Intermittent ADT criteria and rules - Advanced Prostate...

Advanced Prostate Cancer

12,572 members15,250 posts

Intermittent ADT criteria and rules

diller
diller

I know from past posts here, and reading many articles and studies, that the criteria for starting and stopping intermittent ADT (IADT), or doing it at all, can be controversial. Those posts from a search I did here, have been read.

Sorry for rehashing the topic, but now the possibility of it is more real to me.

For example, the different criteria for starting it, as stated by various drs or studies varies a lot, ie:

- how long to have been on adt before starting iadt ?

- what the nadir psa should be before starting iadt ie some say, for those who have not had surgery but just imrt - <0.1 while some studies allowed higher numbers

- how long that nadir psa should have been at that level while on adt ?

- can one with metastases go on it at all OR can one with lymph node metastases go on it if imaging has shown it has not spread to bones ? or if one has spread to bones can they go on it also ?

====> Thus all I can do here is ask for your thoughts and opinions, as relates to my own situation ? I apologize for re-hashing the topic once again. Am considering it, my dr is not a gu medical oncologist and I won't be able to travel to see one, so my research becomes even more important.

====================================================

My history and situation:

a. gleason 7(4+3) multiple cores - 2010

b. imrt with 6 mos of ADT - 2011, no surgery or other treatments done

c. psa starts rising past 0.2 - 2015

d. psa gets to 4.5 and axumin scan done - July, 2017

e. axumin scan shows spread to various pelvic lymph nodes and a bit further up

(para-aortic). It does not see any bone issue.

f. several radiation oncologists felt that imrt to pelvic area and above

would carry too much risk to other organs and advised just ADT.

(even though original imrt did not radiate the pelvic area)

g. ADT started - August, 2017 - is only lupron and not ADT 2 or 3

h. psa was 0.3 for a few months, then as of 2/2018, 0.2, 4/2018 was 0.2

Testosterone has been <3 (don't know if thats the labs lower limit or not)

(next psa and T labs will happen soon and of course I realize those results

might have an impact on this sitution)

i. age 71

j. ADT side effects as per labs show some anemia, some elevation of LDL, and

can only assume the other effects related to bones and muscle and other things

are happening but have no way to know at this time

==================================================

===> thus am asking for your feedback on IADT in general and for my situation

and especially related to being metastatic

and your feedback on your own experiences on it.

My dr encourages me to do this research, and understands as a community oncologist that this research is even more important for me, and I am not able to travel to see the pca experts.

And in case this makes a difference, am on ADT 1 only and dr institution not believe in adt 2 or adt 3 - just mentioning this as a fact, not wanting to revive any discussions about that.

PS

researchtopractice.com/COCP...

shows many drs interviewed do not recommend it if metastatic

but unlike some other studies, they did not differentiate between far and near metastases.

Sorry for such a long post, I didn't intend it be so long.

17 Replies

I think I responded to you on Healingwell. No one has to be on ADT at all before starting iADT. iADT starts with a limited cycle of ADT ("on cycle"). At some point, you take an ADT vacation ("off cycle"). You continue to cycle on and off until castration resistance sets in. They usually want to see a nadir PSA of 4 or less while on cycle. It is more problematic in men staged M1, according to the Hussain study.

Personally, I would want to have an undetectable PSA for at least a year before attempting IADT, or taking a vacation. I believe in ADT 2,3,4,5,6--minimal---> is IMO ADT 3 while trying to get to a nadir of undetectable--then staying undetectable for a year. Important is to know your pathology report--looking specifically for any reference to undifferentiated Pca cells. Having these may lead later to Neuroendrocrine Pca cells---where PSA is of no use as an excellent diagnostic tool.

Reason for long term undetectability as to PSA--is because some Cancer cells[millions] are still there and we cannot detect them by PSA tests or any scan, when undetectable. These cells are going thru a Dormancy cycle[My Theory]. They will cycle from sleep---needing no sustenance, to awake, needing sustenance, allowing others to go to sleep--when in the awake cycle they can be killed, while on ADT, and having a high level of anti-inflammatory drugs and supplements, on board, to prevent messenger RNA to encode the making of certain proteins that the cancer cells need to get up and go and start dividing their nucleus', keeps the cancer cells in a state of numerical decline.

So that is why many MO's like Dr. Snuffy Meyers and others including my MO who is head of Prostate Cancer Research at a Center of Excellence---take the long term view of undetectability--before starting a Vacation--be it long term or IADT. And other experts in Urology and Hormone study like Dr. Zeligs, the inventor of Bioresponse DIM[ADT 5] take the view of controlling DHT and E2, thru the process of getting to undetectability, while undetectable, and on Vacation. Some do not proscribe to the fact that Pca cells love DHT and E2. So while on vacation as your T goes up so does your DHT and your E2---those of us like Meyers agree--do not let DHT and E2 rise as T goes up. Less food for the dormant cells we cannot see, as they come out of dormancy to feed, the better.

