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Posted 6/30/2016 1:21 AM (GMT -5)
Well, although we hit it hard with the triple whammy of RP, RT and 12 months ADT, there is little doubt that we missed something and PSA is rising quite rapidly.

After being undetectable in the last quarter of 2015, I have now had 3 rises, 01/16 .01, 03/16 .03, and 06/16 .09.

While the numbers are low, this represents a pretty short doubling time.

At my last visit with the Uro, I asked at what point we should restart ADT, and he said probably not until PSA hit about 10. That surprised me, and given the short doubling time, I am even more sceptical about waiting til then.

So what determines restart of ADT, a specific number or specific Doubling Time? Appreciate any views.

Am also now going to find a Medical Oncologist, but as far as I can detect, there is no one locally who specialises in PCa, but there is a Genito/Urinary guy, so may seek him out. Alternative is to go to Sydney where there are a couple of Prostate specialists at the Chis O'Brien LifeHouse cancer centre.

How important is it to get a PCa specialist oncologist, rather than a general oncologist?

Chas
Posted 6/30/2016 7:46 AM (GMT -5)
about when to start ADT here is a study on the subject (from 2005 though) that supports delayed start.
If the PSA value increases slowly and Gleason is ≤ 7 one can wait several years before ADT treatment as your uro proposes.
www.ncbi.nlm.nih.gov/pmc/articles/PMC1477575/
The 2 key findings from this study were that 1) among all men, the timing of hormonal therapy did not impact on the risk of developing metastatic disease; and 2) among men with high-risk disease (pathologic Gleason sum > 7 and a PSA doubling time ≤ 12 months), delayed hormonal therapy (starting when the PSA level was > 5 or > 10 ng/mL) was associated with an approximately 2-fold increased risk of metastasis.
Posted 6/30/2016 1:15 PM (GMT -5)
I'm so sorry to hear that your best efforts at a cure failed, but I know you're aware that one can live a long time with it as a managed disease, especially with all the medicines now in our armamentarium (and even more on the horizon).

When they actually did a randomized clinical trial on this subject, which was published just last month, they found a significant survival advantage to beginning hormone therapy earlier rather than waiting. I and many others were hoping for a different outcome. This was an important practice-changing study. However, there are other considerations such as comorbidities and quality of life considerations that may enter into the decision.

Here's the study (It was an Aussie study, btw). You may want to send the link to your oncologist and ask to discuss at your next meeting.

Timing of androgen-deprivation therapy in patients with prostate cancer with a rising PSA (TROG 03.06 and VCOG PR 01-03 [TOAD]): a randomised, multicentre, non-blinded, phase 3 trial

It's also worth reading the Medscape analysis of it (you may have to register):

Immediate ADT Improves Survival in Relapsed Prostate Cancer

As for the doctor, I'd go to the best specialist I could find. They are more likely to keep up with the latest therapies and have the best diagnostic equipment. They are also more likely to be plugged into clinical trials. You don't have to actually meet with the specialist very often. The hormone shots can be administered by your local doctor.

- Allen
Posted 6/30/2016 3:06 PM (GMT -5)
Thanks Gemlin and TA.

Both those reports certainly suggest that early treatment for high risk disease is appropriate, and with my 2 month doubling time, I think I fit the high risk category.

Does also fit with my "gut feel" and given that I didn't suffer too badly from ADT first time around, I think I will be suggesting early treatment.

However there is nothing to indicate at what level of PSA treatment should start. I am still very low at .09, but maybe the short doubling time trumps that and I should start immediately. Would be nice to hold off for a few more months.

Next question will be, does it need to be continuous or can intermittent work?. After completing my last treatment of 12 months, I then experienced 12 months zero psa. If I could continue with 12 months on, 12 months off, that would be very manageable. However, I suspect it wouldn't be that simple.

Allen, do you have any knowledge of the top Medical Oncologists in Oz? Been looking at the profile of Lisa Horvath at the Chris O'Brien Lifehouse and she specialises in prostate cancer and seems to be involved with current treatments and clinical trials.

Thanks again guys. So good to have the support of knowledgeable people at the end of my keyboard, rather than just the treating medicos who you only see infrequently.
Posted 6/30/2016 5:40 PM (GMT -5)
Sorry Chask, I'm afraid I don't know many doctors in Sydney, although I have heard of St. Vincent's and Chris O'Brien Lifehouse.

In the study I cited, those that started hormone therapy early were treated at the time of "PSA relapse," which usually means 0.2 ng/ml. You are right that a rapid PSADT is a warning sign, but PSADT is really not defined for PSAs under 0.1. It is not at all clear that changes in PSA carry the same risk when you're dealing with numbers that small.

You are right to discuss intermittent vs continuous hormone therapy - there are few rules about that. The other major decision is which hormone therapy: an LHRH agonist or antagonist or just Casodex. I spoke to someone the other day who was being treated by Howard Scher (certainly among the top urologic oncologists). He got his PSA down to undetectable with daily Casodex, and now keeps it at that level or close to it by only taking one 50mg pill per week. Very minimal side effects with that, and tamoxifen can control any gynecomastia. And a pilot trial of bipolar androgen therapy (BAT) at Johns Hopkins just reported some early results that seem to be encouraging. All kinds of options.

