First PSA Three Months After Starting ADT Vacation

[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

[6357axbz]

2.0

[Hidden]

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 in reply to Hidden]

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.

[Hidden 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 in reply to Hidden]

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

[dac500]

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.

[Tall_Allen]

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 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 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 in reply to Tall_Allen]

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

Schwah

[Tall_Allen in reply to Schwah]

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

[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 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 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 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 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.

[Hidden 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 in reply to Hidden]

I would guess the Zytiga had worse side effects.

[Hidden 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?

[Zetabow]

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.

[Hidden 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.

[Hidden in reply to Zetabow]

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

[Joes-dad]

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 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 in reply to Zetabow]

Well said...

[Magnus1964]

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

[Horse12888]

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.

[Doseydoe]

Dac500, I've just read this old thread and as it's been a year or so, I was wondering if you would like to give us an update on your prognosis, thanks 😎 DD.

[dac500 in reply to Doseydoe]

I started an ADT vacation in November 2019. My PSA rose to 0.131 by May 2020 with T = 114 and to 0.453 with T = 147 in September 2020. I restarted ADT with Eligard and PSA dropped to 0.266 with T < 20 on November 30 2020. I am going for another PSA on Feb 26, 2021.

[Doseydoe]

Thanks dac, it must be a nerve racking decision when you see your PSA rising. Will you stay on ADT if your PSA drops even more? I've stopped having eligard and casodex and am monitoring my PSA as well. I'll find out how I'm fairing when I see my Oncologist on Friday. All the best, DD 😎

[dac500 in reply to Doseydoe]

I am planning to stay on ADT until my PSA is less than 0.01 for two three monthly reading. But I am more concerned that I may become castrate resistant.

[Doseydoe in reply to dac500]

Thanks dac. I'm not sure what I'll do. My previous PSA tests were 0.03, 0.02, 0.01 and yesterday's came in at 0.02 so happy with how it's trending. I'm seeing my MO tomorrow and will talk it over with him. I'm thinking small fluctuations is to be expected, however, I've read that if PSA doubles three times in a row then that's the trigger to consider returning to ADT. Everyone is different and so is there responses to treatment, good heath brother, cheers 🍻 😎 DD.