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Criteria for immediate commencement of HT

User
Posted 29 Apr 2024 at 09:53

I'm slightly confused as to what criteria are used for commencement of HT immediately upon diagnosis either on presentation of high PSA or on confirmation of cancer following biopsy.

The obvious advantage is that that cancer with a high risk of spreading is treated quicker than if waiting for results from all the scans and meetings with various consultants to discuss treatment options.

The disadvantage is that sensitivity of subsequent scans to pick up cancer may be reduced and an RP may no longer be option even if the cancer is found to be confined to the prostate.

 

At the extremes I can fully understand that if someone presents with PSA in triple figures this would make sense, but the criteria for more marginal cases PSA 40-100 seems to vary between hospitals and regions also when patients present with a lowish PSA but a Biopsy results in a high Gleason score i.e. 4+5 (assuming forumites to be representative) this doesn't seem to trigger commencement of HT, does this scenario represent a lower risk of spreading and existing micro mets than someone presenting with a high PSA alone?

 

Another issue I was pondering is that surgeons don't generally like patients to commence HT before an RP, my consultant told me this is because it makes the cancer “fuzzy” and less defined making the procedure more difficult, fair enough but does anyone know if this perceived difficulty has translated into worse results, either in increased side effects or need for salvage RT?

I was particularly thinking of the large number of patients who were put on HT before RP during the COVID pandemic due to delays and uncertainty of when surgery would be commenced.

User
Posted 29 Apr 2024 at 10:37

There are 4 reasons you might have hormone therapy:

1) Shrinks prostate, which means less total radiation is required to treat it, and less collateral damage for external beam radiotherapy using a narrower beam.

2) Improves low power radiotherapy outcomes, typically halving the recurrence rate for intermediate and higher risk cases.

3) Increases life expectancy for incurable cancer.

4) Pause cancer for diagnostic or treatment delays.

Prostate cancer diagnosis is usually done by urology, yet hormone therapy (in my mind at least) is really an oncology treatment. What often happens is urology start you on hormone therapy once it's been decided your treatment is going to come under oncology. This gets you on to treatment faster, particularly given many oncology departments currently have 6 or more week waiting list for first cancer appointments and it helps hospitals meet their 62 day target to start treatment.

There are oncology treatments which don't require hormone therapy such as some patients going for brachytherapy, and local disease where the new 5 x SABR fractions are offered, so it does require urology to understand something of what may be down the line in oncology. Also, if there's going to be a PSMA PET scan (which is quite rare during initial diagnosis in the UK because of lack of provision), then that should be done before starting hormone therapy as the hormone therapy makes that scan less sensitive.

Edited by member 29 Apr 2024 at 10:55  | Reason: Not specified

User
Posted 29 Apr 2024 at 09:53

I'm slightly confused as to what criteria are used for commencement of HT immediately upon diagnosis either on presentation of high PSA or on confirmation of cancer following biopsy.

The obvious advantage is that that cancer with a high risk of spreading is treated quicker than if waiting for results from all the scans and meetings with various consultants to discuss treatment options.

The disadvantage is that sensitivity of subsequent scans to pick up cancer may be reduced and an RP may no longer be option even if the cancer is found to be confined to the prostate.

 

At the extremes I can fully understand that if someone presents with PSA in triple figures this would make sense, but the criteria for more marginal cases PSA 40-100 seems to vary between hospitals and regions also when patients present with a lowish PSA but a Biopsy results in a high Gleason score i.e. 4+5 (assuming forumites to be representative) this doesn't seem to trigger commencement of HT, does this scenario represent a lower risk of spreading and existing micro mets than someone presenting with a high PSA alone?

 

Another issue I was pondering is that surgeons don't generally like patients to commence HT before an RP, my consultant told me this is because it makes the cancer “fuzzy” and less defined making the procedure more difficult, fair enough but does anyone know if this perceived difficulty has translated into worse results, either in increased side effects or need for salvage RT?

I was particularly thinking of the large number of patients who were put on HT before RP during the COVID pandemic due to delays and uncertainty of when surgery would be commenced.

User
Posted 29 Apr 2024 at 11:21

My reason for starting on Bicalutamide at that point was 4) - pause cancer for more diagnostic procedures, which took 5 months (although I think they were expecting only a couple of months at the time). I was still after a prostatectomy at that stage.

