Is Hormone therapy necessary With radiation

This is for salvage radiation after RP and BCR, why the PSA levels are low. BCR after RP is PSA >0.2 ng/ml so the hormone treatment breakpoint of PSA >0.5ng/ml being effective is well above when radiation should start.

The same type of breakpoint at a much higher level may (or may not) exist for adding ADT to primary radiation treatment but was not considered in this study.

But they have been pushing 24 month ADT for a long time now in cancer guidelines and it seems for little to show in overall survival rates but a lot to show in side effects affecting the quality of life of all those put on it. I think this is why we are seeing so many oncologists now pushing shorter durations of ADT even if counter to guideline recommendations

@jim18
What you’re saying is true but unfortunately we’ve seen a lot of people come into this forum whose PSA has gone above .5 and they’re still not getting salvage radiation.

It just seems that some urologist are not following the standard of care and let people drag on without treatment.

It is true, however, that some doctors like Dr. Kwon and Dr. Scholz (PCRI) Seem to like to have the PSA rise to the point where they have metastasis show up in the PSMA PET scans before they do something and they then want to zap those metastasis as a treatment. I’m sure it must work for some patients. Those that have advanced cases risk long-term problems when treatment is not done in a timely manner.

Definitely can’t say who’s right Without a number of years of clinical trials.

I had HDbrachytherapy performed at a COE, UVA Charlottesville. Being retired and in the medical profession for over 40 years probably made me a pain in the ass to my doctors. Although, I can’t stress enough that everyone should do their homework. I looked at the studies on ADT. I had 4+3 Gleason contained in the prostate. My prostrate oncologist wanted me to go on orgovyx prior to the procedure and the 25 sessions os EBRT. I told him for less than a 2% survival increase it was not in MY decision to have ADT. He completely said that would be fine. It has to be your choice. QOL should be paramount in your treatment options. In medicine, we look at numerous studies and drug companies data on meds to prescribe. Medicine is not an exact science, it basically changes on a daily basis. I continued at the end of my career that many patients had the same if not more knowledge than I did on a particular condition (I was a family GP). When I finished my residency I thought knew everything. Lol. Now being on the other side I can get the same data as the physician. I had cursory knowledge of radiation and wanted to make sure I found the best oncologist and Center of Excellence. Based on this platform, Mayo is at the top of being a COE. In the US most of us are a 2 hour or less driving time finding one. They’re usually a University Medical Center. Good luck and keep on doing your own research.

THANK YOU JEFF for link to this insightful Uro Today March research regarding PSA levels above >0.5 range threshold

APPRECIATE IT .. sentlink to my Doctor but no response yet!

Eight years ago @ 65 retired water chemist/microbiologist I found had prostate cancer just before retirement. had laparoscopic RP. Post RP @ 5- 6 years PSA started to climb had some strange results w/ data showing a drift upwards. Being Houston and busy Med center w/ high demands.... thought maybe lab results were flawed and some concern on data specificity at such low levels. So had it repeated with drift up to 0.09 & decided to take HMU plan for ADT 6 month shot with targeted pelvic radiation. Now at 8 years POST RP PSA non detectable below 0.01 and Testosterone returning post Lupron. ADP and hot flashes not too bad as active but had concerns on hormone disruption or future diabetic or coronary issues but seems successful. Just questioning if doubling PSA at these low levels from 0.01 to 0.03 or 0.04 to 0.09 ALL WELL under 0.1 PSA truly warrants this protocol. Definitely under 0.5 threshold in article but many test methods. Doctors say all is great NOW so ONWARD. so will continue to monitor. GREATFUL today some control re-established

DATA PATHWAY:
3/15/18 age 65 history of prostate cancer treated w/ laparoscopic prostatectomy Houston Methodist Med Center by HMU prior to surgery diagnosed with CAP following finding elevated PSA of 9.2 & biopsy w/ Gleason’s 7 (4+3) carcinoma high volume
surgical path revealed same Gleason w/ SM’s, -LN’s, ECE pT2N0
Date PSA ng/mL Testosterone ng/dL
12/6/18 <0.01 282.96 (9 month post RP)
6/29/21 0.02 175.57 (39 month post RP)
4/4/22 0.03 221.46 (48 months post RP)
7/23/22 non detectable? 203 (51 months post RP)
4/5/23 0.04 277.27 (60 moths post RP)
11/15/24 0.09 - (67 months post RP)
Asked about PSA tests reliability & validity with no testosterone results
12/31/24 second blood test response no report issued but was same verbally (68 months post RP)
0.09 -na?
(NEW plan below was told is recommended- told when ever PSA doubles should intervene) as shown above (0.04 to 0.09) is doubling
Plan 1/14/2025 – 2/27/25 @ Age 72 for 8 weeks
1) ADT hormone therapy Lupron ( 6 months 1 injection)
2) CT simulation
3) 6840 cGy IG-IMRT for recurrence treat fossa& pelvic lyph nodes so 8 weeks w/ 36 treatments
Follow-up post ADP w/Rad
Date PSA ng/mL Testosterone ng/dL
11/5/25 <0.01 52.37 ( additional 9 months w/ testosterone down from ADT
Last tests GOOD this week@ 17 months after ADP & Radiology
6/1/26 <0.01 154.97 age 73 testosterone rebounding but below normal

