First PSA Three Months After Starting... - Advanced Prostate...

Advanced Prostate Cancer

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First PSA Three Months After Starting ADT Vacation

dac500
dac500

Lupron + Casodex treatment for my lymph node metastases (multiple pelvic and abdomen nodes) was started in November 2018 with a PSA of 4.48. By November, 2019 the PSA dropped to 0.06, when on doctor's advice I started a vacation from ADT. Three months later my PSA is 0.07. My last 3-month Lupron was in September, 2019. I am still waiting for my Testosterone result. I suspect it is still in the castrate level. Previously, when I was on Lupron for six months, it took about six months for Testosterone to come above castration level.

Making allowance for statistical fluctuation, my PSA stayed at the lowest level over the last six months. It appears that my metastasis is still hormone sensitive. I expect my PSA to start rising over the next six months. I don't expect my quality of life improve significantly during ADT vacation. How much should I let PSA rise before starting ADT again?

PSA History: Nov 18: 4.48 (start of ADT + Casodex), Feb 19: 0.17, May 19: 0.10, Sept 19: 0.07, Nov 19: 0.06 (start of ADT vacation), Feb 20: 0.07

29 Replies
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If you are asking this group questions like that I suggest you find a new oncologist. Lupron with your amount of disease is minimum of 18 months and some think more. Mine just changed me from 24 to 18 but it’s new. 1 year is short. Where are you being treated?

dac500
dac500 in reply to carlo8686

My initial treatment was brachytherapy in 2011 for Gleason 3 + 3 diagnosis. Then in 2016-17 I had cyberknife + 9 months ADT for extra capsular recurrence. In October 2018, PSMA PET/CT scan found lymph node metastasis (confirmed by a lymph node biopsy). I started Lupron + Casodex in November 2018.

Doctor gave me the option of going on vacation. I suppose, if I want to go back to ADT, he would agree. I wouldn't probably let my PSA go too high. Even a rise to 1.0 will trigger my decision to go back and stay on indefinitely.

carlo8686
carlo8686 in reply to dac500

Just seems like there should be an exact plan with all the cases they see year after year. I just started my first vacation. Wasn’t given an exact psa but mine never was high. 4 tops. Just read Nalakrats post to you. That sounds like a plan. I do want a psma scan but doesn’t sound like I should let it go that high. Another step.

Schwah
Schwah in reply to carlo8686

Agreed. My MO also advised 18-24 months and I did 21 months. Which is like 24 since it took about 6 months for any rise in my testosterone

Schwah

We have different situations, as we are not using the same drug combination when not on vacation. You have had Lymph Node Invasion. I have not. I am on a vacation for this year, and into it by 70 days and my T is already up to 220, as of today. My T recovers faster because I use the Vantas Implant for my Primary ADT. My 2018 Vacation, I got as high as 700+, in 6 months and I am 76 years old. I have already packed on an inch on my biceps in the gym, this past 70 days.

As to when to return to ADT, I wrote a Post on this subject, from a European Paper, for vacationers. What this study determined, that when on vacation, and doing PSA's every 30 days---that when you have 3 consecutive months of a rise in the 2nd decimal point of the PSA--like .06---.07---.08----.09 this indicates Chemical Recurrence is very likely, in your future. So I would for me return to my Implant with Casodex. Some Docs. would want you to let it run so they can see it on a scan---where cancer is--so it might be zapped.

Nalakrats

dac500
dac500 in reply to Nalakrats

My initial treatment was brachytherapy for Gleason 3 + 3 diagnosis with cancer confined in the prostate. Then I had extra capsular recurrence in 2016-17, which was treated with cyberknife and 9 months of ADT. My PSA remained <0.1 and Testosterone at castration level until January 2018. Then it started rising with a PSADT < 2 months. PSMA PET/CT scan in October 2018 found lymph node metastasis in multiple pelvic and abdominal lymph nodes. I was on Lupron + casodex for one year and PSA went down to 0.06 in November 2019, when I started ADT vacation.

Nalakrats
Nalakrats in reply to dac500

Understood---as someone else opined, it is your deal. Have fun! We all need more FUN!

Nalakrats

That is entirely up to you - there are no rules. You are doing this to get a vacation from ADT, so I don't see any point in ending your vacation until you have enjoyed some normal T levels for at least some time. You can look at a variety of factors, including absolute PSA, PSADT, radiographic progression, and time with normal T.

dac500
dac500 in reply to Tall_Allen

Last time I was on ADT for nine months, my T took over a year, after end of ADT, to reach 300. By then I had lymph node metastasis. If QoL is not a big factor, would it be advisable to go back to ADT earlier?

Tall_Allen
Tall_Allen in reply to dac500

If QOL is not a big factor, there is no reason to do intermittent ADT. Why not just stay on it continuously?

Schwah
Schwah in reply to Tall_Allen

Except for the fact that adt in and of itself has long term negative health impacts.

Schwah

Tall_Allen
Tall_Allen in reply to Schwah

Do you have any data showing that those long-term effects are lower with intermittent ADT?

Schwah
Schwah in reply to Tall_Allen

I’m not sure that type of data is needed to reasonably make that conclusion. There are studies that show long term use of ADT is detrimental to your health in ways unrelated to PC. So lesser use of a drug that is shown to be detrimental to your health would logically be less detrimental. I don’t need a study to conclude that anymore than I need a study to show less use of cigarettes, or less exposure to asbestos, or less exposure to any outside element shown to be detrimental to one’s health should be less detrimental. Now of course a double blind study could prove me wrong. But you must admit the odds are against it. If you were in Vegas making a bet on whether IADT is less detrimental to one’s health (aside from PC) or the same, which way would you bet?

With lots of questions still unresolved in all things PC, many of us must make logical decisions based upon the information we do have at hand.

