Help finding a study re treatment: EBRT plus ADT vs ADT alone

Your case is pretty serious. You need to have radiation followed by ADT. As a Gleason nine You should be on ADT for 24 months. There’s plenty of Information about how this is beneficial, You just have to create a search algorithm and go looking for exactly what you want to see. Lots of documentation On the benefits of ADT for somebody with cancer like you have.

Looks like you’re trying to avoid a major decision. You could have SBRT but EBRT will spread The radiation over many more sessions.

It’s possible that SBRT (cyberknife) Could do the job, If you don’t have cribriform. In that case, you would have to have follow up radiation.

Please see your doctor about this. I’ve supplied the above so you can have more information when you discuss treatment with them.

Hi Jeff

Thanks for replying. I'm already on ADT & ARSI (Orgovyx and Nubequa). Treatment plan, as presented, is stay on ADT & ARSI for 3-4 months then add 30 +/- sessions of EBRT while continuing ADT & ARSI indefinitely. I'm looking for a study, everyone keeps referring to, that states adding EBRT, to a patient with low volume mCSPC already under treatment with ADT & ARSI, is more beneficial than ADT & ARSI alone and how much so. It's the how much so part that will guide my decision as to radiation or not. EBRT is to prostate only, not any metastasizes.

And...I found them. It's the STAMPEDE trial and the HORRAD trial.

First, terminology……
> EBRT (external beam radiotherapy) is the general term for all types of external radiation - SBRT, IMRT, IGRT, VMAT, Proton, whatever…….

Yes, a number of studies indicate that IMRT vs PBRT have similar results with no discernible difference in complications or side effects. There are currently two clinical trials looking into this - COMPPARE and PartiQoL. The PartiQoL study has released interim results indicating comparable side-effects. (Nevertheless, even prior to those studies I chose PBRT due to its Bragg-Peak characteristics and success with other cancers.)

So, the decision isn’t “EBRT or not to EBRT,” the decision is actually “If EBRT, what type of EBRT: SBRT, IMRT, IGRT, VMAT, Proton…….”

As for whether or not to use ADT (for intermediate risk prostate cancer) with EBRT, radiation technology is so much improved over decades ago, that some studies show minimal differences: https://www.onclive.com/view/ebrt-with-or-without-stad-shows-improved-15-year-survival-in-prostate-cancer

Dr. Scholz talks about this in this PCRI interview: https://youtu.be/cyY0nHXvzGc?si=vkI-63iM-_ErI-c3

Another consideration is whether it’s preferable to front-load ADT with radiation treatment or backload it. This is a paper titled - “In Prostate Cancer, ADT After RT Better Than Before RT” - that was presented at the American Society for Radiation Oncology (ASTRO) 2020 Annual Meeting, that discusses whether (and why) ADT with (and after) RT leads to better outcomes than ADT well before RT (which is how it is usually given): http://www.medscape.com/viewarticle/940049

(For my localized, 4+3=7, PSA of 7.976, I had treatments during April-May 2021: 28 sessions of proton (@ 2.5 Grays each session) + 6 months of Eligard (April & July) + SpaceOAR Vue.)

Good luck with your decision!

In addition to Stampede, there were a number of other clinical trials looking into doublet therapy. (See attached graphic.)

Thanks Brian. I was looking forward to your comment because I knew it would come with more reading material. 😁

I think I'm pretty much there to proceed with radiation in a few months. IMRT vs PBRT will be the question. It was very obvious that my RO was much more comfortable with IMRT. This will be a decision for another day. I'm done with cancer for today.

My husband has just started radiation therapy. He is on abiratarone and predisone and had his hormone therapy injection 4 weeks ago. I have a few questions. Our medical oncologist and radiation oncologist said that he will be on hormone therapy and abiratarone for the rest of his life. Is that the case? also, my husband is starting to have difficulty with his erection but it is as though he knew it was coming, so he has accepted it. Is there a chance that he will ever get that ability back or no? I have told him that is not the most important thing to me. His health and well being is what matters. But, I really feel that the little folders we get listing side effects, etc are just not adequate. Gdawg

.

His diagnosis (grade, stage, etc.) and other significant risk factors determine how long he’ll be on hormone therapy, as well as his response to his treatments. So much can happen between now and then that often precludes being on hormone therapy “for the rest of his life.”

Difficulty with erections can be from a number of reasons - the hormone therapy (due to low testosterone) or the radiation therapy (often radiation hitting the nerve bundles is unavoidable). They also should have avoided radiating his penile bulb.

For me, except for the hormone therapy causing me to have zero libido, everything still worked. From what I was told by my medical oncologist (MO), the key is to continue “doing it” throughout, despite the “want to” not being there (due to the zero libido). I was told that it’s a “use it or lose it” scenario. It was up to me to keep the blood flowing.