Now I just went thru a bunch of some might say S***. But IMO again--if you do not get to undetectability--even though you had metastatic evidence, and keep it long term; the likelihood of having an advantage is zero. The benefit while off is that you get relief from ADT for the time off, and the body does some healing--but OS remains the same, as I have been told more than once, by Doctors. As I am not one.

Nalakrats

Ran2599dy
Ran2599dy in reply to Nalakrats

Excellent Information - Thanks, you hit the nail on the head

How do you know if you have undifferentiated cells Nalakrats? Because I had IMRT+brachy I suppose there is no post treatment pathology to look at. Would the original biopsy tissue report be useful or not?

George

The original Biopsy report, or if Prostate was removed would indicate undifferentiated, cancer cells.

Nalakrats

My own opinion is based on solid evidence: I started with a gelason of 9, had radical prostatectomy and 40 days of radiation. After 4 years of ADT I went on the "ADT holiday for two years." A chance MRI revealed abnormal lymph nodes, and a follow-up PET with Axumin reveal three areas of mets, all areas with previous surgical experience. This happened with a PSA rising but just under 2.0.

My suggestion: have a discussion with your urologist about the results of the LATITUDE and STAMPEDE clinical trials.

I won’t comment on iadt but will just mention that Dr Dattoli in Sarasota treated my pelvic lymph nodes in 2015 without a problem and without recurrence . I stayed in Sarasota for a couple months. Don’t know why you can’t travel but if possible you should reconsider so you can go to the best for treatment.

I'll try to remember what Dr. Myers has said in his vlog posts. You can always search for them ("askdrmyers").

How long on ADT before beginning ADT? Myers has said that the aim was to get PSA undetectible within 12 months. In his opinion, much shorter periods result in brief off-phases.

His approach - ADT with additional therapies - was intended to lead to a sustained off-phase. This was very important to him since one only gets 2-3 cycles before CRPC.

I have heard a doctor say that ADT should be continuous if there are mets, but that was not Myers' view:

askdrmyers.wordpress.com/20...

He has a series of vlog posts on durable remission which, naturally, touch on IADT.

-Patrick

Thanks to all for their posts, and its important information, and will reply soon.

But want to ask something that I realize I've not understood, in context of discussing nadir psa while on adt -

- about what the expected psa nadir we want to see while on ADT

---> for those who have not had surgery but just radiation, is it even possible

or realistic for their psa while on ADT, to go to the ultrasentive range or might their psa often be higher just cause they still have a prostate ?

(am referring to ADT 1, not 2 or 3 here only cause thats what I am on)

Thanks - and will reply to the important info re iadt you have shared.

break60 - can't travel due to being caregiver to my wife - i was gonna send my info

to dattoli since they wanted to see it and then have the phone call, but in the

meantime had 2nd opinions locally - one from a medical corp and one from a nccn

univ, though not one of the top ones as to pca - if pelvic imrt would be wise to do.

Both said that even though original imrt had not done pelvic area,that they felt

the potential side effects of going up higher than pelvic (to para-aortic)

could lead to some serious side effects, and that if not doing full area,

would not help since not getting it all - and both advised to just do adt.

one said that in any case, since imaging can only see so much, that the horse was probably out of the barn anyway, that is, it was spreading elsewhere in any case

as another reason why no guarantee that this imrt would even be successful

if it were done.

thus thats why did not followup with dattoli to even hear their thoughts on this.

pjoshea,

re your comments - thanks for them, and some followup embedded below:

How long on ADT before beginning ADT? Myers has said that the aim was to get PSA undetectible within 12 months. In his opinion, much shorter periods result in brief off-phases.

>>> I guess that goes to my question in a reply today where I wondered what undetectable meant for one who had not had surgery, and will look into this

His approach - ADT with additional therapies - was intended to lead to a sustained off-phase. This was very important to him since one only gets 2-3 cycles before CRPC.

>>> I think Meyers uses ADT2 or 3 and other things - I don't know how much using those during the off-phase would improve the off-phase (at least am assuming he had people use those other things during the off-phase ?)

I have heard a doctor say that ADT should be continuous if there are mets, but that was not Myers' view:

askdrmyers.wordpress.com/20...

