Decipher ADT

[ramsesthenice]

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How are you guys using decipher for favorable intermediate risk patients? I’ve seen a few of these recently with PSA 4-5 and a single core GGG2 where the urologist did decipher testing and it comes back 0.5-0.7 and they want to give ADT. Curious what other folks are doing.

 

[madchemist89]

I ignore it and follow nccn. If they prospectively validate these tests, like they did with oncotype for breast, then I will give them more credence.

 

[thecarbonionangle]

I ignore it and follow nccn. If they prospectively validate these tests, like they did with oncotype for breast, then I will give them more credence.

until you have true prospective validations on these tests, i would not change SOC.

Would anyone treat a “high risk” patient as intermediate risk because of decipher and only give 4-6 months hormones? 18 months might be reasonable if decipher shows IR.
What about “upgrading” someones ADT from
Someone who might not need it per NCCN but decipher comes back higher?
I haven’t seen any of my colleagues who treat prostate do this but im sure it is being done by someone somewhere.

 

[ramsesthenice]

I ignore it and follow nccn. If they prospectively validate these tests, like they did with oncotype for breast, then I will give them more credence.

until you have true prospective validations on these tests, i would not change SOC.

Would anyone treat a “high risk” patient as intermediate risk because of decipher and only give 4-6 months hormones? 18 months might be reasonable if decipher shows IR.
What about “upgrading” someones ADT from
Someone who might not need it per NCCN but decipher comes back higher?
I haven’t seen any of my colleagues who treat prostate do this but im sure it is being done by someone somewhere.

This is what I have been doing. NCCN is not helpful. Decipher isn't in the flow diagram, but below they waffle back and forth and say "consideration of ADT and/or nodal RT may be considered for patient with other high risk features including molecular profiling." I personally didn't think the data was there, but curious others thoughts.

 

[sirspamalot]

 

[A_DeMichele]

nodal RT based on Decipher? what on Earth is that?

 

[Palex80]

nodal RT based on Decipher? what on Earth is that?

People may be indeed jumping to conclusions too fast... We haven't even established Oncotype Dx as a guidance for radiotherapy in breast cancer.

I advise for nodal RT in all patients who meet POP-RT criteria. I am mindful not to do so, when I think they:
a) may not benefit due to being old or comorbid
b) have risk factors for increased toxicity due to large volume RT (bowel issues, major cardiovascular morbidity)

 

[Palex80]

How are you guys using decipher for favorable intermediate risk patients? I’ve seen a few of these recently with PSA 4-5 and a single core GGG2 where the urologist did decipher testing and it comes back 0.5-0.7 and they want to give ADT. Curious what other folks are doing.

We don't have Decipher available.
However, I don't give ADT in favorable intermediate risk and advise my fellow urologists not to do so either.

 

[RadOncDoc21]

We needed to make prostate cancer more difficult. I guess we’re trying to catch up to breast!

 

[RickyScott]

G8 psa 15 T1cN0 and decipher comes back .98, would you suggest zytiga?

 

[ramsesthenice]

nodal RT based on Decipher? what on Earth is that?

I’m with you. If anything, my ultimate hope for decipher is to DE-escalate therapy. I’d love to be able to tell that guy with a single core of GGG4 disease that six months of ADT is fine. Two years feels like overkill for a lot of folks.

In fairness to our guys, they are mostly doing it on people waffling between AS and treatment. I don’t think that is crazy. But I also don’t see any reason to change what I am doing with them.

 

[ramsesthenice]

G8 psa 15 T1cN0 and decipher comes back .98, would you suggest zytiga?

Not crazy but the bigger question is…will their payer? Not sure they include it in their algorithm.

 

[RickyScott]

Not crazy but the bigger question is…will their payer? Not sure they include it in their algorithm.

It is 100$ a month at cost plus drugs now.

 

[metallica81788]

My urologists are giving everybody from low to high risk ADT for 2 years at the moment, so I have bigger problems than Decipher

If I ever get to the point with urology where they're ordering Decipher serious progress will have been made

 

[Palex80]

G8 psa 15 T1cN0 and decipher comes back .98, would you suggest zytiga?

Nope, does not meet STAMPEDE criteria. He needs at least 2 out of 3: T3a/b, PSA>40, GS8-10

 

[RickyScott]

Nope, does not meet STAMPEDE criteria. He needs at least 2 out of 3: T3a/b, PSA>40, GS8-10

That’s why I posted it. What’s the downside?

 

[Palex80]

That’s why I posted it. What’s the downside?

The downside of giving someone Abi for 2 years who won't benefit from it (or at least we don't know if he would benefit from it)?
Well, it's 2 years of Abi + Prednisolone.

 

[sirspamalot]

I'm a radonc. I don't "give" systemic therapy. I refer my ADT needs to my medonc. If they think he meets the criteria to get Zytiga (haven't had one yet) then so be it. I think breast is the worst, but prostate ain't far behind.

 

[medgator]

My urologists are giving everybody from low to high risk ADT for 2 years at the moment, so I have bigger problems than Decipher

If I ever get to the point with urology where they're ordering Decipher serious progress will have been made

They like prolaris usually

 

[medgator]

The downside of giving someone Abi for 2 years who won't benefit from it (or at least we don't know if he would benefit from it)?
Well, it's 2 years of Abi + Prednisolone.

