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Medical Forum / Diseases and Disorders / Prostate Cancer / December 2003radiation with adjuvant hormonal therapy
My husband is 5 months post surgery and it has been recommended by all three of his physicians that he have radiation for positive margins. Also, 2 out of the 3 physicians recommend adjuvant hormone therapy with radiation. Its suggested to start with 2 months of hormones prior to radiation and then continue the radiation for two years. My husband had a PSA 5, gleason 7 (4+3) with unilateral seminal vesicle involvement. We are having a difficult time deciding whether to just do radiation and wait on hormone therapy or do both initially. Studies do seem to indicate that the hormone therapy will prolong the time before recurrence. Has any one had this type of treatment suggested to them or is anyone going through this treatment? Any input would be greatly appreciated. Just feeling alittle overwhelmed with all these life altering decisions!! Thank you, Sandi > My husband is 5 months post surgery and it has been recommended by all > three of his physicians that he have radiation for positive margins. [quoted text clipped - 11 lines] > Thank you, > Sandi Did the doctors explain the purpose of the hormone therapy? I'm not a doctor and I may be mistaken in some of my thoughts here, but this is my understanding of why hormone therapy is used. 1. HT is often given before radiation to weaken the turmor cells, making them less resistant to damage from the radiation. The idea is that you get a greater likelihood of killing the cancer cells with both together than with radiation alone. 2. Suppressing testosterone makes the prostate gland shrink. That makes the target for radiation smaller, allowing more focussed beams. I presume this does not apply in your husband's case since the prostate is already gone. 3. If and when both surgery and radiation have failed, HT is given to suppress the cancer as long as possible before it starts to grow again. There are different kinds of cancer cells, some of which require testosterone (most cells) and some of which don't. A few lucky men (if anyone with cancer can be called lucky) have almost all testosterone dependent cancer cells and they may live many, many years on HT alone. I would guess that reason 2 doesn't apply, reason 3 isn't yet applicable, but reason 1 is the one that may help in your husband's case. I have been on hormone therapy (Lupron) for about two months now, and I started radiation treatment last week. There has been a loss of libido, and I get hot flashes on a fairly regular basis. But I'm not finding it at all difficult to cope with. I've taken other drugs in my life that have had far more debilitating effects than Lupron. When it's given for a relatively short period of time (i.e. less than one year), I've read that the negative effects are not generally very severe. My personal choice was, and would be again, to get the hormone treatment as an adjuvant to radiation. Even though your husband's cancer has spread beyond the prostate, maybe it hasn't spread very far. Unless the doctors already have evidence that it has escaped generally into the body, it may still be confined to the region right around the prostate. In that case, a complete cure may still be possible. Te most aggressive possible treatment, which means HT + RT, might be enough to get it all. If the cancer has escaped, then the doctors may be thinking about reason number 3 above. I don't want to get your hopes up here. Your doctors know far more about this than I do and also know more about your husband's particular case. Incidentally, Lupron has the initial effect of _increasing_ testosterone for about two weeks. Casodex, a more direct testosterone suppressor, is generally given during or before this period to avoid having this "testosterone flair" feed the cancer during this period. I hope this helps. Best of luck to both of you. Alan >Subject: radiation with adjuvant hormonal therapy >From: sjbenton@earthlink.net (Sandy) [quoted text clipped - 16 lines] >Thank you, >Sandi Your husband's numbers sound almost exactly like mine, except I was 59 years old. Get the radiation. The "hormones" this time will probably be Casodex and Proscar. They make the radiation more effective. I hope you have much better luck than I did- I am