I welcome your always thoughtful response.

Schwah

Tall_Allen
Tall_Allen in reply to Schwah

ADT is not cigarette smoking, and "logic" is not a valid way of doing science - only empirical observation is. I can easily hypothesize that the breaks one gets from intermittent ADT are insufficient to reverse those long-term effects (let's say, on BMD) and that intermittent use leads to the same BMD outcomes as continuous use. We know that QOL is no different on most measures.

We saw a similar thing with testosterone - above some low level, all the androgen receptors are saturated and adding more T doesn't lead to more AR activation.

I've noticed that some people on this forum are suprised to learn that castration resistance occurs at exactly the same time whether one is on intermittent or continuous ADT, and that survival is exactly the same (except in men with low volume metastases in whom continuous ADT leads to longer survival).

dac500
dac500 in reply to Tall_Allen

One of the reasons my MO gave me for taking a ADT vacation is that it might delay becoming castrate resistant. Recently, I read an article on adaptive treatment of prostate cancer that mentions the same thing (ncbi.nlm.nih.gov/pmc/articl...). While I have read a few articles that agree with what TA says. So, I am little bit confused.

Tall_Allen
Tall_Allen in reply to dac500

Not all "evidence" is of the same quality.

In your link, only 11 patients have been on the trial for more than 10 months, and with only historical controls. The authors are only putting forth a hypothesis - they write: "While favorable, our results should be viewed with caution. The application of this strategy to mCRPC will require further study in larger clinical trials. " You should take them at their word.

Larger clinical trials with much longer follow-up have demonstrated equivalent times to CRPC and death. From the Hussain trial (n=1535; median f/u 10 years):

"Median survival was 5.8 years in the continuous-therapy group and 5.1 years in the intermittent-therapy group. Intermittent therapy was associated with better erectile function and mental health at month 3 but not thereafter. There were no significant differences between the groups in the number of treatment-related high-grade adverse events."

Figure S-5 shows that the median time to castration resistance was 2.2 years in the iADT group and 2.6 years in the cADT group. The authors attribute the 4-month difference to an artifact of the study design. Clearly, there was no advantage in time to castration resistance or survival conferred by intermittent ADT.

nejm.org/doi/full/10.1056/N...

The only valid reason for iADT is temporary QOL improvement.

dac500
dac500 in reply to Tall_Allen

My metastasis developed after brachytherapy after initial diagnosis and cyberknife treatment after extra-capsular recurrence. I suppose PSA of 4.48 at the start of current treatment doesn't indicate high volume metastasis. Perhaps I shouldn't have agreed to a vacation from ADT. But since I have started a vacation, I want to see it through the next three to six months. In June, I may have to go for some imaging. Let's we what happens to my PSA and Testosterone by that time.

carlo8686
carlo8686 in reply to Tall_Allen

I’m a month off Zytiga and lupron and am feeling great compared to being on the drugs. If you had to guess or maybe you know stopping which drug made the most difference? I was told the lupron would be active for another 3 months. Boy I feel better.

Tall_Allen
Tall_Allen in reply to carlo8686

I would guess the Zytiga had worse side effects.

carlo8686
carlo8686 in reply to Tall_Allen

i felt better (awake) within week or so of being off Zytiga. You mentioned in a response to someone about the disease moving forward toward metastasis while on vacation. Can you explain again?

I've read about vacations and asked my Oncologist about it, he said it would likely be the end of me as he thinks my PSA would just spiral out of control, in other words, not a good idea for me.

carlo8686
carlo8686 in reply to Zetabow

What is your situation if you don’t mind saying. I’m making the same decision. My doctors have recommended the intermittent method. Mine was Gleason 8 t4 tumor out of the prostate.

carlo8686
carlo8686 in reply to Zetabow

I’ve got to read on before asking questions that have already been answered. Thanks for sharing.

I'm not criticizing what anyone is doing. Everyone is different (or no one is the same). I see my treatment decisions as forks in the road and I have to keep deciding which direction to go when I get to each fork. My doctors share their wisdom and give me advice but I still decide which way to go. What I read on this forum also helps with those decisions.

I'm always rooting for everyone who goes on a vacation (that they enjoy it and it's the right decision for them). For me I'm 26-months into this and I don't ever see myself letting up on my treatment for a vacation. Like Zetabow's Oncologist, I think my cancer will take off and I won't be able to beat it back down. It's not worth taking the chance.

Zetabow
Zetabow in reply to Joes-dad

I was 1386 PSA, Gleason 9 with Mets to every bone. Combined Chemo and ADT got the PSA down to 0.028 pretty fast and it's stayed steady for 7-8 months, so I asked about the holiday and he explained why it wasn't a good idea and I trusted his advice.

9 months and PSA is climbing again, will likely start Radium 223 in the Spring.

We're not all the same and your MO knows better than anyone here the state of your PC and what it might do next. I get most of my questions for him on this site and why I find this site useful to me, he at least knows I'm researching my options and not just blindly following him. He has been very open with me and I've always been satisfied with the answers he gives, I have a good level of trust with him and all the Doctors in this Hospital looking after me.

I couldn't imagine the stress if you had a Doctor you lost trust in, I've read a couple of horror stories of Oncologists with poor bedside manner.

Joes-dad
Joes-dad in reply to Zetabow

Well said...

If casodex is still working why the vacation? I don't think that makes sense.

There are different protocols for restarting ADT. My MO uses PSA 4.0

I'm surprised to know that there is a doctor out there somewhere who leaves the trigger event up to the patient! I can tell you with great certainty that my MO would NEVER ask me when I wanted to get started again.

Even if you have no QoL issues (which is extremely rare; I'm thrilled for you), you should use IADT to reduce bone loss, CVS damage and the rest, and to postpone CRPC.

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