Also, you may want to reconsider treatment plan if in high-risk group to either RP or SBRT (< 2% are high risk for both). Looks at 21 biomarkers responsible for repairing DNA, responding to stress and inflammation. This test was developed at UCLA but just became commercialized this year. Probably not covered by insurance. Maximum out of pocket $395 or lower based on income.

@climateguy Yeah, there was no talk of the benefit of tracking whether the prostate moves, just that it didn't add much to the process. Seemed odd to me if the markers don't really help.

Maybe it was one ball (or whatever) moved from spot to spot. I got the impression from the description that it would be multiple balls put in and removed in short order. That's what my notes from the visit say. Regardless, it wasn't LDR that stays in place where you can't hold your grandkids in your lap.

They also mentioned the possibility of a strength training study a couple of days a week during proton therapy, so that may be a way of getting more exercise than what I already do.