THANK YOU

So many studies support current guidelines exactly because of a 2% to 5% overall more favorable overall survivability result. I personally feel that whether you are in the 2% to 5% , you might as well go to Las Vegas and just bet your money on the statistics for that game. Most people feel they would not do that and i feel if I believed I could continue with a quality of life I am happy with why risk it for such a low percentage increase whether the cancer guidelines say you should do it. Those guidelines are often made based on that low overall statistical advantage. That again in my opinion is why you should not just restrict yourself to the cancer guidelines. Everyone agreeing to less months of ADT is doing exactly that. That is why a decision whether to wait for a PSA increase to reflect in the PET to direct radiation is one of the most discussed issues today regardless of current cancer guidelines

And just in case there's any confusion, this study applied only to people with early-stage, non-metastatic prostate cancer.

If you have metastatic prostate cancer, you almost definitely need more than just radiation. Doublet therapy involves being on ADT + an ARSI (like a lutamide) indefinitely, but there's ongoing research to see if it's possible to drop the ADT and continue with just the ARSI.

@jeffmarc Dr. Kwon’s position was that if you can’t see the recurrent cancer in the PSMA PET scan, then you don’t know where to target the radiation. Thus his desire to “….have the PSA rise to the point where they have metastasis show up in the PSMA PET scans before they do something…”

I’ve seen patient postings in various forums mention that their radiation oncologists zapped the prostate bed anyway - while not knowing where the recurrence was - because (post-prostatectomy) that’s where recurrence was most likely to happen. Yet, Dr. Kwon’s position was that “…. only 1/3 of men who have recurrence following prostatectomy have recurrence only in the prostate bed; they SHOULD NOT get salvage radiation there unless they’re absolutely certain of the location of recurrence; first confirm where the recurrence is.” (See his presentation at: https://youtu.be/Q2joD360_pI. His specific statement on this is at about timestamp 3:10.)

So, when and where to treat recurrence seems to depend on one’s RO’s philosophy regarding post-prostatectomy recurrence.

@cbball Yes, doing one’s own homework is crucial to getting a desired outcome (the definition of which can vary person to person).

Similarly, being a retired computer scientist, I was into the technical and analytical details of the treatments. I don’t think I was a “pain in the ass,” but I had questions regarding diagnostics and treatments for which my doctors would comment “No one has asked us those questions before.”

I was initially diagnosed (in 2012) with low-grade, localized disease (PSA 4.2, Gleason 6, with no other adverse risk factors), and the urologist wanted to do a prostatectomy. I chose to go on active surveillance which lasted for 9 years. (But over those years he was good enough to provide me referrals to specialists in any treatment modality I requested, so that I could interview them while doing my own research.)

So, it goes behind just doing one’s homework; it also involves (what I call) becoming a “student of prostate cancer,” learning the language, self-advocating, and sharing in the decision-making.

As for that extra 2%, I would take that small change - with the full understanding that by incorporating a robust resistance-training exercise program, that I could minimize/avoid most of the common ADT side-effects. (And being a gym-rat myself, that’s what I did.) Quality of life was equal priority for me as was successful treatment.

I’ll take that 2% using the ADT (which I did), plus the few % with a rectal spacer, plus the few % with a full bladder, plus the few % with an empty bowel, plus a few % monitoring my diet, plus, plus, plus……..during and after treatment those small plusses add up to something meaningful.

There’s a study that Dr. Scholz cites about ADT providing little benefit for Gleason 7. (It might be the same one you’re referring to, I don’t know.) When I listen to that Scholz video, he refers to Gleason 7 as well as “intermediate disease,” but never mentions whether that’s 3+4 or 4+3 (or favorable/unfavorable). Similarly, when I located the literature on that study he was citing, it also refers to Gleason 7 as well as “intermediate disease,” but never mentions whether that’s 3+4 or 4+3 (or favorable/unfavorable). So, depending on how weighted that study was towards 3+4 rather than towards 4+3 might explain the small % survival increase of using ADT.

(Ultimately, I had 28 fractions of proton radiation + 6 months (two 3-month injections) of Eligard. The radiation treatments were relatively uneventful; the Eligard was a 9-month annoyance.)

Wish there was some breakout in this study that Jeff just posted stratifying patients by risk such as gleason grade, decipher score et al. '

Maybe the studies they analyzed not include those stats..