>>> I didn't hear him mention mets in that video but video was quite interesting re him elaborating the side effects he was most concerned about - the cardio, kidneys, insulin resistance, etc

video was in 2010, don't know if more recent studies re iadt vs cadt would have impacted his thinking like the Hussein one in 2012 or a related that said that heart issues were more in iadt vs cadt.

tallguy2 - thanks for your comments, ie

My own opinion is based on solid evidence: I started with a gelason of 9, had radical prostatectomy and 40 days of radiation. After 4 years of ADT I went on the "ADT holiday for two years." A chance MRI revealed abnormal lymph nodes, and a follow-up PET with Axumin reveal three areas of mets, all areas with previous surgical experience. This happened with a PSA rising but just under 2.0.

>>> just to make sure i understand - you are saying that during the iadt period was when the mets became visible, since they had not been visible post surgery ?

and thus the iadt was not the right choice to do since these mets developed during the time when on iadt, even though the psa still <2.0 and am assuming the trigger to restart adt would have been > 2.0, like 5 or 10 ?

>>> thus am assuming that even if one on iadt, that imaging should be done as soon as

rising psa is high enough so that imaging can be done with a chance of high accuracy

but am also assuming your experience is that iadt was not the best thing to do in any case ?

(sorry if I am misunderstanding anything you said)

nalakrats - thanks for your comments

although the details you give are way beyond my understanding, I think that the message here is that the doctors you mention feel that its very important for the psa to be at an undetectable value for a year, and I realize that just this criteria itself might be controversial re other doctors re your comment later on in your post.

but in any case seems that the nadir psa is important to begin with - its just defining it and should that be same for those who just had radiation, and then also the how long at nadir question - ok my head is spinning now once again.

As to about OS being no different re iadt or cadt, I do understand that, at least from reading as best I could various studies, where some say iadt as good as or equivalent where others use the words not inferior to, whatever that means.

Hidden
Hidden

I think you should consider staying on ADT. If you want to do kind of iADT, then explore supplemental T shots. You get tighter control of your T levels in the blood this way. and don't have to guess on where your testes are in the production of Testosterone.

I would even consider orchiectomy, and then maybe supplemental T shots when you need relief from low T. Could even be cheaper.

There seems to be a logic in using T prior to any chemo, but I have not seen any studies on this, and do not know what the realities are on this possibility. Murky and involved.

Martin, thanks for the reply.

You mention my considering to stay on ADT - is that due in your opinion to that there are the mets,

and/or that psa was not low enough or for a long enough amount of time or something else ?

(am not challenging anything here, just asking for more data and opinions in this post)

IAlso, s the supplemental T shots related to the BAT approach, where they give T shots sometimes and then sometimes ADT, or something like that ? This is first I've read about T shots. And how would the T shots but having ADT which reduces the T - how does that work together ?

thnx for that link - researchtopractice.com - looks very useful, comparing several drs. on each topic - wonder how i missed it all these months.

your history looks similar to mine in some details: i'm also 71, PSA went from normal to 12.4 during 5-6 years while i was not monitoring it, then to 16.9, which forced me to succumb to biopsy, which im still not convinced is so accurate an indicator of anything anymore.

found GL 4+3, 60% GL 4, was put on bicalutamide and scheduled for IMRT which i cancelled, when informed (quite off-handedly) by my urologist, that some men choose ADT as a monotherapy instead of an adjunct to radiation.

there are several kinds of ADTs and chemos (hormones are chemical substances, but drs. insist hormone-based chemos should not be called chemo, only hormone. screw them, i say) so it's helpful to mention which ones you're referring to.

i'm not sure i can help you, brother, other than to wish you well and tell you you're not only in this battle.

Rich in reno

This is original poster - just to update re my post

after doing lots of research, and reading comments here, I realized iadt criteria could be controversial, esp re nadir psa, how long at nadir and especially if mets.

Talked with my MO (community MO) and they said they felt it ok to try it,

even that the psa was 0.1 for just 1 month (it had been 0.2 and 0.3 for the prev

10 months since adt started.

I asked about the mets and that axumin scan had seen them in pelvic area but said not in bones - and they said they had other men in similar situation on iadt.

(though as commented in another post, now have doubts about axumin scan report re the bones, since axumin was not fda approved for bones and no studies done then on that, though there are some starting now. thus don't know if report saying not in bones is just in context that axumin does not do bones.

(and medicare not cover Na F bone scans anymore, so it would be cash out of pocket)

Thus decided to try it, again knowing this is highly controversial and also goes against many comments just in this thread.

Now the stress shifts to how long psa will stay down and I guess how high the T goes back up, it was always high end though I never felt anything different cause of that and always wondered if the labs were mistaken.

Hopefully will be able to have bone scan again once psa gets higher, see comments above about axumin and na f scans.

Thanks again to all who responded.

You may also like...