Prostate Cancer
Questions discussed in this category
If ADT acts as a systemic treatment, we would have expected to see a benefit with an RP just like with radiation. Yet, this is not the case. What are ...
If a patient presents with de novo oligometastatic (i.e., meeting STAMPEDE low met burden criteria) prostate cancer with no prior history of primary t...
Are there specific AR Pathway inhibitors that can be crushed and used through feeding tube or would you just avoid ARPIs in such patients?
For example, if MRI revealed prostate-confined disease but PSMA had moderate avidity in the bilateral seminal vesicles, would you obtain further biops...
How does time since radiation, original PSA and grade group/gleason score inform your decision?
Would you treat this patient any differently than any other very high risk prostate cancer patient? Are there any additional dose constraints for the ...
Would you consider adding docetaxel to ADT and novel hormonal agents?
FDG PET, Axumin PET, Bone scan? Or just proceed with salvage ADT/RT?
With the recent publication of PSMAfore, what are your current criteria for offering Lu-177 therapy?
The study showed no benefit in terms of cancer control or toxicity. There was a significant finding of worse sexual function, but this was deemed to b...
If pursuing a sequential approach with boost to dominant prostate nodules as seen on MRI, what dosing and fractionation would you use in the initial a...
Should external beam radiation be 'maxed out' before use of lutetium-177?
When and how are you incorporating tumor sequencing to plan treatment of metastatic prostate cancer?
Given the FDA approvals for PARP inhibitors and combinations in mCRPC, when do you obtain NGS for mCRPC? Do you have a preferred assay?
Would you be willing to treat an elderly patient on blood thinners who has PSMA+ PET, elevated PSA, and multiple urologists have deemed biopsy too ris...
If delivering 300 cGy per fraction to the DIL, what urethra dose constraints to you use for 26 and 28 fraction regimens?
With the advent of PSMA PET/CT, this is my study of choice for high risk prostate cancer. Are there scenarios where standard FDG PET is useful? For ex...
Would you consider 36 Gy in 6 once-weekly fractions?
What dose constraints are you most worried about in the re-irradiation setting with such high doses prior?
Based on the recent guidelines, should prostate SBRT dose be no higher than 3625 cGy in 5 fractions?
The recently published executive summary from ASTRO/ASCO/AUA hypofractionated radiation therapy for localized prostate cancer states "Five-fracti...
Do you start neoadjuvantly? Concurrently?
Long-term ADT is deleterious to multiple organ systems (bone/sexual/psychiatric) and increases the risk of MACE. What level 1 evidence do we have to c...
On the EMBARK trial (Freedland et al., PMID 37851874), 25% of men had a prostatectomy and the publication states, "Patients were excluded … if ...
What fields? Would you treat the pelvis? What factors would help you determine this?
PSMA or Flucyclovine defined focal nodule
NCCN, NRG contouring guidelines, and NRG-GU-009 all recommend treating non-metastatic high risk prostate cancer with dose escalation to involved gross...
RADICALS-HD trial (ESMO 2022) demonstrated metastasis free survival benefit with 24 months compared to 6 months of ADT.
Which criteria/factors would you use to decide whether to de-intensify prostate bed/fossa treatment? For instance, surgical margin status or biochemic...
STAMPEDE answer is yes, intuitively it seems there must be a line somewhere though.
For patients staged only with PET that is widely M1, should a CT ...
Current NCCN guidelines recommended not combining relugolix with these agents until more data is available.
Any drug interaction concerns or ot...
Would you treat similar to small cell carcinoma? What is the suggested chemotherapy regimen? Will you continue ADT?
Given the limited # of patients with PALB2 mutation on the PROfound trial (de Bono et al., PMID 32343890) and the benefit primarily driven by Cohort A...
Would a specific Gleason score, age, pathological feature, or PSA be an indication for covering the pelvic nodes? Would giving concurrent ADT affect y...
Or, to manage tenesmus and discomfort after any type of pelvic radiation.
If so, do you modify your external beam dose?
Only the mCRPC population was included in the Fizazi et al. study, but the FDA approval is for prevention of skeletal related events from any solid tu...
How would poor urinary or bowel function affect the recommendation?
If a patient has already received ADT+ARSI would you use PARPi over chemotherapy in 2nd line?
Which patients specifically benefit from both mpMRI and PET-PSMA?
ARSI may be controlling a hormone sensitive clone. Some patients flare after stopping the drug.
How would it change your risk group or management? Does Decipher help further inform treatment?
