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Cancer: Prostate Message Board

Cancer: Prostate Board Index

Iím sorry your shot at a cure with surgery did not work out. At least you have rid yourself of the bulk of the cancer.

As you may know by now, usually cancer that has spread beyond the capsule is not far from the capsule for a substantial time, as a rule. The odds are good that it will be within the range of radiation, and radiation in 2016 should be enough for a good chance of a cure, especially with a boost from ADT.

About the decision whether to wait or go straight to radiation with ADT: My impression is that prostate cancer doctors now believe it is better to go with radiation fairly soon after surgery for cases that have some higher risk factors, such as your evidence of local spread and a moderately aggressive Gleason score (on the unfavorable side of Gleason 7). However, with the aid of an ultrasensitive PSA test that detects PSA down to a level of less than 0.01 units of PSA, you could wait to see how your PSA tests turned out before starting radiation, without incurring much added risk. My informed laymanís impression is that radiation doctors would want to start radiation if the PSA reached 0.04, or perhaps as low as 0.03, but that they would probably be comfortable with holding off if your PSA was lower and fairly steady at the low level. Despite that spread to the seminal vesicles and what I take to be other positive margins, you might be lucky Ė the surgery might have gotten all your cancer. That happens more than you would expect when patients have positive margins. On the other hand, it would not be surprising if you already had a PSA of, say, 0.05 or higher, even .1, which would indicate a strong likelihood of a recurrence (PSA hits 0.2 after surgery), and likely a recurrence fairly soon. Research in the past year or two has bolstered the view that radiation is more successful when the PSA is quite low.

Whether to add ADT to radiation: I believe you are getting good advice here. The radiation community is convinced, based on research, that ADT is of no benefit for patients in low-risk situations. However, research has also shown that a short course of ADT benefits intermediate-risk patients, and a long course of ADT looks best for higher-risk patients. A long course would likely be from 18 months to 24 months, but with no clear-cut evidence yet on which would generally be best. Iím thinking the doctors would view your case as higher in risk, but they might consider it an intermediate risk situation.

What you did not mention Ė adding chemo at the start of ADT: two recent trials have shown that that combo helps metastatic patients with a higher volume of metastases, which you likely do not have, but the research is not in the context of ADT to support radiation. However, updated results seem to indicate that adding chemo in metastatic patients with low-volume metastasis is of little benefit. Therefore, there is an even stronger argument that chemo to bolster ADT would not help you.

Your concern about side effects of ADT: There is a substantial difference in side effects from short term (such as 4 to 6 months) versus longer term ADT. For short term ADT you would likely experience hot flashes and sweats, beginning to decrease bone density, have some difficulty in keeping weight off, and have difficulty building or maintaining muscle mass, as well as some other possible side effects. However, the decrease in bone density would probably not amount to much over just a few months, and then would recover as your testosterone (and hence estradiol, made from testosterone and needed for bone health) recovered. For a longer course of ADT Iím a big believer in using medication plus calcium and vitamin D3 supplementation to prevent or minimize bone loss. Several medication types are available, ranging from Fosamax (generic alendronate), Boniva, other fairly mild bisphosphonates and similar drugs, and transdermal estrogen delivered with patches on the skin. Iíve been on Fosamax, Boniva and Vivelle estrogen when Iíve been on ADT.

There are some pros and cons. While the bisphosphonates did a good job for me, I was on them for more than ten years - long enough that there was growing risk that I might break a femur, so we switched to estrogen. The big downside there is some breast growth, which can be treated, but I liked the way I felt with what was a normal amount of estrogen for a male while on ADT. My impression is that men taking estrogen for bone density feel they are cognitively sharper than when on a bisphosphonate while on ADT; I felt that way. That said, having followed research on cognitive and memory effects of ADT closely, Iím convinced the evidence is not clear that ADT causes these problems Ė for many of us who track this issue the jury is still out. A huge confounding factor is that many men who are put on ADT are at an age where dementia is not uncommon, so it may be advancing age that is causing cognitive/memory problems and not the ADT. Of course, if hot flashes are not countered and seriously disturb sleep, that causes cognitive problems.

You likely will do better than average on ADT (and with fatigue from radiation) because you are a runner. It appears that aerobic and strength exercise are wonderful for preserving energy, warding off depression, maintaining muscle mass and minimizing or avoiding weight gain. I actually was able to increase my strength slightly while on ADT that lowered my testosterone to 20 and lower, though it was much harder. During my last two cycles of blockade, I learned about using branch-chain amino acid pills to reverse weight gain. I would pop two pills on rising on gym days, do some intense exercise two or three days a week at the gym with no food until noon, then pop two more BCAAs and eat a hearty lunch. I regained full control of my weight despite being on ADT. While on intermittent ADT over many years, I had a mentally challenging job in Navy R&D procurement, negotiating and arranging complex and high-value contracts. I believe you will probably continue to do very well with your work because of your fitness and exercise ethic, though there will be some added challenges to work through. (I continued racewalking for fitness while on ADT.)

This is probably longer than you can absorb at this point, but please feel free to follow-up. I hope you get some other responses too.

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