Only thing in NCCN, otherwise I'm sure some would try xtandi or nubeqa

 

[RickyScott]

The downside of giving someone Abi for 2 years who won't benefit from it (or at least we don't know if he would benefit from it)?
Well, it's 2 years of Abi + Prednisolone.

The 5mg prednisone is just to make up for corticosteroid that is depleted by the abi. I think a very high decipher test is concerning and suggestive of aggressive disease.

 

[sirspamalot]

Instead of "let it be" the song should be rewritten and sung by Glaucomfleken as "I don't know... I don't know...."

 

[salubalu]

Ill wait on GU 09/10 before changing management with decipher off trial for intact prostate cases

 

[evilbooyaa]

I ignore it and follow nccn. If they prospectively validate these tests, like they did with oncotype for breast, then I will give them more credence.

Right answer!

G8 psa 15 T1cN0 and decipher comes back .98, would you suggest zytiga?

NO. We have no data that outcomes will be better for that patient with intensification with a toxic therapy.
"Do not punish the patient for having a poor prognosis/biology disease by throwing toxic treatments at them with no evidence whether it will be beneficial" - Dan Spratt

My urologists are giving everybody from low to high risk ADT for 2 years at the moment, so I have bigger problems than Decipher

If I ever get to the point with urology where they're ordering Decipher serious progress will have been made

Woof. Wild wild west.

I'm a radonc. I don't "give" systemic therapy. I refer my ADT needs to my medonc. If they think he meets the criteria to get Zytiga (haven't had one yet) then so be it. I think breast is the worst, but prostate ain't far behind.

Lots of Rad Oncs writing Rx for Relugolix and tons of Urologists giving ADT alone. Fair number of Uros giving Abi/Enza as well.... I disagree with the latter but former is not unreasonable.

Prostate is fine. People make it too complex because they're sick of waiting for 15 years for all prospective data. Follow the KISS principle.

 

[RickyScott]

Right answer!


NO. We have no data that outcomes will be better for that patient with intensification with a toxic therapy.
"Do not punish the patient for having a poor prognosis/biology disease by throwing toxic treatments at them with no evidence whether it will be beneficial" - Dan Spratt


Woof. Wild wild west.


Lots of Rad Oncs writing Rx for Relugolix and tons of Urologists giving ADT alone. Fair number of Uros giving Abi/Enza as well.... I disagree with the latter but former is not unreasonable.

Prostate is fine. People make it too complex because they're sick of waiting for 15 years for all prospective data. Follow the KISS principle.

How is zytiga toxic?

 

[sirspamalot]

Waiting for the "radiation is toxic" PROSPECT gang from themednet Medonc gang to materialize here..

 

[SneakyBooger]

 

[evilbooyaa]

How is zytiga toxic?

??

Anecdotally - Clinically patients can have bad diarrhea, worse if given concurrently with RT

https://www.nejm.org/doi/full/10.1056/nejmoa1702900

G3-5 Tox went from 33% in ADT alone to 47% w/ ADT + Zytiga. That's.... not trivial. So adding on Zytiga when we have no evidence that it will improve outcomes is.... questionable to me.

 

[Mandelin Rain]

Do people prescribe short ADT if the "only" unfavorable criteria is 50% cores positive?

Say... 4 cores GG2 and 2 cores GG1.

NCCN makes this unfavorable intermediate and 4-6 months ADT, but doesn't feel right.

 

[sirspamalot]

Nothing feels right any more in radiation oncology. But, we swim the herd. Less prone to getting eaten .. they say.

 

[evilbooyaa]

Do people prescribe short ADT if the "only" unfavorable criteria is 50% cores positive?

Say... 4 cores GG2 and 2 cores GG1.

NCCN makes this unfavorable intermediate and 4-6 months ADT, but doesn't feel right.

This is a space where I sometimes budge from NCCN guidelines.
Assuming > 50% cores is the ONLY UIR driver (GG2 OR PSA > 10)
If they would be > 50% cores with GG2 alone, then I do recommend ADT.

If the only way they would be > 50% cores would be combining GG1 disease, then I say 'while technically UIR, this patient likely has disease more similar to FIR, and thus omission of ADT is an important consideration, etc. etc.)

If you have 11/12 cores GG1 you're low-risk and we recommend AS

If you have 10/12 cores GG1 and 1 core GG2 you're now UIR and we recomment RT + ADT?

 

[sirspamalot]

Just do whatever you "Feel" is best. I mean, prostate is the

 

[ramsesthenice]

If you have 11/12 cores GG1 you're low-risk and we recommend AS

If you have 10/12 cores GG1 and 1 core GG2 you're now UIR and we recomment RT + ADT?

I have made this exact comment here before.

If the only risk factor is 50% of cores and most of them are GGG1, I don't recommend ADT. If they have GGG2 in 8/12 cores, I think ADT makes more sense.

 

[sirspamalot]

"But I like schtupping my wife" says the guy with 5/12 cores of 3+4=7 except for one with 5% 4+3=7 and PSA 10.1

 

[madchemist89]

You have to draw the line somewhere.

 

[sirspamalot]

Somewhere.. indeed.

 

[DoctwoB]

Agreed. I re-interpret NCCN guidelines in my head for >50% of cores positive to ">50% of cores positive for GG2 or higher disease"

 

[BobbyHeenan]

...

If you have 10/12 cores GG1 and 1 core GG2 you're now UIR and we recomment RT + ADT?

On these ones I sometimes use a Decipher score to help with this. I dont' know if that's the right thing to do though. Just looking for some more info to help.