Though I have no empirical data to support this (only my MO’s advice that it would work - and it did), my experience not having ED while on ADT might be related to me ramping up my resistance-training and cardio programs to minimize the side-effects of hormone therapy; that might(?) also have the side-benefit of keeping the blood flowing “down there” as well; I don’t know - but, I never had any issues. Libido eventually returned to normal after stopping the Eligard when my testosterone levels returned to normal. Everything in that department is as it was before treatments started.

This 2023 presentation out of Stanford University describes how everything works down there, and might provide insight into solutions —> “Penile Rehab: Optimizing Recovery of Erectile Function after Prostate Cancer Treatment” —> https://youtu.be/aRp1NXjPGLE?si=VyF2ALSgU1J5r4OI

Good luck!

Dear Brian: Thank you SO MUCH for your reply to my queries and uncertainty. I really found the youtube video from Stanford University to be insightful. I encouraged my husband to watch it, as well. He had his original biopsy in late SEptember and was rated Gleason 4-3. A urologist, who had been assigned to us, called and said that the cancer had been caught early. This urologist only does surgery so as we discussed the options, and the fact that he didn't seem that concerned of the urgency, my husband thought he would go with the radiation seeds. We go away in the winter for 3.5 months but I made it clear to the doctor that we did not have to go away. My husband's health was our first and only priority. The urologist said he would refer us to a radiation oncologist and said that we would not get in to see him until after that time, anyway. So, we went away. As soon as we returned, my husband had an MRI and it looked a bit concerning. When we left his PSA had been 8 . When he got his blood test mid April, it had gone to about 15 . We paid for a PSMA on April 29 and it showed that the cancer had gone into two lymph nodes above the prostate. So, our options for radiation seeds , or anything else, really, were gone. On May 15 my husband had his hormone therapy shot, two weeks later he started on abiraterone and prednisone and on July 4 he began his 25 days of radiation. He has a medical oncologist and a radiation oncologist. Both have indicted that he will be on the hormone therapy for the rest of his life. I have watched you tube videos from PCRI. org and read some other information and so often they mention, when you discontinue the hormone therapy then your libido will come back and you must maintain your muscle mass, etc. for that event. I am not sure why these doctors feel that my husband will be on the hormone therapy forever. I really appreciate your personal information, saying that you maintained your physical strength training. My husband had always been in favour of that but, for some reason, right now, it is a difficulty for him to feel like doing it. I feel as though the side effects which have been outlined by the doctors have made him feel that it is inevitable and that he can't affect those inevitabilities. Your response gave me hope and I am going to encourage and support him to the best of my ability, so that he can see that he CAN impact these results.

Warm regards,

Glenda

It’s amazing how much you learn over time. I regularly use the phrase “If I only knew then what I know now!” That phrase certainly applies to prostate cancer diagnosis and treatment decisions.

Even with just PSA there are quite a few numbers to know; and with MRIs there are quite a few numbers to know; and with biopsies (4+3=7) there are quite a few numbers to know; and then with biomarker, genetic, and PSMA PET scans, there are quite a few numbers to know. So much information is needed to know how things really are.

So, a 4+3 (like I had) may or may not have been caught early……it depends on all of those other tests and results. A 4+3 (intermediate unfavorable) is where the concern starts, because that “4” cell structure can be the start of trouble.

PSA going from 8 to 15 in that short of time is unusual. Then again, knowing those other numbers and results from his PSA, MRIs, biopsies, biomarker, genetic, and PSMA PET scans, might have given some insight as to what might be coming. However, It’s easy to second-guess decisions, but that isn’t helpful.

> When you mention that “We paid for a PSMA on April 29….” - was that out-of-pocket or did insurance pay for that?

So, brachytherapy is out of the picture, he’s had a hormone therapy injection (which one?), is on Zytiga, and has started radiation.

> Did he use a rectal spacer (SpaceOAR, Barrigel, or BioProtect) prior to his radiation treatments starting?

> Are they hitting his lymph nodes with radiation?

> Has he had genetic (germline) testing?

> What have they proposed to kill the cancers? Chemotherapy?

As for staying on hormone therapy forever, that’s not a desirable option (for a number of reasons).

Novartis announced the results of a Phase 3 trial, called PSMAddition, that has shown positive results when used in combination with hormone therapy for patients with metastatic hormone-sensitive prostate cancer (mHSPC). You might ask his doctor if that treatment is an option yet.

With so many novel treatments being developed almost yearly, what is said to “be on the hormone therapy forever…..” might be a very, very short time. Just take it a day at a time.

It’ll work out well.