Very high risk prostate CA

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Reaganite

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So I've had this epic run of very high risk prostate CA patients (Gleason 9-10, gross ECE and SVI, etc.) receiving RPs at the local NCI designated cancer center and then either never reaching undetectable or developing very early PSA relapse. I see many of these patients pre-surg, and I have found there is just nothing I can say that will dissuade them from getting a surgery once they're seen at this particular center. (This guy even has metastatic patients convinced they need prostatectomies). Is there any data (or trends in the data) to suggest we may be compromising survival in this cohort of very high risk patients by not doing early upfront ADT + Abi? Patients who relapse after surgery are generally getting ADT + XRT, so they miss out on this initial window of combined androgen blockade which clearly improves survival in the frankly metastatic setting. Any suggestion from data this matters in the non-metastatic, very high risk setting?
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No data that I am aware of showing decreased survival with RP. There are plenty of data showing improved survival with RP but hopelessly confounded...propensity matching does not a randomized trial make

If...a big if...I see these people prior to surgery I tell them-

1) Surgery is unlikely to cure you
2) Additional treatment will be required (XRT + ADT +/- abiraterone or one of the utamides)
3) There is an alternative that seems to work as well (XRT + ADT +/- abi) without surgery
4) The surgery first approach leads to worse long term QOL (primarily because of urinary incontinence)

There is an open ongoing RCT (at link below) but accrual is slow

ClinicalTrials.gov

clinicaltrials.gov clinicaltrials.gov
 
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I know of two trials now looking at adding second agent in salvage setting. This is the option the salvage very high risk patients get and their prognosis is not that good (risk of death by prostate cancer approaching 50% at 15 years if I recall correctly).

STEEL trial of salvage XRT and adt (+/- Enzalutamide) and a strange ECOG 4 arm PET directed +/- intensification of local vs systemic therapy via apalutamide and SBRT to limited metasatatic disease trial that I am concerned will confuse us all. (I think trials should try to answer one question at a time.)
 
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Reaganite said:
So I've had this epic run of very high risk prostate CA patients (Gleason 9-10, gross ECE and SVI, etc.) receiving RPs at the local NCI designated cancer center and then either never reaching undetectable or developing very early PSA relapse. I see many of these patients pre-surg, and I have found there is just nothing I can say that will dissuade them from getting a surgery once they're seen at this particular center.
Click to expand...
Two words that I have found to be very effective:

Penile..... Shortening
 
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dieABRdie said:
Two words that I have found to be very effective:

Penile..... Shortening
Click to expand...
Well, not only do we champion trials to reduce our footprint, we also make sure to provide evidence XRT+ADT is the path to shortest equipment:

1646940120897.png
 
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dieABRdie said:
Two words that I have found to be very effective:

Penile..... Shortening
Click to expand...
Which I'm sure you tell them is only transient, right? ;)
pubmed.ncbi.nlm.nih.gov

Changes in penile length after radical prostatectomy: investigation of the underlying anatomical mechanism - PubMed

The SPL was shortest at 10 days after RP and gradually recovered thereafter in the present study. Anatomically, the glans and corpus spongiosum surrounding the urethra are an integral structure, and the proximal urethra is drawn into the pelvis during urethrovesical anastomosis. This is the...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
 
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Reaganite said:
So I've had this epic run of very high risk prostate CA patients (Gleason 9-10, gross ECE and SVI, etc.) receiving RPs at the local NCI designated cancer center and then either never reaching undetectable or developing very early PSA relapse. I see many of these patients pre-surg, and I have found there is just nothing I can say that will dissuade them from getting a surgery once they're seen at this particular center. (This guy even has metastatic patients convinced they need prostatectomies). Is there any data (or trends in the data) to suggest we may be compromising survival in this cohort of very high risk patients by not doing early upfront ADT + Abi? Patients who relapse after surgery are generally getting ADT + XRT, so they miss out on this initial window of combined androgen blockade which clearly improves survival in the frankly metastatic setting. Any suggestion from data this matters in the non-metastatic, very high risk setting?
Click to expand...
You don't tell them that they will probably need caverject or an Austin powers pump post RP vs just some cialis or blue pill with you? (post lupron obv assuming things return)
 
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Haha, man, I mention EVERYTHING you guys wrote including the penile shortening. Had a patient tell me he lost an inch about a year ago and have mentioned that to every patient since. I just can't beat a pretty famous guy at an NCI center. I'm a very reasonable guy too. The patients I'm referring to are these Gleason 10 patients with extensive EPE, gross SVI, some with levator involvement, ? nodes on CT. Oh well.
 
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Reaganite said:
Haha, man, I mention EVERYTHING you guys wrote including the penile shortening. Had a patient tell me he lost an inch about a year ago and have mentioned that to every patient since. I just can't beat a pretty famous guy at an NCI center. I'm a very reasonable guy too. The patients I'm referring to are these Gleason 10 patients with extensive EPE, gross SVI, some with levator involvement, ? nodes on CT. Oh well.
Click to expand...


