G7 PC. Need advice

Thanks for joining us. From the look of it, you're receiving well within standard of care--your ADT started when your PSA reached nadir + 0.5--which may be a bit early, but with the evidence of metastases, not out of bounds.

This is really a question for your oncologist--I doubt they will be OK with you stopping the ADT now, they probably want you to continue it for at least a year, probably longer.

I'm sorry to say that, but stopping it early is not a generally good idea.

I think you should visit with an excellent radiation oncologist to assess the known tumors for possible ablation as Mumbo says. This is not the domain of the medical oncologist. Only get radiation assessment from a board certified RO with a lot of experience using fine spot radiation.

If you stop ADT now, your testosterone production will resume and the cancer will most likely start feeding and growing and spreading again. Your PSA will begin climbing and tumors will likely start showing on scans. For a situation like yours, it is typical to give 12-18 months of ADT and then take a vacation from the drugs to see what happens. You may stay stable at a very low PSA, or start experiencing an increase rate that is acceptable for a while before starting back on ADT to knock the cancer down for a while. Everyone is different, so an accurate prediction for you is impossible. Unfortunately, in the last 15 years we have been learning that some PCa adapts well to the absence of testosterone and morphs into a very aggressive form called neuroendocrine. While this appears to be a small subset, there is some risk. So even if you are allowed ADT vacations, stay very close to your MO for regular monitoring.

I was on ADT for three plus years. It was not fun, but I adjusted some aspects of lifestyle and coped very well. To combat fatigue I stepped up my exercise, added more fruits and vegetables and water hydration to diet. Alcohol, caffeine and carbonated drinks were eliminated and I sought a lot more sunlight especially through several outdoor walks throughout the day. Also look at supplements to see that you have sufficient levels of Vitamin D, B12 and C. These actions all helped. And an occasional 20 minute power nap would refresh my energy. I was on Lupron/Eligard and Avodart. What drugs does your doctor have you on?

https://www.nejm.org/doi/full/10.1056/nejmoa2303974

Gadenjer,
With visible mets, you definitely need to be on ADT and a Medical Oncologist definitely should be directing your care. You ought to be on ADT and one of the 2nd generation anti-androgen drugs as SOC. I hate to say it but unless you refuse treatment (unwise) it is unlikely that you will be going off ADT treatment any time soon. In fact, if you are having a bona fide recurrence, you will likely be on ADT more or less for life. If you didn't know that, I wish I didn't have to be the one to wreck your day. Eventually, an ADT vacation could be in the cards for you. The thing is, I don't understand how these "vacations" provide any relief because usually as the T level increases so does PSA (and cancer activity). Meaning that before a patient can really start feeling better, it's already time to resume ADT. Nevertheless, some guys swear they feel better. I've never tried it so I don't know, but I've always thought it was along the lines of a placebo effect.

The link I included is the write up for the EMBARK clinical trial for Enzalutamide (Xtandi) that was published last fall. The trial started in 2015 and had a built in intermittent ADT component that you can read about if you like. Incidentally, Xtandi has proven over the years to be a top notch 2nd gen anti-androgen drug. There others also. It's something to discuss with your doctor if you aren't already taking one these meds.

Finally, and this isn't discussed often, some doctors are willing to prescribe stimulants such as Ritalin or Adderall to help with the fatigue and cognitive issues that most lifetime ADT users suffer. Some guys don't want it, others have said it didn't help, but I think for many guys it is life-changing. Problem is that in recent years with the hysteria surrounding any controlled substance prescription, most doctors are scared to death of the DEA, as they should be. With the resources of the Fed govt, the DEA can destroy any doctor's career, if they so choose. If you ask your MO for such a script they may say check with your PCP. The PCP might then say it's the MO's call. Not long ago Lupron might work for 3 years and that was that. But now with ADT combination therapies that are started when patients are castrate sensitive, many men are living 10 years or more. That's a hell of a long time to live on ADT. These days it should be a part of the standard of care to offer lifetime ADT guys some relief with stimulants for the rather severe ADT side-effects.

Just some things to consider as you move into the next phase of your treatments.

Good luck!

Unfortunately, your case is serious. In addition to the very valid comments above, I would want to add that there are (clumps of) cancer cells floating through your body looking for a place to settle (and too small to see with currently available methods). You don't want to give them a chance to do so and grow. Hence, continued ADT is highly advisable.

Post Edited (Sr Sailor) : 8/3/2024 8:03:02 AM (GMT-8)