I have a pair of patients with MRI+ and biopsy+ disease who have staging PSMA PET/CT that do not show disease within the prostate (or anywhere else).&...
When (if ever) would you consider immune checkpoint inhibitor up front? Would you be less inclined to offer triple drug therapy? (Some thought that ta...
If baseline testosterone is at castrate levels (e.g. <50), would you consider patient to have castrate-resistant disease?
How does margin positive influence your decision?
Do you preferentially use Ra-223 first given the RALU study?
In particular, in the modern era of multi-parametric prostate MRI and PSMA-PET, certain findings such as EPE, SVI, or pelvic lymphadenopathy may be no...
Do you feel comfortable stopped abiraterone after 2 years?
In the setting of EBRT alone, a "FLAME"-style boost may increase bPFS. Does anyone have experience with increasing the EBRT dose in combination EBRT+L...
He cannot sense bladder fullness but has no incontinence. Intermittently he urinates by increasing intra-abdominal pressure resulting in a good stream...
For example do you use Prolaris, or other genetic tests to guide ADT decision making?
Assume recurrence is biopsy proven. Would you ever consider focal vs whole gland brachytherapy?
Patients in their later 40s with favorable intermediate-risk prostate cancer s/p 7000cGy/28 EBRT only.
24 months ADT + abiraterone + definitive RT is indicated for cN1 disease but not for pN1 disease per NCCN. Can the data be extrapolated to this popula...
Notably, the patient presented with renal failure due to ureteral obstruction and hydronephrosis, receives hemodialysis, and has limited systemic opti...
For example: radiation fractionation schedule, modality (proton, MRI linac, cyberknife, etc), risk categorization, prostate size, history of IBS, hist...
Do you also give neoadjuvant, concurrent, and adjuvant ADT in the same manner as for non-SBRT EBRT?
How would you sequence therapy, and what dose and volumes would you use for radiation? Prostate cancer is localized, Gleason 4+3, PSA 65.
Pretreatment PSA 25.3 with Gleason 4+3=7 and MRI suspicious for ECE. Eight months after pelvic nodal and prostate XRT to 79 Gy, PSA is 5.02 (down from...
A recent NCBD analysis (Rusthoven et al., PMID 27325855) suggests that the addition of prostate RT significantly improves survival compared to AD...
Specifically if metastatic risk estimate approached the failure rate in control arm of STAMPEDE for high-risk non-metastatic disease (69% MFS at 6 yea...
If so, how long are they on degarelix before the switch?
Would you recommend elective nodal radiation and sequential boost to the node? What dose? Would you recommend treatment similar to OLIGOPELVIS-GETUG P...
There is a recent publication that nicely summarizes the molecular/genetic tests for prostate cancer (Ross et al., PMID 26123120). What should be done...
If ADT +/- ARPI + RT, what duration of systemic therapy do you recommend?
Are there exceptions?
What imaging modality do you use (conventional, PSMA PET, etc.)? When do you image (ex: a PSA threshold or PSADT)?
Would you consider these as metastatic sites? Would you biopsy to confirm?
If so, when do you resume?
Would you switch to enzalutamide or apalutamide if not giving docetaxel given darolutamide data for mCSPC is only from ARASENS trial with docetaxel?
Would you prescribe ADT for a patient with dementia who has biochemical recurrent, non-metastatic prostate cancer, but otherwise good physical PS?
Is this considered salvage or definitive since HIFU is not standard of care?
Does receipt of upfront HIFU impact ability to perform stand...
When do you order PSMA PET? Do you preferably order Locametz (gallium Ga 68 gozetotide) PET?
PSMA PET vs Conventional imaging vs combined imaging?
Is there an extent of nodal involvement in prostate cancer above which you would not offer definitive XRT? With PSMA/PET we see some patients with inc...
Do you wait for radiographic progression? What is your preferred imaging modality for re-staging?
If a patient who has undergone radical prostatectomy many years previously presents with biochemical failure and is found to have a nodule in the pros...
How would you treat such a patient?
Specifically, in the TZ and PZ? What references do use for prostate nodule boost as done in FLAME trial?
Hypointensities are contoured on T2W M...
What would you use after platinum/taxane/IO first line therapy?
Would you consider repeating a biopsy?
How high would you try to boost those involved nodes if they are in a favorable location with respect to his rectum and small bowel?
Would you use an FDG PET to further inform decision?
Would you treat with ADT if no metastatic disease?
Does absolute PSA (e.g. PSA<2) inform decision?