Edited by member 29 Apr 2024 at 11:22  | Reason: Not specified

User
Posted 16 May 2024 at 13:18

Hi Richard99

I started my  HT in 2020 as part of my preparation for RT but  because of my OAB  could not go ahead with RT  and im now being considered for Active Surveillance.  

KB

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User
Posted 29 Apr 2024 at 10:37

There are 4 reasons you might have hormone therapy:

1) Shrinks prostate, which means less total radiation is required to treat it, and less collateral damage for external beam radiotherapy using a narrower beam.

2) Improves low power radiotherapy outcomes, typically halving the recurrence rate for intermediate and higher risk cases.

3) Increases life expectancy for incurable cancer.

4) Pause cancer for diagnostic or treatment delays.

Prostate cancer diagnosis is usually done by urology, yet hormone therapy (in my mind at least) is really an oncology treatment. What often happens is urology start you on hormone therapy once it's been decided your treatment is going to come under oncology. This gets you on to treatment faster, particularly given many oncology departments currently have 6 or more week waiting list for first cancer appointments and it helps hospitals meet their 62 day target to start treatment.

There are oncology treatments which don't require hormone therapy such as some patients going for brachytherapy, and local disease where the new 5 x SABR fractions are offered, so it does require urology to understand something of what may be down the line in oncology. Also, if there's going to be a PSMA PET scan (which is quite rare during initial diagnosis in the UK because of lack of provision), then that should be done before starting hormone therapy as the hormone therapy makes that scan less sensitive.

Edited by member 29 Apr 2024 at 10:55  | Reason: Not specified

User
Posted 29 Apr 2024 at 11:01

Thank you, I understand that Andy, but as an example with a PSA of 57 you started on Bical within around a month of diagnosis and before all your scans were completed, had you spoken with an Oncologist by that point and stated you were wanting to have RT?

Where's I presented with a PSA of 42, but was never given an option of commencing Bical nor was it even discussed until all my scans were completed, my only route to start on Bical was after I finally got a consultation with a Radiologist more than 3 months after my initial PSA test.

Edited by member 29 Apr 2024 at 11:08  | Reason: Not specified

User
Posted 29 Apr 2024 at 11:21

My reason for starting on Bicalutamide at that point was 4) - pause cancer for more diagnostic procedures, which took 5 months (although I think they were expecting only a couple of months at the time). I was still after a prostatectomy at that stage.

Edited by member 29 Apr 2024 at 11:22  | Reason: Not specified

User
Posted 16 May 2024 at 13:18

Hi Richard99

I started my  HT in 2020 as part of my preparation for RT but  because of my OAB  could not go ahead with RT  and im now being considered for Active Surveillance.  

KB

User
Posted 16 May 2024 at 15:09

Hi KB,

I know nothing of OAB, but it clearly has serious implications for those seeking RT.

I'm a little confused by your posts (I'm probably being stupid), I see that you commenced HT in 2019. Are you still on HT or has that now stopped? Also if you are on AS I hope and assume they're going to be very active given that they consider you to be already over the threshold for Radical treatment. Have you discussed treatment options for the future?

Edited by member 16 May 2024 at 15:10  | Reason: Not specified

User
Posted 16 May 2024 at 17:56

Hi Richard99

Thanks for your reply. 

I have now come off the HT.

My future Radical Treatment is complicated by the fact that i have had  a previous Open Surgery for another condition. So initially my MDT ruled out Surgery and suggested RT.  Going forward, because of my OAB , RT is ruled out and i have no option  but to go for surgery when it becomes necessary..

I have, however,  been advised that Robotic Surgery may not be appropriate for me given my history.

My concern is that most of the Urology Surgeons now practice Robotic Surgery and  it may be difficult to find an experienced Surgeon who does Open Radical Prostatectomy.

Regards

KB

User
Posted 16 May 2024 at 18:24

I think there are still a few about who do open surgery, someone posted fairly recently on the forum that that's what they were having.

I'm assuming that all forms of RT have been ruled out and that the tumour is too large for any kind of focal therapy?

hopefully you'll be on AS for a long time, so that it's not an issue.

Edited by member 16 May 2024 at 18:33  | Reason: Not specified

User
Posted 16 May 2024 at 18:41
Surgeons have to be proficiant administering Open surgery prior to moving to Robotic surgery. In the event of a problem with the robot, which thankfully is quite rare during an operation, they have to revert to Open Surgery. There are also some situations where Open is considered preferable anyway
Barry
 
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