The radiation oncologist threw a curveball that I wasn’t expecting at this morning’s appointment.
In a nutshell, he suggested doing concurrent androgen deprivation (hormone) therapy with the salvage radiation. That was not something that we discussed at our first meeting. The ADT would be for six months if done concurrently.
Doing ADT concurrently would give an estimated 10% benefit to the radiation and longer-term PSA reduction according to the doctor. But he also said that my case would also justify doing the salvage radiation alone and holding off on any hormone therapy until after the radiation is completed. He could argue for either option, but was leaning to the more aggressive concurrent therapies.
I asked about the ADT now lessening its effectiveness later when it’s needed most, and he said that six months of ADT would not really make the cancer hormone resistant.
We didn’t do the body mapping this morning based on this little twist, and that’s okay.
He offered to let me contemplate this over the weekend, and he’ll call me Monday morning to answer any further questions and see which option I would prefer.
I have to admit that the acceleration in my PSA increases is making me lean toward the more aggressive concurrent therapy.
If I choose the straight radiation, I’d go back to UCSD and get mapped and begin the actual zapping a few weeks later. If I choose the concurrent therapy, I’d have to go back to the VA San Diego for the shot and then wait up to two months (I have to confirm, I wasn’t in the note-taking mode) before starting the actual radiation back at UCSD.
Whichever option I decide, I learned this morning that I’m going to have to practice the art of bladder filling.
I was told for the mapping session that I should come in with a full bladder, so I started drinking water about an hour before the 8:30 a.m. appointment: about half a liter at 7:30 a.m. and another half a liter around 8 a.m., plus sipping on water in the waiting area.
By the time the nurse called me back to the exam room around 8:45 a.m., my bladder was about to burst and I had to run to the toilet. “Try to keep some of it in you,” she blurted as I scurried out the door. Yeah, right. By the time I was leaving after seeing the doctor (about 9:15 a.m.), I had to make another mad dash to the toilet. This has the potential to be pretty tricky.
On a somewhat related note, I needed a bit of escapism in advance of the appointment, and I noticed that the weather in Tucson, Arizona was going to be around 74° F / 23° C the first half of this week. I wanted to head over to spend some time in Saguaro National Park and Organ Pipe Cactus National Monument. It was a hectic trip, but I had fun and it definitely diverted my attention away from all of this.
If you’re interested, you can check out my report and photos here:
Saguaro National Park and Organ Pipe Cactus National Monument
Dan's Journey through Prostate Cancer 
Hi Dan thank you so much for sharing your journey. It’s been helpful, insightful and inspiring all rolled into one. I wish you all the best and am happy to share some resources I’ve discovered on biochemical recurrence. Let me know if you’d like to chat about it sometime.
LikeLike
Thanks, Sanjeev.
LikeLike
Good luck with your radiation treatments. I was told the first time I went in that I had a small bladder so I didn’t have to drink so much to fill my bladder. I started my ADT about two weeks before I started the radiation (last April) and just now coming off of it (6mo)!!. I live about 15min from my hospital in Houston so getting ready was not to bad except one day I had to let go and restart water drinking after I got there, but that was ok, there used to that happening. BTW, I love your cactus photo’s. You sure are having a good time traveling, I wish I could enjoy that but in my old age (72) I’ve become a homebody. Good luck!
LikeLike
Thanks for sharing your experience! I suspect that all radiation centers are used to guys having to urgently empty their bladders. Thanks, too, for your kind words about my trip and photos. It was pretty therapeutic for me. All the best.
LikeLike
Hi Dan
I believe we are on somewhat similar paths when I replied to you a month or so ago. When I had my consult with the head of oncology at BC Cancer on February 8th her recommendation was similar to the one you received. One shot of Zoladex, approximately two weeks after starting on a pill called Bicalutamide which I was to take for 30 days. The shot got delayed but I received my shot on March 16th. No side effects as of yet but it is still early. The second shot will be in 3 months at which time the SRT will begin for 33 work days. She felt that the inclusion of the ADT would improve the outcome although I did not debate the issue with her. She also indicated that she did not believe I would require any further ADT based on her review of the PSMA-PET scan. There is an excellent book on ADT written by Messrs. Wassersug, Walker and Robinson.
