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Radiation Therapy and ADT in CRPC

Panelists: Raoul S. Concepcion, MD, Comprehensive Prostate Center in Nashville; Evan Y. Yu, MD, Fred Hutchinson Cancer Research Center; Michael A. Carducci, MD, FACP, Sidney Kimmel Comprehensive Cancer Center of Johns Hopkins Hospital; Neal D. Shore, MD, FACS, Carolina Urologic Research Center; Glen Gejerman, MD, DABR, John Theurer Cancer Center
Published: Thursday, Jul 20, 2017



Transcript:

Raoul S. Concepcion, MD, FACS:
Glen, can you explain, for our audience, recommendations as they relate to radiation therapy and androgen deprivation therapy? Where do we stand, right now, with that in terms of the length of ADT: 2 years, 6 months, 18 months, 36 months?

Glen Gejerman, MD, DABR: What we’re learning is that less is more. It’s better to give less because these are not benign drugs. When I speak to a patient who’s got a Gleason score of 8, 9, or 10, I tell him or her, “Look, you need to have neoadjuvant therapy, and then concurrent therapy, and then future androgen suppression. You have to understand what it does—what the benefits are. But you also have to understand the impact on your quality of life.” These are really metabolic effects that most patients don’t really anticipate. Besides the sexual side effects, there’s a tremendous effect on bone metabolism. They lose muscle mass. There’s change in the insulin resistance. There are debatable papers about cardiac issues or, perhaps, dementia.

So, if we can give less, it’s better. The initial trial by Bolla gave 3 years. Gerald Hanks repeated that, and it was 2 years. We’re seeing, now, that we’re rationing it down. In my practice, for patients who are at the highest risk, a Gleason score of 9 or 10, we keep them on therapy for 2 years. If it’s less than that, we’ll probably do 18 months of treatment. If there’s a compelling reason to give someone with a Gleason score of 7 androgen suppression, which I’m not convinced there is, I’d make sure it’s much less than that. These are not the benign drugs. I think when you add androgen suppression to radiation, there’s a tremendous impact on the quality of life.

Raoul S. Concepcion, MD, FACS: What are the data on the use of ADT in radiation for patients who need adjuvant therapy because of a high-grade tumor: pathologic stage T3, especially T3C?

Glen Gejerman, MD, DABR: It’s recently changed. The RTOG (Radiation Therapy Oncology Group) study really showed us new data. This is always a question: we know that adding androgen suppression to external beam therapy works when your prostate is intact, but does it work in a postoperative setting? We just didn’t know. But now we do have data that the 10-/12-year survival data are better.

Again, how long should it be given? The trial gave it for 2 years. Does that mean that is what we should be doing? I’m not convinced of that. I think we’re going to probably ratchet it down, but there’s pretty clear evidence that for patients who either have a biochemical recurrence or are at very high risk for that, when you treat the prostate fossa, you do need to add androgen suppression.

Raoul S. Concepcion, MD, FACS: Wasn’t there also a trial where they gave concomitant therapy with the radiation therapy? Instead of going with full-blown ADT, they used bicalutamide?

Glen Gejerman, MD, DABR: Absolutely.

Transcript Edited for Clarity

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Transcript:

Raoul S. Concepcion, MD, FACS:
Glen, can you explain, for our audience, recommendations as they relate to radiation therapy and androgen deprivation therapy? Where do we stand, right now, with that in terms of the length of ADT: 2 years, 6 months, 18 months, 36 months?

Glen Gejerman, MD, DABR: What we’re learning is that less is more. It’s better to give less because these are not benign drugs. When I speak to a patient who’s got a Gleason score of 8, 9, or 10, I tell him or her, “Look, you need to have neoadjuvant therapy, and then concurrent therapy, and then future androgen suppression. You have to understand what it does—what the benefits are. But you also have to understand the impact on your quality of life.” These are really metabolic effects that most patients don’t really anticipate. Besides the sexual side effects, there’s a tremendous effect on bone metabolism. They lose muscle mass. There’s change in the insulin resistance. There are debatable papers about cardiac issues or, perhaps, dementia.

So, if we can give less, it’s better. The initial trial by Bolla gave 3 years. Gerald Hanks repeated that, and it was 2 years. We’re seeing, now, that we’re rationing it down. In my practice, for patients who are at the highest risk, a Gleason score of 9 or 10, we keep them on therapy for 2 years. If it’s less than that, we’ll probably do 18 months of treatment. If there’s a compelling reason to give someone with a Gleason score of 7 androgen suppression, which I’m not convinced there is, I’d make sure it’s much less than that. These are not the benign drugs. I think when you add androgen suppression to radiation, there’s a tremendous impact on the quality of life.

Raoul S. Concepcion, MD, FACS: What are the data on the use of ADT in radiation for patients who need adjuvant therapy because of a high-grade tumor: pathologic stage T3, especially T3C?

Glen Gejerman, MD, DABR: It’s recently changed. The RTOG (Radiation Therapy Oncology Group) study really showed us new data. This is always a question: we know that adding androgen suppression to external beam therapy works when your prostate is intact, but does it work in a postoperative setting? We just didn’t know. But now we do have data that the 10-/12-year survival data are better.

Again, how long should it be given? The trial gave it for 2 years. Does that mean that is what we should be doing? I’m not convinced of that. I think we’re going to probably ratchet it down, but there’s pretty clear evidence that for patients who either have a biochemical recurrence or are at very high risk for that, when you treat the prostate fossa, you do need to add androgen suppression.

Raoul S. Concepcion, MD, FACS: Wasn’t there also a trial where they gave concomitant therapy with the radiation therapy? Instead of going with full-blown ADT, they used bicalutamide?

Glen Gejerman, MD, DABR: Absolutely.

Transcript Edited for Clarity
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