- Allen
Posted 6/30/2016 11:46 PM (GMT -5)
Thanks Allen, plenty to think about and discuss with my Uro and Oncologist. And you have justified my waiting a short time at least before jumping back in to ADT. Though with my current PSADT, I'll be up to .2 well before the end of the year.

Chas
Posted 7/1/2016 3:18 PM (GMT -5)
The decision to proceed with salvage therapy should not be based on prostate specific antigen doubling time calculated using ultrasensitive prostate specific antigen values, according to this study:
Poor agreement of prostate specific antigen doubling times calculated using ultrasensitive versus standard prostate specific antigen values: important impact on risk assessment
Posted 7/1/2016 7:58 PM (GMT -5)
Thanks Gemlin, that very much confirms TA's comment "PSADT is really not defined for PSAs under 0.1" and is quite comforting.

And of course it completely makes sense. .01 = .0, .02 suggests a doubling, but is still .0, as is .04 and so on. And I can fully imagine that measurements that small hold a degree of error.

I will hold off pushing for ADT at least until I reach .2

Chas
Posted 7/1/2016 9:03 PM (GMT -5)
Excellent discussion! Great info which I hope I won't but probably will need at some point.
Bob
Posted 7/4/2016 8:51 AM (GMT -5)
Hi Chask,
Sorry to read of your rising PSA.

My oncologist and I have been using the "about 10" trigger through three rounds of intermittent ADT with several sets of CT and bone scans indicating no mets so far. My PSA doubling time is 3 or 4 months once the numbers get to single digits. Treatments have been 12 months on and about 18 months off but I've experienced at least a 6 month "hangover" after the last shot before there is any T recovery. Still, ADT vacations have made it much easier to bear.

In light of the studies cited by Tall Allen this regimen may no longer be viewed favourably, will see what my doc says with my next PSA test and visit. (I am currently in the hangover stage of my third vacation) If something like 0.2 becomes the trigger that would likely mean continuous ADT for me.

All the best,
Posted 7/4/2016 2:06 PM (GMT -5)
Biker56,

I don't remember posting anything unfavorable about intermittent ADT. Which studies are you referring to? You may be interested in the thread I just started on the BATMAN trial.

- Allen
Posted 7/4/2016 3:07 PM (GMT -5)
Biker56, should treatment period be as long as 12 month? European guidelines writes about intermittent ADT:
Stop treatment when the PSA level is < 4 ng/mL after 6 to 7 months of treatment.
The induction cycle cannot be longer than 9 months, otherwise testosterone recovery is unlikely.
Resume treatment when the PSA level is > 10-20 ng/mL (or to the initial level if < 20 ng/mL).
Posted 7/5/2016 12:31 AM (GMT -5)
Sorry Allen, didn't mean to imply that you or the studies recommended against intermittent ADT. My point was that if starting/restarting ADT at very low PSA levels becomes best practice, then ADT vacations, in my case at least, would be so short that the ADT is virtually continuous.
Posted 7/5/2016 12:48 AM (GMT -5)
Gemlin,
6 or 7 months sounds good to me but my oncologist says 12 months and its only in the last few months and the months following treatment until some T recovery that my PSA drops to <0.1. I hadn't heard of a nadir of 4 considered as successful or sufficient.
Posted 7/5/2016 3:28 AM (GMT -5)
Biker, thanks for your posts. I think I am pretty much in tune with your treatment regime.

Though it was a first time treatment, my original ADT treatment went for 12 months and had a following 12 months of zero PSA (and T). So far I have been off ADT for 18 months, and that should continue for a little while longer, though as you can see PSA is rising.

Can't say I feel comfortable with the European guidelines mentioned by Gemlin.

I did go back to 0 after only 3 months on ADT, but based on some other study provided by TA, convinced my Uro that I should continue ADT for at least 12 months.

I was one of the lucky ones who didn't find the SE's too bad. I did have hot flushes, but bearable, and didn't really have too much fatigue. Was able to do my 2 mile walk daily and generally go about my business. It did render me a Eunich! Though at 71, sex is not a big issue, and my wife agrees. I would like to retain some muscle tone, if only to be able to hit my golf ball a bit further!

Again, like you, I would not be comfortable with a nadir of 4. What I really want is that magical <.01, but I suppose as time goes on, I'll have to recognise that is going to become less acheivable.

Chas
Posted 7/5/2016 3:25 PM (GMT -5)
Biker56-

Now I understand what you were referring to. That was a study on when to start lifelong ADTinitially and had nothing to do with the timing for "restarting" it. Sorry for the confusion.

As far as I know, there is no "best" intermittent ADT protocol. As far as I know, there has never been a test where patients were randomized to one protocol or another. It is most likely highly individual as to what would work best. I've seen mathematical models that try to individually optimize protocols, but they are not yet in use. It is often done on a trial and error basis, taking patient preferences into account.

- Allen
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