The NCI center will buy you soon

Nancy and Ronald are shaking their heads in their graves

In all seriousness - have any of the patients ever told you what the surgeon says to them about radiation? I wonder.
 
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jondunn said:
The NCI center will buy you soon

Nancy and Ronald are shaking their heads in their graves

In all seriousness - have any of the patients ever told you what the surgeon says to them about radiation? I wonder.
Click to expand...
"Your penis will fall off."
 
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jondunn said:
In all seriousness - have any of the patients ever told you what the surgeon says to them about radiation? I wonder.
Click to expand...
There was one where I trained who would tell them fecal incontinence was a common complication for prostate RT. Multiple patients brought it up.

I’m pampered where I am. I think our surgeons are very fair when it comes to prostate discussions. MIBC…that’s another story. Very old school on that front. Still tell people RT is rarely curative for bladder cancer.
 
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I had a guy wake up with a totally numb weiner after Brachy about a year ago. That was a bad day for me. Thank god it he regained about 80% of his baseline sensation over several weeks.
 
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DoctwoB said:
Seen it once. But not from XRT, prostate artery embolization gone wrong.
Click to expand...
Please tell me you guys hence forth address that particular interventionalist as Dr. Bobbitt.
 
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Reaganite said:
So I've had this epic run of very high risk prostate CA patients (Gleason 9-10, gross ECE and SVI, etc.) receiving RPs at the local NCI designated cancer center and then either never reaching undetectable or developing very early PSA relapse. I see many of these patients pre-surg, and I have found there is just nothing I can say that will dissuade them from getting a surgery once they're seen at this particular center. (This guy even has metastatic patients convinced they need prostatectomies). Is there any data (or trends in the data) to suggest we may be compromising survival in this cohort of very high risk patients by not doing early upfront ADT + Abi? Patients who relapse after surgery are generally getting ADT + XRT, so they miss out on this initial window of combined androgen blockade which clearly improves survival in the frankly metastatic setting. Any suggestion from data this matters in the non-metastatic, very high risk setting?
Click to expand...

Surgeons gonna surgeon, and academic urologists are arguably the biggest swinging dicks of them all. There is nobody that is too high risk for a motivated academic urologist. I would recommend that you just follow them personally post-op if you're seeing them pre-op at q3 month intervals, I predict their rates of needing salvage are much, much higher than the 50% seen in RADICALS/RAVES. Better to catch it early and see if you can potentially spare them ADT with the salvage XRT.

Some urologists "don't believe" the 12 week post-op PSA that is still detectable and will "monitor" these patients with q3-6 month PSAs hanging out at 0.2 or 0.3 basically praying that the cancer spontaneously regresses.

That being said, I am not sold on adding Abi in the non-metastatic patients, even VHR ones, although my prostate knowledge may be a touch outdated. Is that commonplace nowadays?
 
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DoctwoB said:
View attachment 351811
Click to expand...
The fact that @DoctwoB hangs out with us brings joy to my otherwise bleak existence where every week my prostate patients ask

1) how their disease is responding based solely on my daily CBCT
2) pontificate why their stool caliber is 5mm smaller than that time they had a bowel movement 6 months ago
3) want to know why I'm recommending 6 months of ADT, not 4
4) are confused when I tell them "just taking it out" with surgery is not a guaranteed 100% cure rate
5) give themselves diarrhea by changing the diet they've eaten for 20 years overnight because they "thought they couldn't eat XYZ" despite admitting literally no one told them to do that
6) asking me about some obscure supplement they found on Amazon which they take religiously
7) if their PSA is 24, telling me it's "relatively low" because they have a friend with a PSA of 79
8) asking me if I'm "the best" at prostate radiation, forcing me to dance around how it's the easiest thing we do (from a contouring/treatment planning perspective)
9) telling me they have to make "man sounds" (grunting, evidently) to urinate but they don't want Flomax (ok this was only one patient who ever did this)
10) having long, elaborate thoughts about the fact that they're urinating an additional 1-2 times per day

Etc, etc.
 
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at my institution Abi is being offered to VHR patients who fit stampede criteria (T3/T4, PSA >40, N+)
 
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elementaryschooleconomics said:
The fact that @DoctwoB hangs out with us brings joy to my otherwise bleak existence where every week my prostate patients ask

1) how their disease is responding based solely on my daily CBCT
2) pontificate why their stool caliber is 5mm smaller than that time they had a bowel movement 6 months ago
3) want to know why I'm recommending 6 months of ADT, not 4
4) are confused when I tell them "just taking it out" with surgery is not a guaranteed 100% cure rate
5) give themselves diarrhea by changing the diet they've eaten for 20 years overnight because they "thought they couldn't eat XYZ" despite admitting literally no one told them to do that
6) asking me about some obscure supplement they found on Amazon which they take religiously
7) if their PSA is 24, telling me it's "relatively low" because they have a friend with a PSA of 79
8) asking me if I'm "the best" at prostate radiation, forcing me to dance around how it's the easiest thing we do (from a contouring/treatment planning perspective)
9) telling me they have to make "man sounds" (grunting, evidently) to urinate but they don't want Flomax (ok this was only one patient who ever did this)
10) having long, elaborate thoughts about the fact that they're urinating an additional 1-2 times per day

Etc, etc.
Click to expand...
11). Bitching about adt side effects while under treatment. (seriously, never seen it??)
 
