Duration of ADT for high-risk prostate with significant CAD?

[napoleondynamite]

I have a guy in his mid-60's with history of MIx3 including prior CABG. Now has a Gleason 8, PSA 20, T2b prostate cancer.

We discussed options including XRT alone, XRT+ ADT and surgery with likely adjuvant XRT which could avoid long-term ADT.

He is opting for XRT. I'd be interested to hear opinions about duration of ADT in a patient like this?

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[BobbyHeenan]

I too really struggle with these patients.

I usually advise against prostatectomy for high risk patients, but I can see the benefit here if it saves him ADT. I still would probably not favor that route, but that's probably my bias as a rad onc.

If going for XRT in this scenario I usually shoot for at least of 6 months total of ADT (2 months before, 2 months during, 2 months after XRT), then I extend ADT on the basis of tolerance, reliability of follow up with cardiology, and weight gain/diabetes control. I make sure these patients have a cardiologist (not just a PCP managing their HTN, CAD), and go from there. I sometimes even call the cardiologist to get thoughts (ie was their last angio a disaster, are they a ticking time bomb, etc). With underlying CVD, I pretty much never go past 18 months.


Most of the intermittent vs. continuous trials showed more cardiovascular deaths in the continuous arms, so there must be some sort of process going on suggesting long term androgen blockade poses cardiovascular risks. However, this recent editorial from JCO and it's corresponding study suggests it may not be simply that it's not just the long term ADT is contributing to atherosclerosis - there may even be increased risk for CV events within 1-4 months of initiating ADT.

 

[ramsesthenice]

This is the rare patient I would actually like to see an MRI and do surgery if there is not obvious ECE or SV invasion.

Otherwise I agree with Bobby.

 

[BobbyHeenan]

That's a great point about the MRI. Their Partin risk for ECE/SVI is high (~40%), but if MRI is negative you've got a compelling argument there for surgery with an experience urologist. The best MRI images are at least a couple of months after biopsies, so it may delay therapy but it makes some sense.

 

[medgator]

This is the rare patient I would actually like to see an MRI and do surgery if there is not obvious ECE or SV invasion.

Otherwise I agree with Bobby.

Correct, but I would r/o with an mri otherwise there's a good chance you're buying him both modalities

 

[Haybrant]

I'd like to hear more from people on what is standard at their institution. I have to go back to the paper but there is a large metaanalysis in JAMA from 2-3 yrs back found no increased CV risk from ADT long or short duration. There is a Damico study from 2007 in JCO that showed shorter time to fatal MI in age greater than 65 recieving 6+ months ADT vs. no ADT.

 

[ramsesthenice]

Correct, but I would r/o with an mri otherwise there's a good chance you're buying him both modalities

That is absolutely how I meant it. No reason to sign up for multimodal therapy if you can avoid it. But if it looked like surgery had a reasonable chance of cure I would go for it. The data on ADT and CV risk is not entirely clear and there probably is some risk so I think surgery might be a great out and best serve this particular patient.

 

[medgator]

Anyone giving adt with xrt post op for bad disease? I've been doing it for 4-6 mos in pts with bad disease (g9, psa20+, high psadt etc)

 

[ramsesthenice]

Anyone giving adt with xrt post op for bad disease? I've been doing it for 4-6 mos in pts with bad disease (g9, psa20+, high psadt etc)

Absolutely. I'm upfront that the data is unknown but we won't have data one way or the other for many years. It comes down to exactly what you think the ADT is doing which admittedly is not exactly clear either. I think it makes sense.

 

[BobbyHeenan]

I too sometimes offer ADT (most of the time 6 months only like on RTOG 0534) for the very high risk post prostatectomy patient like you've mentioned above.

There are some interesting data backing up that decision (RTOG 8531 and RTOG 9601), but as mentioned, ultimately we will await 0534 for more definitive evidence of benefit - and what kind of benefit.

 

[napoleondynamite]

Interesting discussion guys, thanks for the help.