1. < Prostate Cancer

Overtreatment of Prostate Cancer

Posted by craftsmanctfl @craftsmanctfl, Oct 21, 2023

Urologists are trained to do invasive treatment, such as prostatectomy, for many levels and types of prostate cancer. There may be a tendency to overtreat since treatment is what they’ve learned and likely constitutes the greater part of their prostate cancer practice. I’m 74 and a nodule was found by my urologist through a digital rectal exam (DRE). He set up both a CT scan and MRI (both covered by insurance - Medicare Advantage - in my case). The MRI reading came back suspicious for the nodule and found one other small lesion that was suspicious. I then had a transrectal ultrasound biopsy which showed cancer in two of 14 cores taken. The small one was Gleason 3+3 and the larger one was 3+4. That put me in the staging group of intermediate favorable. My urologist then had my biopsy tissue sent for a genetic/genomic test by , which was also covered by my insurance). It came back indicating I was in the active surveillance (AS) category, although at the high end. My urologist and I agreed to go the AS route with appropriate PSA testing and likely biopsies going forward. If progression is found, I can then opt for appropriate treatment before any metastasis can take place. And newer, more effective treatments may then be available. My point, and it is only that of an informed layperson, is that Gleason cancer scores of 3+4 are not necessarily an indication for treatment. However, the younger you are, the more likely that 3+4 may require treatment. Always review your particular situation with a trusted urologist. But different urologists can have differing viewpoints on treatment, so second opinions are often appropriate. Excellent YouTube videos on many aspects of prostate cancer are by Mark Scholz MD and Michael Ahdoot MD.

Interested in more discussions like this? Go to the Prostate Cancer Support Group.

kujhawk1978 | @kujhawk1978 | Jan 6 11:41am

So, I'm going to disagree with you...

My PCa has metastasized, the C11 Choline scan in January at Mayo showed four PLNs, one pretty high up. My medical team said it was likely not far off from spreading to the bones and organs. We chose triplet therapy, the treatment plan was for 24 months of ADT.

Based on literature search about duration of ADT, data was emerging that 18 months may be about right, better than 6 and 36. I asked my medical team about it, they said given my response to treatment, they were ok with stopping at 18 and actively monitor.

We, myself and my medical team had decision criteria for stopping, actively monitoring while off treatment, labs and consult every 2-4 months, three or more consecutive PSA increases, PSA .5-1.0 and image with a Plarify scan...

That decision criteria was met in March 2023, so, 4-1/2 years off treatment. WHile the goal of triplet therapy was a "cure," I think we all knew, the goal was a durable remission. It's no different this time, we have decision criteria for stopping ADT at 12 months, actively monitoring, resuming treatment.

A literature search of IADT will not bring a definitive answer. Most say is not inferior in terms of overall survival and may improve QOL (well, duh!).

So, my answer was to a specific individual's post, his clinical data, de novo, GS, imaging results and triplet therapy. In his case, he may not want lifetime ADT. I did say read the NCCN guidelines and discuss with his medical team. Here's my take on the NCCN guidelines, they are the science but not the art of diagnosis and treatment. They are population based and based on historical data. Toi be fair, when my insurance denied one of my four C11 Choline scans at Mayo, I cited the NCCN guidelines and won, the science! Of course, the reverse can be true, not in the NCCN guidelines, insurance company can often successfully say no! Given the revolutionary changes in imaging and treatment combined with the heterogeneity, not homogeneity of this darn disease, well, we have choices. lots of them, a dizzying aea, choosing is part science, part art. In his case, the SEs are impacting his QOL to a point where he wants to explore his options. As an example, the EMBARK trial where individuals on Xtandi as a mono-therapy could be a consideration to discuss with his medical team

Another reason not to be on continuous ADT is the adaptation of our PCa, driving resistance. There are others, some many experience deep depression, the fatigue is too much and interferes with being able to function reasonably, the financial burden to some...

That being said, there are reasons to be on continuous ADT, I did not say that in a general context. I am not a medical person who has had training, education and is licensed to practice, there are few if any on these forums who are. That is understood, fellow layman, sharing our experience and passing along information such as NCCN guidelines...