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elementaryschooleconomics said:
The fact that @DoctwoB hangs out with us brings joy to my otherwise bleak existence where every week my prostate patients ask

1) how their disease is responding based solely on my daily CBCT
2) pontificate why their stool caliber is 5mm smaller than that time they had a bowel movement 6 months ago
3) want to know why I'm recommending 6 months of ADT, not 4
4) are confused when I tell them "just taking it out" with surgery is not a guaranteed 100% cure rate
5) give themselves diarrhea by changing the diet they've eaten for 20 years overnight because they "thought they couldn't eat XYZ" despite admitting literally no one told them to do that
6) asking me about some obscure supplement they found on Amazon which they take religiously
7) if their PSA is 24, telling me it's "relatively low" because they have a friend with a PSA of 79
8) asking me if I'm "the best" at prostate radiation, forcing me to dance around how it's the easiest thing we do (from a contouring/treatment planning perspective)
9) telling me they have to make "man sounds" (grunting, evidently) to urinate but they don't want Flomax (ok this was only one patient who ever did this)
10) having long, elaborate thoughts about the fact that they're urinating an additional 1-2 times per day

Etc, etc.
Click to expand...

12) when they tell you about their "diarrhea" which is actually having 1.5-2 normal quality bowel movements per day
13) I'm peeing so much! Are you drinking more fluids? Yes all the water you make me drink for the treatment! How much water do you normally drink? None!
 
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metallica81788 said:
I tried being a good steward and sending to Medonc for this reason and they didn't do it so I don't know what to do any more. Find a different one?
Click to expand...
Anyone prescribing this themselves? Tempting now that it's generic but really don't want to get into closely watching labs/ managing side effects.
 
Wildcat321 said:
Anyone prescribing this themselves? Tempting now that it's generic but really don't want to get into closely watching labs/ managing side effects.
Click to expand...
We are discussing this with our med oncs, but I feel it's better to hand over treatment to them.
Abi needs to be given for 2 years, which is quite a long time and you need to take care of everything (just like you said labs, etc). 5mg of Prednisone needs to be given too, with additional possible side-effects. I'd seriously consider giving bone-modifying agents to counter osteoporosis in these patients.
 
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elementaryschooleconomics said:
The fact that @DoctwoB hangs out with us brings joy to my otherwise bleak existence where every week my prostate patients ask

1) how their disease is responding based solely on my daily CBCT
2) pontificate why their stool caliber is 5mm smaller than that time they had a bowel movement 6 months ago
3) want to know why I'm recommending 6 months of ADT, not 4
4) are confused when I tell them "just taking it out" with surgery is not a guaranteed 100% cure rate
5) give themselves diarrhea by changing the diet they've eaten for 20 years overnight because they "thought they couldn't eat XYZ" despite admitting literally no one told them to do that
6) asking me about some obscure supplement they found on Amazon which they take religiously
7) if their PSA is 24, telling me it's "relatively low" because they have a friend with a PSA of 79
8) asking me if I'm "the best" at prostate radiation, forcing me to dance around how it's the easiest thing we do (from a contouring/treatment planning perspective)
9) telling me they have to make "man sounds" (grunting, evidently) to urinate but they don't want Flomax (ok this was only one patient who ever did this)
10) having long, elaborate thoughts about the fact that they're urinating an additional 1-2 times per day

Etc, etc.
Click to expand...

I thought I was the only one getting these questions on the regular
 
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elementaryschooleconomics said:
The fact that @DoctwoB hangs out with us brings joy to my otherwise bleak existence where every week my prostate patients ask

1) how their disease is responding based solely on my daily CBCT
2) pontificate why their stool caliber is 5mm smaller than that time they had a bowel movement 6 months ago
3) want to know why I'm recommending 6 months of ADT, not 4
4) are confused when I tell them "just taking it out" with surgery is not a guaranteed 100% cure rate
5) give themselves diarrhea by changing the diet they've eaten for 20 years overnight because they "thought they couldn't eat XYZ" despite admitting literally no one told them to do that
6) asking me about some obscure supplement they found on Amazon which they take religiously
7) if their PSA is 24, telling me it's "relatively low" because they have a friend with a PSA of 79
8) asking me if I'm "the best" at prostate radiation, forcing me to dance around how it's the easiest thing we do (from a contouring/treatment planning perspective)
9) telling me they have to make "man sounds" (grunting, evidently) to urinate but they don't want Flomax (ok this was only one patient who ever did this)
10) having long, elaborate thoughts about the fact that they're urinating an additional 1-2 times per day

Etc, etc.
Click to expand...
Do we have the same patient cohort? The existence is so so bleak and the OTVs so so long.

14) I'm up all night peeing. Do you drink water before bed? Yes I drink it every time I get up at night. (facepalm)
 
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