on chemotherapy now. > >Also, 2 out of the 3 physicians recommend adjuvant hormone therapy > >with radiation. Its suggested to start with 2 months of hormones > >prior to radiation and then continue the radiation for two years. I just reread my original post and realized what I said. What I meant to say was 2 months of hormones prior to radiation and then continue the HORMONES for two years after completion of radiation treatment. The oncologist mentioned Lupron as drug of choice. I'm somewhat naive about the hormone aspect of treatment thus far, I had hopes we could avoid them for awhile so I haven't focused much of my research in that regard. I'm not really sure what the oncologist's theory is other than him stating that the latest clinical trials are showing an increase in survival for high risk patients and delayed recurrence by using long term hormone therapy post-radiation so I'm assuming we are attempting to deal with the seminal vesicle involvement and delaying any potential growth of micrometastases as opposed to potentiating the radiation. Interestingly, the female radiation oncologist strongly opposed the use of hormones with radiation and suggested only doing the radiation. She cited the long list of "horrible side effects from hormones" while in the same breath she made us aware of the fact that the post surgical radiation would make my husband 100% impotent. Gosh, so much to look forward to! By the way, my husband was 59 years old as well at diagnosis. Sandy I went for the RP when I 45,my first psa afterwards looked good but not less than zero the next 3 kept going up.Time for a prostacint scan .It pinpointed the remaining cancer cell in the prostate bed.I took Casodex before radiation one during and one after.I had 40 treatments I was suppose to have 38 but I was doing so good they gave me two extra I think they lost count because of the snow days.I don't have any major side effects or ED.The only lasting effect is I get tired much easier and I didn't have the desire to have sex .But I can when we want.My doctor told us the same thing yours told you I think they want to prepare you for the worst.I wouldn't count on what she said as absoulut.I have been on Clomid now for about a week I feel like I'm almost bask to normal.(Maybe tonight again)When he gets ready for radiation write, its not as bad as it sounds. Hi Sandy...Lots of people practice HT after treatment when it is suspected that the PCa is systemic. It seems that many of these men use HT on an intermittent basis. That is, they'll take the hormones for a certain amount of time until their PSA is low and stable and then come off and stay off until the PSA rises to some predetermined point, at which time they start the HT again. There are also lots of different ways to practice HT, such as ADT1, ADT2 and ADT3 which involve the use of 1, 2 or 3 hormones respectively. From the little bit I've read, it seems ADT3 is practiced by many. I've also seen posts discussing the use of DES (thought to have been one of the main ingredients in pc-spes). Some people with pretty advanced PCa claim that it can even make mets disappear (and they say they have Prostascint and other data to back up their statements). There are some doctors (Liebowitz, for example) and published articles that support this approach and discuss how it might be working. You might want to check out the Advanced PCa discussion group at Don Cooley's website (info can be found at http://www.prostate-help.org/cadisgr.htm). There you can talk with men that are very knowledgable about advanced disease, men that have "been there and done that." As to taking hormones prior to RT, I think that's an open question. Some docs think it is beneficial for reasons outlined in the earlier posts. Some docs don't buy it. This latter group argues that cells are most vulnerable to death during RT when they are actively dividing. At this time a new set of DNA is being produced and radiation at this time has the best chance to induce a lethal mutation that leads to cell death. If the cell is dormant, as during HT, then such genetic mutations during cell division are less likely to occur. I suspect the fact that two camps exist suggests that there just isn't enough data on HT prior to RT to permit a clear answer...Best wishes and good health, Ron > > > >Also, 2 out of the 3 physicians