Does ADT affect the results of a biopsy?
Additional imaging of the potential lesions, biopsy or assume negative given normal PSMA PET/CT.
Or would you proceed with cabazitaxel or other therapy? Initial chemo-hormonal therapy was ADT + Docetaxel x6 cycles.Docetaxel rechallenge at time of ...
Do you find the ibPFS endpoint sufficient to change practice for any or all patients, or will you await OS or other data/trials?
Alternatively, is a biopsy of a metastatic bone lesion preferred in a patient who has already progressed on chemo and hormonal therapy and has bone-on...
Do you allow this finding to change your management, or ignore it, as the "lesion" was not malignant?
How do you differentiate between olaparib, rucaparib, niraparib, talazoparib?
If yes, would you directly add olaparib at progression on abiraterone vs waiting to use abi/olaparib at a later line of therapy?
Is the benefit in PROpel driven by BRCA1/2 or ATM mutated tumors vs all comers?
Would you offer adjuvant radiation? (Dose? Target?) vs Salvage?
Would you add ADT? Would you add abiraterone?
Would the number of lymph nodes involv...
Would you consider using them in patients with CHEK2 mutations?
Do you have a preferred way to incorporate advanced androgen blockade vs chemo vs sip-T vs Lu-PSMA vs PARP vs other targeted agents?
Is prior Ra-223 a contraindication for treatment?
Patient has ED unresponsive to cialis/viagra; would you recommend testosterone replacement therapy?
Do you have a preference for bicalutamide? Can abiraterone be used instead?
At what PSA would you become suspicious for biochemical recurrence and pursue restaging? Is there a threshold value?
What imaging modality would you ...
Would you use it for initial staging or at time of biochemical recurrence?
If a patient is not a surgical candidate, what it the most appropriate treatment?
The trial inclusion criteria was essentially "docetaxel candidate per the treating oncologist"
Is there a concern regarding rarer side effect emergence (cardiac, bone, muscle, cognitive) of long term exposure to "maximal" androgen deprivation? I...
Would you consider boosting the nodes? What dose? Would this change your recommendation for length of ADT?
Would you consider chemotherapy, androgen blockade or triple therapy (chemo and AR targeting)?
Would the results of PEACE-1 trial justify this?
Are there clinical features (post-op PSA, Decipher score, pN+, pT3, etc) that would inform your decision?
Given GU003 presented at ASTRO 2021- how does this impact your recommendations for adjuvant and salvage prostate RT?
Do you worry about false negatives on PET, CT, MRI if ADT is started before the scan? Scheduling scans can sometimes book 2-4 weeks out.
Would you treat with PARP inhibitor or Check-Point Inhibitor?
Per lutathera information, a patient who had previous treatment for describes an estimated radiation absorbed dose of 12.8 Gy to the bladder. Would yo...
Is there a role of EBRT to the prostate with extended fields to cover the retroperitoneal nodes plus ADT (definitive therapy) or would you treat as ca...
PSA rose from 25 to 30 ng/mL over 6 months on darolutamide for M0 CRPC, prompting scans which showed oligometastatic disease to bone, not amenable to ...
Or would you restrict such treatment to patients with known pathogenic germline BRCA mutations?
Given ductal histology, is docetaxel preferred over NHT?
Are there other high or very high risk features that would also contribute to your decision making?
GS 4+4. PSA low (1-2). CT and bone scan negative for lymphadenopathy or metastatic disease. Prostate MRI pending.
Patient previously had prostatectomy and salvage RT
Would you recommend surgery first or neoadjuvant therapy such as concurrent cisplatin/RT or another regimen?
Did you change your practice given the SRE results in the control arm of EORTC 1333 at ASCO 2021?
When using bisphosphonates or denosumab, what dosin...
Would you consider adding ADT?
For the purpose of this question, please assume an initially undetectable post-prostatectomy PSA, no presence of positive margins, extracapsular exten...
Are there certain situations where a hydrogel spacer is most useful based on treatment modality (SBRT, protons, brachy, etc) or other factors?
Do prior treatments for mHSPC change your thinking on whether or not to use sipuleucel-T?
No targetable mutations detected
In addition to ADT, would you treat with abiraterone, enzalutamide or docetaxel? Or other treatment - platinum/taxane?
Gleason 4+3=7 and PSA 4
Are there other adverse features aside from seminal vesicle invasion, positive margins, or extraprostatic extension that you consider?
Does post docetaxel PSA influence your decision?
