18 Months ADT represents a new standard of care for HRPC

I saw my RO yesterday and had my blood work done and talked about how things are going. I was there also to get a Lupron shot which was supposed to be the next to last 4 month shot. As we talked she said that I probably didn't need to get my last shot as new studies say that 18 months is becoming the new standard for length of ADT for HRPC. I was surprised yet thrilled that yesterday was my last shot.

I'm very happy but also apprehensive about this great news. I hope this is correct. The few studies I have found state that the QOL outcome is much better and that the OS at 9.4 years was 62.4% for men receiving 36 months ADT vs 62.0% for those that received 18 months.

This is just another example of how fast treatments are changing as we go further out in time. It's like IMRT hyper-fractionation shortening the length of time for RT patients. These are two major changes in treatments that have already made a difference in the type of treatment I am receiving. Actually there's 3. There's adjvant chemo (Docetaxel) for HRPC with prostate confined patients that is becoming more and more popular.
Any way, it was a good appointment yesterday as my PSA came back at <0.01. It seems that every other test I get I loose the < sign , but who's complaining.

Battle On Brothers!

The Artistic One - Mark

Interesting.
There are studies that say, 6, 12, 18, 24, 32 months are best. Until the high levelclinical trials compare head to head, the standard here is substandard but rather comparative with bias at play.

But I think 18 months is probably reasonable. Yes standard of care is changing. When we were working on the AUA/ASTRO/SUO clinical guidelines for the treatment of localized prostate cancer the topic came up on using HT in various terms but it was off topic. The use of HT in localized prostate cancer was off topic except in primary radiation in high risk cases. And that too carried controversy and bias. To the point that proper word smithing of those relevant guidelines was needed.

www.auanet.org/guidelines/clinically-localized-prostate-cancer-new-(aua/astro/suo-guideline-2017)

Good luck on the future, Mark. So far so good it appears.

Tony

This is very much a judgment call. I think your doctor is referring to the Nabid study from 2013 that showed that 18 months of Casodex (bicalutamide) is equal in effectiveness to 36 months:

High-risk prostate cancer treated with pelvic radiotherapy and 36 versus 18 months of androgen blockade: Results of a phase III randomized study.


Not only was it limited to bicalutamide, but the radiation dose was only 70 Gy (80 Gy is the standard of care these days).

Since then, the DART 01/05 study compared 28 months of goserelin (similar to Lupron) to 4 months. They all started with 2 months of bicalutamide too, and everyone received 76-82 Gy of external beam radiation (3D-CRT)). The longer schedule made a significant difference for high risk patients but not for intermediate risk patients.

High-dose radiotherapy with short-term or long-term androgen deprivation in localised prostate cancer (DART01/05 GICOR): a randomised, controlled, phase 3 trial

So we are left with lots of questions about optimal timing when modern high-dose radiation is used and when the hormone therapy is a drug like Lupron. All we can say with certainty is that 4 months is too little. I think patients have to ask themselves what they are most comfortable with, given the trade off between side effects and the unknowns about efficacy.

I am a Myers patient of 9 years and he has told me one year of undetectable by ultrasensitive before holiday. This is for intermittent AFTER primary therapy

Good news Mark... 18 months was long enough for me. Slowly I am coming back to all man, all the time. Take care. -JR

TA-Thanks, that is definitely consistent with what we've heard from both Drs. Rettig and King...both of whom also acknowledged that there is no "magic determined length" and there's a bit of an educated guess and leap of faith involved in any choice.

I think you were the one (I could be wrong) you described a "too short" ADT length as being similar to not finishing a course of antibiotics...the cells left behind are the most virulent of the cancer cells. I guess I'm still trying to understand what good the post-radiation ADT is meant to accomplish (I understand that the ADT retards growth/spread, and that ADT also makes the cancer themselves more radiosensitive, but if there's no spread, once the radiation is complete, what is the function of the ADT at that point if it's not still meant to be cleaning up cells left behind?).

All of the doctors we've seen, without exception, have told my husband he really has to drop some weight. We're both thinking that if he can get off the ADT sooner and safely...it will be way easier for him to focus on his overall health, which might be more beneficial to long term cancer control than staying on Lupron for a longer course. I wonder if that is my reasonable brain though or just the part of me that wants his T back.

Hey Artist Mark...I just want to say I'm glad you're here still

What the headlines giveth, the fine print taketh away. Things are not always as certain as they seem. Look for cautionary statements regarding studies, and don't simply accept the apparent results as gospel.

To those who like to do so, please don't attack me for pointing out the words in one of the articles. I post this merely as a reminder that when making these choices it is important to assess both pros and cons.

From the second article:
"That conclusion, though, may be somewhat premature. Susan Halabi, PhD, of Duke University Medical Center in Durham, North Carolina, was the discussant for the session, and she pointed out that a non-significant test result from a superiority comparison cannot be used to establish similarity between the treatments. “The optimal duration of ADT for high-risk localized prostate cancer is not known, and remains a clinically important question.” (emphasis mine)

I watched the webcast of the panel discussion following Dr. Nabid's presentation again.

Dr. Nicholas Vogelzang was in the audience and made this remark regarding what Susan Halabi had said:

"I would say the quality of life in this case superseeds the potential negative effect of an 18 months vs. 36 months treatment. And I think the PSA relapse, higher rate of PSA relapse, [..], is related to testosterone induced recovery of normal prostate tissue. I do not think that men should fear that slight PSA rise. It does not translate into survival, it does not translate into increased risk of death. And I have seen too many people give lupron forever because of that PSA fear. So I applaud Dr. Nabid for taking that step to get us off the 36 months and into the 18 months period."

Dr. Nabid then said that they designed the study twenty years ago expecting that 18 months of ADT would result in a little bit reduced overall survival. So the patient could then decide if he would select a slightly higher chance of overall survival with 36 months of ADT versus quality of live with 18 months of ADT. However, the trial showed no difference between 18 and 36 months of ADT.