recommend adjuvant hormone therapy [quoted text clipped - 21 lines] > > By the way, my husband was 59 years old as well at diagnosis. > ... > As to taking hormones prior to RT, I think that's an open question. [quoted text clipped - 9 lines] > and good health, Ron > ... This is one of the maddening things about this disease. We get expert doctors with opposite opinions, each based on very well reasoned arguments. And there just isn't enough clear empirical evidence to decide. I read the results of a clinical trial that showed significantly more men, especially those at "intermediate risk" (Gleason 7) showing low PSA 5 years after HT + RT than RT alone. That decided me to get the HT. But is it right? Were there perhaps other factors that also differentiated the two groups that the doctors didn't see? Did the HT merely lower the PSA in the HT + RT group, without actually increasing long term survival? One conclusion I came to was that I wanted to be treated by the doctor that inspired the most confidence in me. I wanted a doctor that seemed very careful, very concerned, willing to spend time with me, and open to arguments about what is the right way to go. Maybe that's the best we can do - pick the best doctor and go with his or her recommendation for the best treatment. It's all such a crap shoot. Alan It's not quite a crap shoot. There are a lot of variables to consider -- like all the other decisions in your life. The only difference is this one determines the length of your life (maybe). But, like all your other decisions, once you've made it, you have to go on and forget about the other alternatives you had.  SignatureSteve Kramer PSA 16 10/17/2000 @ 46 Biopsy 11/01/2000 G7 (3+4), T2c RRP 12/15/2000 PSA .1 .1 .1 .3 .4 .8 EBRT 05-07/2002 @ 47 PSA .3 .2 .2 .2 .3 Erection 05/12/2003 @ 48 Begin Lupron 07/21/2003 @ 48 PSA .1 > > > ... [quoted text clipped - 36 lines] > > Alan > > One conclusion I came to was that I wanted to be treated > > by the doctor that inspired the most confidence in me. I wanted [quoted text clipped - 6 lines] > > > > Alan I just wanted to thank all of you who shared your valuable input. Just to update you, my husband and I went to the oncologist today not really knowing for sure what to do. The oncologist (little itsy bitsy guy from Argentina) came in and first off apologized to us stating that he thought he may of come off too abruptly during the first encounter with us since he really encouraged us to do the hormones and radiation and we were still resistant to it. He also remembered that I needed statistics - yes, he had them for me. He spent a good hour or so with us helping us sort through this dilemma. We voiced some concerns we had with our urologist and he immediately darted out of the room to call him. I truly feel this man is concerned about my husbands well being and I have confidence in him and his decisions. So yes, Alan, I think you're right that when all the data proves to be so contradictory and unproven, you've got to put your faith into a medical professional to help guide you down this pathway. My husband went ahead and started the hormones today - it was ultimately his decision. Interestingly, part of me feels relieved that we finally worked through this turmoil and made a decision so we can move forward and another part of me feels sad because it just makes the cancer and our less than desirable situation too real for me. Anyway, thank you all for providing my much needed support. For your information, statistically this is what we are looking at: "patients with pathologic T3 disease have lower disease free and overall survival rate. Postive margins are also linked to an increased risk of local recurrence and the same with seminal vesicle invasion which also increases risk of distant failure. Salvage radiation therapy gave 5 yrs freedom from failure of 57%. The seminal vesicle invasion was assoc. with 36% of pts. having 5 yr. freedom from failure (vs. 81% when no seminal vesicle invasion was present). Salvage radiation therapoy will improve the outcome of 21 - 64% of pts. treated. In addition, androgen deprivation concomitantly with radiation therapy demonstrated potential advantage (ECOG 85-31). Progression free survival at 5 years was 65% for radiation plus LHRH analog vs. 42% with radiation therapy alone. " My husband started the Casodex today and will receive his first Lupron shot christmas eve - merry christmas, huh? Actually, if it works it is the best present I could ever ask for!!! Sandi Just saw this study today, it compares HT vs no HT post RT...Ron J Clin Oncol. 