PSA-Only Relapse...Hormones or not?

jim,

I don't know which "latest studies" you are referring to (perhaps you can provide it). But a PSADT < 6 months is an indicator for salvage ADT, especially given your high risk pathology. You can do intermittent ADT.

A bone scan and CT will show nothing at your PSA. There are PET scans that might, but I don't know what you'd do with that info (assuming your pelvic LNs have been treated). Your cancer is systemic and requires systemic treatment.

I would venture to say that as you've already undergone ART, delaying HT at this point would likely not introduce any problems. Sure, ADT would lower your PSA for now, but it might also hasten castrate resistance. Also the PSA is coming from somewhere. Without ADT, established tumors might grow large enough to show on a scan and be treated.

TA--Here is one article that relates. . https://doi.org/10.1093/jnci/dju278, However, this study may not apply to those at high risk. My MO offers me a PET scan when and if my PSA rises to 0.50. Apparently, this scan can detect areas of PC at that low PSA.

Yeah...that last sentence is scary. And, less than 6 months before my Dad died of spinal metastases, an RO pronounced him cured. (after pinpoint radiation to spots on his ureters.)

Ouch. But I truly believe that lots of doctors DO have that attitude: treat "my" disease, even if it leads to other problems. Just like the surgeon who 'cured' my mom's intestinal blockage--6 weeks before she died of pneumonia caused by aspiration after they pulled the feeding tube.

End rant.

jim48

First of all, there are some circumstances in which all oncologists agree that ADT should begin:
(1) detection of metastases
(2) high PSA
(3) rapid PSADT

Unfortunately, you fall into that third category. One can argue about how high and how rapid, but in concept there is little disagreement. Most MOs i've talked to would definitely start ADT if PSA>10 ng/ml or if PSADT <6-9 months. Your PSADT based on the two readings from the same lab is only 2 months.

That reference you showed was based on a retrospective observational study from 2014, and that was certainly the way a lot of MOs thought (and myself) for a while. Then, in 2016, we got the results of the first randomized clinical trial of early vs delayed ADT in non-metastatic men. It showed that the retrospective studies were wrong (as is often the case). Among the findings:

• Early start increased both prostate-cancer survival and survival from other causes (for some unknown reason)
• Health-related quality of life was not impacted by starting early, at least not in the first 2 years
• Intermittent ADT was used by ⅔ of all men in the study
• The highest survival rates were noted in men who started immediate intermittent ADT
• Castration resistance set in sooner among men who waited. It was delayed in men who used immediate ADT probably because it prevented the evolution of castration-resistant cancer cells. Many hypothesized that the opposite would happen because earlier ADT would exert selective evolutionary pressure for castration-resistant cancer cells to predominate.

Timing of androgen-deprivation therapy in patients with prostate cancer with a rising PSA

Beyond the abstract comments

But this trial is beside the point for you, based on your PSADT.

To me this is really simple. If you are concerned about the cancer that you have is advancing then you treat it and slow the advance. Otherwise, then have a nice day.

According to Dr Strum ADT kills non resistant cells, but not resistant cells. Non resistance cells will eventually mutate into resistant cells so it is better to kill them before they mutate. That's why he and others suggests ATD early rather than later.

In no cancer I have ever heard of it is better to treat later than earlier.

I just wanted to highlight the good point that John T made about Strum's approach. I would summarize it as hitting it as hard as you can as early as you can. The theory (baked by the RCT I cited) is to reduce the population of hormone sensitive cells as much as possible. This might entail using an advanced hormone therapy like Zytiga or Xtandi, if you can get your insurance to pay for it. After, say, a year on the regimen, you might get a vacation for the next 3-4 years. So you would wind up with less total time on ADT rather than more time on it.

Another approach is to cycle 3 months of ADT with 3 months of testosterone supplementation. This approach, if it works for you, gives you half of every year where you feel great and also reduces total time on ADT.

/pcnrv.blogspot.com/2016/09/testosterone-to-treat-prostate-cancer_5.html

Yet another approach is the one Traveller58 is using (recommended by Howard Scher at MSK). He takes only 50 mg Casodex only twice a week. He finds this "lite" regimen has been enough to maintain his PSA at low levels. He takes raloxifine with it to prevent gynecomastia, the worst side effect of it. He finds that unlike tamoxifen, raloxifine maintains his testosterone at a level so that he feels good while on it, and doesn't have hot flashes, loss of libido, loss of lean muscle mass, etc. This is an n of 1, but it seems worth trying in a clinical trial.

garyi said...
While ADT effects haven’t been terrible for me, I can say this with absolute certainty, “several months after starting Lupron and Casodex, I’ve started to feel old for the first time in my life.”

Gary, during the almost 22 months I've been on ADT, feels like I aged 6 - 7 years!!

Bobby Mac

Bobby Mac said...

garyi said...
While ADT effects haven’t been terrible for me, I can say this with absolute certainty, “several months after starting Lupron and Casodex, I’ve started to feel old for the first time in my life.”

Gary, during the almost 22 months I've been on ADT, feels like I aged 6 - 7 years!!

Bobby Mac

Interesting.....

My wife just mentioned the the acceleration of the aging process through these treatments is, at least, the same for her. No doubt.

Something tells me there is zero interest in having clinical trials on this issue.

Thanks Allen.

The simple patient questionnaire is something. I believe the entire issue of the effects of ADT on the long term health of patients hasn’t been given the attention it, and we, deserve.

It seems many radiation oncologists give short shrift to the issue, while bravely telling us they want to be aggressive and throw the kitchen sink at A/SRT. Yet in depth discussion of what the real impact of the ravages of chemical castration is seemingly nonexistent. It appears that study and medical knowledge is also lacking.

The fact that so many brothers on HW are concerned about the risk/rewards of ADT on their QoL should be alarming, and cause for study. We do have studies on potential benefits of ADT on PCa and radiation success, but next to nothing on the long term impact of ADT on our quality of life. It’s a shame that facts are so difficult to find about such an important issue IMHO.