Specifically, would you offer salvage radiation to a patient who underwent a prostatectomy with PLND and had a post-op PSA of 12 with pathology reveal...
What line would you give pembrolizumab?
Would you add abiraterone or enzalutamide?
Would your management change if the prostate and lymph nodes were treated with radiation two years ago?
What clinical scenario(s) do you find results to be the most beneficial?
Does the specimen (blood vs tissue) used to detect mutation affect your consideration?
Are there particular populations in whom you would add an AR targeted agent after docetaxel?
Assuming patient received appropriate local therapy for brain metastases, which agent would you use?
HERO study - https://clinicaltrials.gov/ct2/show/NCT03085095
Given that ADT + abiraterone and ADT + docetaxel have not been directly compared.
What is the time window in which you would consider adding AR targeted therapy?
Is there a time frame in which you would NOT consider introducing sin...
Is there an optimal strategy to minimize unnecesary steroid use?For example, pre-treatment dexamethasone or 3 day dexamethasone? Prednisone only conti...
Is there data and FDA approval for this indication?
What about for nodal failure after radiation?
What dose constraint would you use for the neobladder? Small bowel constraint of 54Gy? Or would you recommend observation or ADT alone or low dose RT ...
Assuming patient is not a surgical candidate and wishes to pursue definitive radiotherapy, what duration of ADT would you give?
How would a much higher risk cancer affect decision making? How would you treat him?
Abstract 5014 at ASCO annual meeting 2019 showed superiority of PSMA-PET imaging over fluciclovine-PET imaging. Are you utilizing these speciali...
Do you offer EPO and TPO support? Do you modify your systemic therapy up front or after subsequent cycles?
In the SPARTAN trial, median PSA at study entry was ~ 7. Does the MFS benefit extend to patients with low PSA(< 2 or < 1)?
For instance, if the fluclicovine scan shows a few small avid nodes not only in the pelvis but extending to the paraaortic region, would you treat the...
Will your recommendation change if there is suspicious/confirmed locally recurrent nodule in the prostate bed?
In this case, Gleason 5+5 in all cores, clinical T4.
How long would you continue androgen deprivation after radiation?
In a patient with a prior response to ADT and progression on taxane and platinum chemotherapy, would you consider AR directed therapy?
Per the ALSYMPCA study, they excluded patients with > 3cm lymphadenopathy. Patient is currently on enzalutamide and leuprolide and refuses docetaxe...
Does the STAMPEDE trial, showing a survival benefit with the addition of docetaxel to standard treatment, change the standard of care for high risk, n...
Is there a benefit to one fractionation schedule v. the other?
Assuming there was an initial period of response to the mCRPC treatment.
Would you add atezolizumab to carboplatin + etoposide for small cell/neuroendocrine prostate cancer?
Treatment for small cell/neuroendocrine prostate is extrapolated from data on small cell lung cancer. It now appears that Carboplatin + Etoposide + At...
Are you directed by symptoms, PSA changes or do you have a standard schedule regardless of those factors?
Do we need to really worry about neutron contamination?
Abstract LBA5_PR ‘Radiotherapy (RT) to the primary tumour for men with newly-diagnosed metastatic prostate cancer (PCA): survival results from S...
Prospective International Randomized Phase II Study of Low-Dose Abiteraterone with Food versus Standard Dose Abiraterone In Castration-Resistant Prost...
Is there a dose response relationship, as suggested in the phase I MSKCC dose escalation study presented at ASTRO 2017?
Should it be started at the initial diagnosis of bone mets?
For which patients would you consider addition of apalutamide or enzalutamide? How do you decide between the 2 drugs?
NCCN recommends to change therapy or maintain current therapy in this setting without further clarification. What thresholds would cause a change in t...
Based on the updated results of the PCS IV trial is 18 months of ADT the new standard of care for men with high-risk prostate cancer treated with...
If yes, what factors push you to test for AR-V7 or would you test all patients in this clinical scenario?
Would you initiate abiraterone or enzalutamide for the rising PSA or wait until the patient is symptomatic or has a new site of metastasis?
Is there data to support this practice, which appears in the NCCN guidelines?
In the case of patients many years out from RP who have a slowly rising PSA, do you offer salvage RT while the PSA is still very low or follow the PSA...
In patients with new bone pain and without any evidence of bone metastases receiving GnRH agonists, how do you manage pain symptoms?
With biopsy-proven, negative systemic restaging disease, what dose and fractionation is appropriate if treating with IMRT? Should ADT generally b...