Kevin

REPLY
1 reply
northoftheborder | @northoftheborder | Jan 6 11:45am
In reply to @kujhawk1978 "So, I'm going to disagree with you... My PCa has metastasized, the C11 Choline scan in..." + (show)
@kujhawk1978

So, I'm going to disagree with you...

My PCa has metastasized, the C11 Choline scan in January at Mayo showed four PLNs, one pretty high up. My medical team said it was likely not far off from spreading to the bones and organs. We chose triplet therapy, the treatment plan was for 24 months of ADT.

Based on literature search about duration of ADT, data was emerging that 18 months may be about right, better than 6 and 36. I asked my medical team about it, they said given my response to treatment, they were ok with stopping at 18 and actively monitor.

We, myself and my medical team had decision criteria for stopping, actively monitoring while off treatment, labs and consult every 2-4 months, three or more consecutive PSA increases, PSA .5-1.0 and image with a Plarify scan...

That decision criteria was met in March 2023, so, 4-1/2 years off treatment. WHile the goal of triplet therapy was a "cure," I think we all knew, the goal was a durable remission. It's no different this time, we have decision criteria for stopping ADT at 12 months, actively monitoring, resuming treatment.

A literature search of IADT will not bring a definitive answer. Most say is not inferior in terms of overall survival and may improve QOL (well, duh!).

So, my answer was to a specific individual's post, his clinical data, de novo, GS, imaging results and triplet therapy. In his case, he may not want lifetime ADT. I did say read the NCCN guidelines and discuss with his medical team. Here's my take on the NCCN guidelines, they are the science but not the art of diagnosis and treatment. They are population based and based on historical data. Toi be fair, when my insurance denied one of my four C11 Choline scans at Mayo, I cited the NCCN guidelines and won, the science! Of course, the reverse can be true, not in the NCCN guidelines, insurance company can often successfully say no! Given the revolutionary changes in imaging and treatment combined with the heterogeneity, not homogeneity of this darn disease, well, we have choices. lots of them, a dizzying aea, choosing is part science, part art. In his case, the SEs are impacting his QOL to a point where he wants to explore his options. As an example, the EMBARK trial where individuals on Xtandi as a mono-therapy could be a consideration to discuss with his medical team

Another reason not to be on continuous ADT is the adaptation of our PCa, driving resistance. There are others, some many experience deep depression, the fatigue is too much and interferes with being able to function reasonably, the financial burden to some...

That being said, there are reasons to be on continuous ADT, I did not say that in a general context. I am not a medical person who has had training, education and is licensed to practice, there are few if any on these forums who are. That is understood, fellow layman, sharing our experience and passing along information such as NCCN guidelines...

Kevin

Jump to this post

Thank you for the reply. I'd love to see the links for the studies, because they will help me in discussions with my own team. The only ones I found said that ADT holidays made no difference in overall survival for non-metastatic prostate cancer, but did have an impact on metastatic prostate cancer. More information is always good.

REPLY
ness23456rs | @ness23456rs | Jan 6 3:08pm
In reply to @northoftheborder "@kujhawk1978 wrote "I can say this, six months may be too short, 36 months too long,..." + (show)
@northoftheborder

@kujhawk1978 wrote "I can say this, six months may be too short, 36 months too long, anyon saying lifetime, no…"

Reminder for anyone reading this out of context: "lifetime, no..." applies to ADT only if the prostate cancer hasn't already metastasised. Once you have metastatic prostate cancer (castrate-sensitive or -resistant), then it's "lifetime, yes..." as far as I've learned so far (or at least, as long as you're in active treatment rather than final palliative care).

But yes, there's good evidence going back over a decade that it's fine to take treatment "holidays" from ADT, for months or sometimes years (until your PSA rises significantly again), for non-metastatic prostate cancer — in consultation with your oncology team, of course (don't just unilaterally decide to stop taking it).

