Would you give Lupron without 2 weeks of Casodex for an intermediate risk prostate cancer?
Lupron without Casodex
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Should always give it with the 2 weeks of casodex to help mitigate the "androgen flare" that occurs when using a GnRH agonist.
The alternative (what I do) is to start with 1-3 months of firmagon (GnRH antagonist) to get an immediate drop in testosterone/PSA before switching to a 3 month lupron, so the patient ends up getting 4-6 months for intermediate risk.
I usually err on no ADT for intermediate risk until we see results from the RTOG trial looking at the role of adt in the setting of modern dose-escalated xrt. I will consider it for >50% biopsies with g4+3=7 disease, >10 psa etc
The alternative (what I do) is to start with 1-3 months of firmagon (GnRH antagonist) to get an immediate drop in testosterone/PSA before switching to a 3 month lupron, so the patient ends up getting 4-6 months for intermediate risk.
I usually err on no ADT for intermediate risk until we see results from the RTOG trial looking at the role of adt in the setting of modern dose-escalated xrt. I will consider it for >50% biopsies with g4+3=7 disease, >10 psa etc
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Bilateral orchiectomy... Who wants to do a shot every couple of months...
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That's overkill for intermediate-riskBilateral orchiectomy... Who wants to do a shot every couple of months...
Besides the obvious sex-life killer, lots of other things with early androgen ablation (osteoporosis, fatigue etc).I agree that from a societal cost standpoint, it may not be a bad way to go for high-risk prostate CA in the elderly or in the metastatic setting.
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Bilateral orchiectomy... Who wants to do a shot every couple of months...
Seriously though.. For the first time recently (ironically with this post) I had a patient ask me if he could just have an orchiectomy rather than have the regular injections. I sent him to urology to discuss, then he came back to me yesterday less excited about orchiectomy but earnestly asked me if I could just irradiate his nuts.
It got me thinking..I mean, I've never seen that done or heard of it done. He's in his 80's and is basically begging me to do it. I did a lit search and the only thing I could come up with was an abstract (PMID 25694011) published earlier this year that wasn't all that impressive. They compared 17Gy in 2 fractions to 24Gy in 3 fractions and neither regimen resulted in castrate levels. I must admit this surprised me. I would have thought 8Gy in 1 would knock the boys out..
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Well, some of you do may remember that talking a couple of years on the Roach trial, saying that the whole pelvis RT in RTOG 9413 may have been better, because due to the larger field sizes more dose may have hit the scrotum, thus acting as a long term antihormonal treatment. There were some replies, shooting down that theory, but who knows...
I don't think you can reach castration levels with RT, you will need quite a high dose for that probably. A decrease in testosteron levels can be observed with rather limited doses actually, there are data on that coming from the studies on TIN-irradiation.
I don't think you can reach castration levels with RT, you will need quite a high dose for that probably. A decrease in testosteron levels can be observed with rather limited doses actually, there are data on that coming from the studies on TIN-irradiation.