Would you consider this an indication to treat lymph nodes, if you would typically not do so?
Is there an upper limit to offer definitive RT? Is it possible to have a PSA of 100-500 and still have only local disease?
Is there a role for salvage LN dissection or salvage RT to the node? And is there a role for systemic therapy (ADT or chemotherapy) in addition? If yo...
Should the workup change with the PSA level (for example, >2 vs <2 ng/ml post-op PSA)? Is there a PSA level for which salvage radiotherapy...
Two retrospective studies from Stanford showed that patients who received ADT had an increased risk of dementia and Alzheimer's. Is this finding ...
Do you use a PSA threshold, PSA doubling time, or only evidence of metastatic disease to trigger ADT? For those without rapid doubling time, do you ev...
If so, what criteria do you use to guide your decision?
In the recent 10 year update of the ARO (adjuvant pelvic RT versus observation) trial, their definition of PSA failure was 2 successive rise...
Do other factors (i.e. Gleason score, pretreatment PSA, or pT stage) affect your decision?
Given recent advancements in the understanding of biological differences in prostate cancer patients of African vs. other ancestry, does your manageme...
Does PSADT play a factor in your decision-making? If so, how specifically?
I've tended to wait until the PSA is 10-15, re-image, and then begin...
Are there specific subsets for whom these results should change management?
If so, how do you sequence this with other therapies? In addition, in the absence of an effect on radiographic PFS or serum PSA, how do you asse...
In situations where there is a significant risk of either local or nodal persistence/recurrence post prostatectomy with a rising PSA, or nodal involve...
A recent systematic review suggested that disease progression owing to a testosterone "flare" may not be a real phenomenon: http://www.ncbi.nlm.nih.go...
The role of adjuvant docetaxel with ADT following RT for high risk disease has been previously elucidated by RTOG 0521. Following prostatectomy,...
At the ASCO 2016 annual meeting, results of the PRINCE trial were reported. A strategy of intermittent docetaxel was found to be non-inferior to conti...
In a patient with node positive disease, treated definitively with radiation, should continuous or intermittent ADT be administered? If a patien...
Typically radium-223 is reserved for men with symptomatic bone disease after failure of multiple other therapies. Is there a population of men w...
Guidelines dont seem to account for this possibility. Could it just be normal prostate tissue growing back that is leading to PSA, why just assume it ...
Do you offer RT if the patient is well controlled on medications?
In starting prostate SBRT at an instutution, what are issues with the treatment that one should pay special attention to?
On what other factors should be considered in making a treatment recommendation for salvage radiation therapy?
What factors should be considered with offering SBRT to oligometastatic bone disease in prostate cancer patients? Should this been done off of a proto...
With ultra-sensitive PSA, it's unclear to me whether a doubling from 0.01 to 0.02 or 0.02 to 0.04 is significant. Is there a certain value that you wo...
If a patient is deemed high risk enough to require hormones with RT in the salvage setting, how long would you maintain them on ADT? Would you extrapo...
Would you favor only offering salvage therapy if the PSA rises?
When counseling patients with organ-confined prostate cancer, what rates of impotence, incontinence, rectal toxicity, and urethral stricture shou...
The optimal timing of post-prostatectomy RT in high-risk patients is debatable and currently the question of prospective randomized trials; however, g...
Fore example for a T3N0 rectal cancer on EUS?
In this case, the patient is currently on maintenance BCG.
If so, what selection criteria do you use for such patients?
Do you use a particular cut-off? For example, someone in their 40's?
The patient has a positive bone scan (2 lesions), grade 4+5=9/10 prostate, and cancer cannot urinate without a catheter.
More specifically, which cardiac risk factors do you look for? Diabetes? Previous MI? Dyslipidemia? Peripheral vascular disease? CHF?
In general how do you counsel patients with high risk prostate cancer when choosing radiation verse prostatectomy? What numbers do you quote for ...
This is a patient who would have been an appropriate candidate for radiation upfront, but was managed with androgen deprivation therapy instead. On th...
Sometimes the scans don’t line up well because of differences in rectal and bladder fullness- any tips to optimize the fusion?
I ask this because I am seeing more and more patients who have had surgery despite presenting with high risk disease.
I know many do not treat the pelvis at all, but for those who do, what criteria do you use? Risk? Gleason? PSA? T stage?
And should special precautions be taken (such as dose reduction, prophylactic symptom management, etc)?
Would you treat this as high risk?
Papers discussed in this category
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