Jump to this post

Wow. I've scoured the internet, local support groups, and comrades waiting in the IGRT waiting room, and it is astonishing how personal and unique our situations are. And yet I see doctors at my large university hospital trying to fit me into a structured treatment they are not even following. (My next appoint is 2/1/2024, over two months after the end of 28 days of IGRT. I'm paying for my own PSA tests to keep track)
Perhaps there is a lot of CYA? Better to overtreat than risk a death down the road?
And I hope none of their decisions are financially motivated.
It sad to think that way but my localized cancer treatment cost is now over $250,000.
Personally, and thanks to all who contributed here, I will for choose quality of life over (potential) cure and hope nothing like a car accident, stroke, or fall will make the decision moot.
Or a rising PSA score on 2/1/2024 upends my life plans...again.
It has been a pleasure being reassured, warned, and educated by this group and I'll keep watching and learning.
Best wishes to all!

REPLY
northoftheborder | @northoftheborder | Jan 6 5:12pm
In reply to @kujhawk1978 "https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2859136/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5772839/ Here's two, as you can tell,all over the map" + (show)

Thank you for sharing those. I'm reading quickly and don't have any medical expertise, but it seems that they're calling for more research because intermittent ADT *might* be useful for advanced/metastatic prostate cancer, but not actually recommending it (yet) because there's not sufficient evidence to support it.

The first one still recommends that "Based on randomized studies, continuous ADT appears appropriate for patients with advanced, metastatic prostate cancer" and the second says that "patients with large tumors, multiple metastases, and prostate-specific antigen (PSA) levels >100 ng/mL do not have a good prognosis with IADT, mainly due to a shorter life expectancy and a shorter off-treatment period" (for now, anyway).

For people with non-metastatic prostate cancer, the second one (IIRC) points out that intermittent ADT has a slightly-higher mortality rate from cancer, but that's balanced by a slightly-lower mortality rate from other causes like heart disease associated with the side-effects of ADT.

I hope that with more research, we'll find a way to reduce or limit ADT use for people with metastatic or oligometastatic prostate cancer, but for now, it looks like we're not quiet there yet.

REPLY
hbp | @hbp | Jan 6 9:30pm

I was on ADT and Erleada for 13 months after RP. Neither the surgery nor the meds had a terrible effect on me, but certainly some manageable effect and I would do the meds again as I suspect that it is in my future. A good attitude helps to travel this journey that none of us have chosen

REPLY
pieperfarm | @pieperfarm | Jan 7 3:19am

I am 57 and just had HIFU on my first Gleason 7 lesion with good results. Still have Gleason 6 PC on one side of prostate.

REPLY
heavyphil | @heavyphil | Jan 7 7:12am
In reply to @michaelcharles "SPPORT trial findings may be helpful. Also rising PSA after treatment Jan 2023 video PCF.org. BCR..." + (show)
@michaelcharles

SPPORT trial findings may be helpful.
Also rising PSA after treatment Jan 2023 video PCF.org.
BCR (PSA .19) immediately after RP led to radiation treatment of the whole pelvic region (WPRT) together with the pelvic lymph nodes.
Also 4 mos of ADT.
I thought that I saw the SPPORT trial recommendation was 4 - 6 mos ADT for intermediate PCa and 18 - 24 mos for aggressive disease.
however , I have not been able to re-locate that information.
My Gleason score was a 9, together with 8s.
However my Rad Onc prescribed 4 mos ADT.
2 "radiation buddies " received 6 mos ADT.
And I am not entirely sure why my ADT course was only 4 mos.
I chose Center of Excellence for treatment, so I am having faith.
1st PSA 6 mos following completion of 37 radiation txs (66.6 gy) and ADT undetectable. I will feel better if PSA remains undetectable for at least a couple more tests, but so far so good.
Sincere best wishes.

Jump to this post

Hey Michael, thanks for posting. Hoping 6 months ADT is what I get. Just read article from ACRO that said most men up to .7 do not need hormones, as the long term survival rates are similar and, in fact, many men are harmed by the hormones themselves.
Again, I feel all cases are different and I would rather have a little more treatment than too little. After all, how many more chances do you get?

REPLY
View MoreView Less
Please sign in or register to post a reply.