LikeLike
Hi Gary. Thanks for sharing your experience and insights. I’ll also look into getting the book. All the best to you and I hope the side effects are minimal. Dan
LikeLike
I did concurrent ADT and salvage radiation… finished sr one year ago, finishing up 2 year course of Eligard in June.. undetectable so far. I had to drink 34 oz of water 1 hour prior to treatment to achieve proper bladder displacement…tough but doable. Good luck Dan
LikeLike
Thanks for sharing your experience and good wishes, Walter. Yeah, I drank about a liter and a half in an hour and that may have been a bit much, so I’ll back off next time around. I had my water bottle in the exam room with me, and the doctor pointed at it and said that that was the best way to minimize the chances of any issues–having a full bladder during the session.
LikeLike
Good luck, Dan. The bladder control was tricky for me, too. There were a handful of times I had to unleash my bladder before the radiation could actually be performed. UCSD was pretty good about not giving me a hard time. It was either that or soaking their multi-million dollar piece of equipment, though.
LikeLike
Thanks, Scott. I suspect drinking about a liter and a half in about an hour had something to do with that… I may lessen the volume next time around.
LikeLike
Can you ask your doctor if you should get Proton Beam Therapy instead of normal radiotherapy, as it could be less invasive for the surrounding area? They normally use PBT for brain etc, but if insurance allows or if you can pay privately, you should be able to do it for Prostate as well.
Another thing you can ask is if they install space OAR to protect the area.
I am not a doctor, these terms I came across while talking to doctors and reading on internet.
LikeLike
Hi Dan, 6 months is very unlikely (nothing seems to be 100% in prostate cancer) to induce castrate resistance. However ADT in my case had a very quick effect on my PSA dropping it from 800 to about 8 in a couple of months. I interpret that as being pretty effective at killing off or inducing apoptosis in a significant number of prostate cancer cells. With these cells out the way I would expect the radiotherapy to be more effective than if they were still there needing treatment and getting in the way. It can also reduce the area/volume to be treated. I would and did try to get SPACE OAR in place to help protect my bowel but because my cancer was also extending into the seminal vesicles it was not an option for me whereas I would expect it would be for you. I don’t know if it is an option for you since you have already had your prostate removed. Perhaps that makes a difference to the placing of the space OAR – a question for a SPACE OAR knowledgeable doctor to answer. Good luck with your decision making!
LikeLike
Hi Charles, Thanks for sharing your experience. I asked about the Space OAR and he said that it’s not used in a post-surgery case.
LikeLike
Dan,
Since they are not considering Space OAR…I assume you are only having prostate bed radiation…not full pelvic as well. I believe that the Proton Center in San Diego (referred through UCSD) routinely uses Space OAR (pump type so that it can be held in place because there is no prostate…not the gel type) after RP for SRT in the pelvic area. But if pelvic area is not being done…there probably no need.
If you are heading the ADT route…you might want to see if the RO can order a quick PYL PSMA PET/CT since your PSA has risen after your GA PSMA PET/CT…you might get lucky and see something for better planning. Obviously, after you get the ADT…PSMA images are of little value for some time…hopefully you will never need another one!
Best – Max
LikeLike
Hello Dan,
I’m not any kind of doctor or expert so please consider my comments on neo-adjuvant (concurrent with but starting before radiation) ADT (androgen deprivation therapy, also called hormone therapy) with radiation in that light.
First of all, I have heard many comments like those of Charles McGill above. I think he’s probably right. I’ll add to what he said that, in addition to killing off many tumor cells and shrinking the prostate gland, ADT can weaken the tumor cells that survive the hormone treatment. This weakening can make them more vulnerable to radiation so that more rumor cells are killed by the radiation than would otherwise be the case.
Secondly, I think there is a lot of research now that shows that combinations of treatments can be more effective than sequential treatment. For some categories of patients and some combinations of treatments, administering treatment A and B together can produce longer survival than treating with A, waiting for recurrence, then treating with B.
I don’t know what trials to look for, but I have been told by radiation oncologists that, for some categories of patients, combining ADT with radiation produces better long term results than radiation alone. I’ve never met anyone who said he liked ADT, but it is tolerable and I’ve met a lot of men who have benefited from it.
Best of luck with your treatment.
Alan
LikeLike
Thanks, Alan, for sharing your insights. (And apologies for not responding sooner.) I agree with both of you that this is the best course of action and is the one with the best chance for long-term success.
LikeLike