Current Studies on When to Start ADT ... - Advanced Prostate...

Advanced Prostate Cancer

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Current Studies on When to Start ADT after BCF

Researcher50
Researcher50

I am finding conflicting studies. Older ones said there was no difference in OS when starting ADT immediately after BCF reached following RT or waiting a couple of years However a recent study said that it was true for high risk, but intermediate risks showed better outcome if ADT started immediately. What's the best practice currently?

21 Replies
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This is what the guidelines recommend:

The NCCN guidelines: "Patients with an increasing PSA level and with no symptomatic or clinical evidence of cancer after definitive treatment present a therapeutic dilemma regarding the role of ADT. [......] Early ADT is acceptable, but an alternative is a close observation until progression of the cancer, at which time appropriate therapeutic options may be considered."

The European guidelines: "Do not routinely offer ADT to asymptomatic men with biochemical recurrence."

Researcher50
Researcher50 in reply to GP24

This is one of the studies that would seem to contradict. ascopubs.org/doi/abs/10.120...

However they based it on DT as opposed to risk level, so I don't know if applicable.

GP24
GP24 in reply to Researcher50

In my opinion there is no definitive answer whether you should do early ADT or start later when there is a biochemical recurrence after radiation. So you can just follow your gut instinct and nobody can prove whether this is right or wrong.

Some doctors recommend intermittent Casodex monotherapy in this case. The patient sees the PSA value decline and has very few side effects. This could be a compromise.

Researcher50
Researcher50 in reply to GP24

Thanks! The idea of a compromise is appealing, especially if you like to feel that you are "doing" something.

Attn Darryl: Neither OS nor BCF are in the PCa Abbreviation List.

This is controversial and very much an individual decision. The TOAD randomized clinical trial had only 5 years of follow-up so far and a fairly small sample size.There was a significantly lower rate of overall mortality among those who started ADT earlier.

thelancet.com/journals/lano...

They also followed up with a pooled analysis of quality of life, and found no difference:

urotoday.com/beyond-the-abs...

One of the more interesting findings (to me) was that 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.

Now, most of their participants had RP, not primary RT. Have you had an Axumin PET/CT?

Schwah
Schwah in reply to Tall_Allen

You say hormone resistance is “delayed In man who use immediate ADT.” Do you mean it’s delayed from the time they start using ADT or delayed overall?

Schwah

Tall_Allen
Tall_Allen in reply to Schwah

"The development of the castration-resistant phase occurred significantly earlier in the men who started treatment after a delay."

If I were in BCR again I would monitor the cancer with PSA measurements and periodic Ga 68 PSMA PET/CT. If metastases appear I would discuss about direct treatment if there are few and the treatment is possible. I will try to get Lu 177 PSMA treatment if there were many mets or the few mets were impossible to irradiate.

The longer one delays the use or ADT , chemo and the new anti androgens without significant progression of the cancer, it may be possible the longer the cancer will be hormone sensitive and the longer it will take for the cancer to mutate and become a disease impossible to control.

To wait until the CT and body scan shows something or the PSA is 6 to 10 or the PSADT is less than one year, it does not make sense to me when there are techniques which could make a very early diagnosis of the progression of the disease,one of the main criteria to start some form of treatment.

Researcher50
Researcher50 in reply to tango65

Meeting with urologist on Monday. Could you explain " techniques which could make a very early diagnosis of the progression of the disease", if you don't mean a scan or PSA or PSADT? which I thought were the ways to make early diagnosis?

tango65
tango65 in reply to Researcher50

The techniques are the PSMA PET/CT scans (Ga 68 or 18F DCFPyl). These scans have a good detection rate (better than any other PET/CT scan). depending on the PSA values:

40% for <0.5 ng/mL (n = 136)

60% for 0.5 to <1.0 ng/mL (n = 79)

85% for 1.0 to <5.0 ng/mL (n = 89)

97% for ≥5.0 ng/mL (n = 173)

These scans allow to make a very early diagnosis of disease progression. Once there is this evidence, one can plan an adequate treatment such as direct treatment of oligo metastases or systemic treatment with Lu 177 PSMA . The idea is to treat very early and to delay as much as possible using ADT, new antiandrogens and/or chemo.

There are some clinical trials for these scans:

clinicaltrials.gov/ct2/resu...

clinicaltrials.gov/ct2/resu...

Lu 177 PSMA treatment in this situation has to be obtained abroad (Europe or Australia) if they do agree to treat patients without ADT. They are treating hormone sensitive patients now. I got treated in Germany in 2016 and I was hormone sensitive.

By the way, you should consult with a medical oncologist specialized in prostate cancer and not with an urologist.

Tall_Allen
Tall_Allen in reply to tango65

Everything I've read says just the opposite. Do you have any evidence for your assertion that "The longer one delays the use or ADT , chemo and the new anti androgens without significant progression of the cancer, the longer the cancer will be hormone sensitive and the longer it will take for the cancer to mutate and become a disease impossible to control."

There is a great deal of mythology about this that you are perpetuating without proof. It leads to dangerous conclusions, like putting off ADT when it could extend life.

Vany4
Vany4 in reply to tango65

This is the exact path and situation my husband is on now. He’s not on ADT after psa started rising. And his drs are at Sloan Kettering. Glad to see agreement with this path we are taking. Psma scans, sbrt (2017) now seeking lu 177.

tango65
tango65 in reply to Vany4

Glad to know real doctors at a center of excellence for the treatment of PC are using this approach. This path is not my personal idea. It was proposed by my oncologist. I am becoming castration resistant, no metastases and he wants to delay treatment with new anti androgens as much as possible. I consulted about this in Southern California and at the Sloan Kettering Cancer center and they supported the plan. I am not proposing anything I was saying if I was with BCR again I would do this plan since it makes sense to me. Glad to know it also makes sense to Drs at the MSKCC. Difficult to believe that adenocarcinoma of the prostate is going to become castration resistant if testosterone is kept above 50.

Best of luck to your husband and please keep us posted.

Vany4
Vany4 in reply to tango65

We have not had good luck being accepted for Lu 177 at TUM in Munich because he’s still hormone sensitive. Bad Berka also believes it’s too soon. I’m working on finding another place. In the meantime, waiting to do another psma pet, but his dr wants us to wait until psa is 4 or 5 which seems scary to us

tango65
tango65 in reply to Vany4

Contact this center in Vienna:

minute-medical.com/en/contact/

This is the email of the doctor doing the Lu 177 PSMA treatments:

markus.hartenbach@meduniwien.ac.at

Some profile:

researchgate.net/profile/Ma...

minute-medical.com/en/news/...

Use chrome browser to translate the link:

meduniwien.ac.at/web/ueber-...

Please, let me know what happens.

Best of luck!!!

Vany4
Vany4 in reply to tango65

Thank you!

tango65
tango65 in reply to Vany4

Best of luck. Keep in touch.

Ok we need to research you.. Please post your age, location, psa and gleason scores, procedures to date, treatment location(s), Doctor's name(s). Post info on your home page so we may view it. It's all voluntary but it helps us help you and helps us too. Thank you.

Good Luck, Good Health and Good Humor.

j-o-h-n Friday 10/18/2019 6:17 PM DST

Researcher50
Researcher50 in reply to j-o-h-n

j-o-h-n, I am the designated family medical researcher, so will try to gather info you requested and post under my profile, especially if it will help in some way.

j-o-h-n
j-o-h-n in reply to Researcher50

Thank you, and it sure does....... I'm the designated Hysterian in my family...

Good Luck, Good Health and Good Humor.

j-o-h-n Saturday 10/19/2019 9:04 PM DST

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