2003 Nov 1;21(21):3972-8. Phase III trial of long-term adjuvant androgen deprivation after neoadjuvant hormonal cytoreduction and radiotherapy in locally advanced carcinoma of the prostate: the Radiation Therapy Oncology Group Protocol 92-02. Hanks GE, Pajak TF, Porter A, Grignon D, Brereton H, Venkatesan V, Horwitz EM, Lawton C, Rosenthal SA, Sandler HM, Shipley WU; Radiation Therapy Oncology Group. Fox Chase Cancer Center and Radiation Therapy Oncology Group, Phialdelphia, PA 19107, USA. PURPOSE: Radiation Therapy Oncology Group (RTOG) Protocol 92-02 was a randomized trial testing long-term (LT) adjuvant androgen deprivation (AD) after initial AD with external-beam radiotherapy (RT) in patients with locally advanced prostate cancer (PC; T2c-4) and with prostate-specific antigen level less than 150 ng/mL. PATIENTS AND METHODS: Patients received a total of 4 months of goserelin and flutamide, 2 months before and 2 months during RT. A radiation dose of 65 to 70 Gy was given to the prostate and a dose of 44 to 50 Gy to the pelvic lymph nodes. Patients were randomly assigned to receive no additional therapy (short-term [ST]AD-RT) or 24 months of goserelin (LTAD-RT); 1,554 patients were entered onto the study. RESULTS: The LTAD-RT arm showed significant improvement in all efficacy end points except overall survival (OS; 80.0% v 78.5% at 5 years, P =.73), compared with the STAD-RT arm. In a subset of patients not part of the original study design, with tumors assigned Gleason scores of 8 to 10 by the contributing institutions, the LTAD-RT arm had significantly better OS (81.0% v 70.7%, P =.044). There was a small but significant increase in the frequency of late radiation grades 3, 4, and 5 gastrointestinal toxicity ascribed to the LTAD-RT arm (2.6% v 1.2% at 5 years, P =.037), the cause of which is not clear. CONCLUSION: The RTOG 92-02 trial supports the addition of LT adjuvant AD to STAD with RT for T2c-4 PC. In the exploratory subset analysis of patients with Gleason scores 8 to 10, LT adjuvant AD resulted in a survival advantage. > > > >Also, 2 out of the 3 physicians recommend adjuvant hormone therapy [quoted text clipped - 21 lines] > > By the way, my husband was 59 years old as well at diagnosis. Sandy My RPP removed a bad (T3 & Gleason 9) cancer But the op founf the cancer was excaping in the perenial area. Both my Uro and oncologist recommended salvage radiation but only my oncologist recommended HT til the RT. I have read that there is a greater survival rate if the HT continues for 2 years after the RT. Refer to the mag http//www.PSA Rising.com I am waiting for the RT and have started the HT. The anti androgens taken daily (with the Lucron Injection (4 monthly)) are severly weakening me and providing acute lethargy. That is all for this session .........Good Night Hank B Schokker Age 53 Jackie 123 Kg & 183cm Good Health 2 Salem PL Rivervale WA PSA 00 / 03 3.28 7.8 8.7 9.4 Biopsy Oct 02 inconclusive Jun 03 Gleason 8 RPP 1 Sep 03 Stage T3 Gleason 4+5=9 Extensive adenocarcinoma; Multifaceted; Extensive perennial invasion Catheter out 16 Sep 03 and DRY PSA Oct/03 <00.1 2nd opinion that a Gleason 9 is virulent and Radiation is scheduled & HT in interim EBRT Due Feb 04 HT 14 Oct 03 Sandy, I had a RPP 12/15/2000. My post-op biopsy showed seminal vesicle involvement, but no positive margins. My uro intended to do EBRT (radiation) four months down the line, but decided against it when my PSAs were coming back < 0.1. But, alas, by 2002, they were going up, so we did the EBRT May to July. I guess we could have gone either way in 2001. I don't know that I lost or gained anything or even if I had anything to gain or lose. SignatureSteve Kramer PSA 16 10/17/2000 @ 46 Biopsy 11/01/2000 G7 (3+4), T2c RRP 12/15/2000 PSA .1 .1 .1 .3 .4 .8 EBRT 05-07/2002 @ 47 PSA .3 .2 .2 .2 .3 Erection 05/12/2003 @ 48 Begin Lupron 07/21/2003 @ 48 PSA .1 > My husband is 5 months post surgery and it has been recommended by all > three of his physicians that he have radiation for positive margins. [quoted text clipped - 11 lines] > Thank you, > Sandi |
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