Lupron - 18 months vs 24 months

[boness]

Husband just finished 18 months on Lupron. He has appointments next week for PSA testing and his three month Lupron shot. Prior two PSA readings were below 0.05. His medical oncologist at Sloan Kettering initially wanted him to stay on it for only a year, but radiation oncologist insisted on two years. He just received a message from the medical oncologist saying he is stopping the Lupron! No explanation. Doc's response to message back asking why the change in plan is "the range is 18 to 24 months on Lupron. He is fine with either." Huh? Thoughts?

[LearnAll]

With PSA coming down to 0.05...18 months is more than enough IMO. Too long ADT increases the risk of early castration resistance.

[DarkEnergy in reply to LearnAll]

"Too long ADT increases the risk of early castration resistance.", is there a study that compares "Too Long" vs "Too Short"?

[Tall_Allen]

You didn't provide enough info to address your question. You are posting on an advanced prostate cancer forum, so I assume he has been diagnosed as metastatic? If so, how many metastases and where are they (in his bones?)? Have they treated his prostate - surgery or radiation or both? If the number of metastases is small, continuous rather than intermittent Lupron may be preferable. It is unusual to set just a time limit for Lupron in such cases.

[boness in reply to Tall_Allen]

Diagnosed Dec 2016. Gleason score evaluated three times from different cancer centers - 7, 9, 7. Docs went with Gleason 7. Seeds and radiation. No surgery. PSA continued to rise to 28. Axumim scan showed pelvic lymph node cancer. Zapped the lymph nodes, then started Lupron and Zytiga Dec 2018. Thanks you. We're struggling with the decision.

[Tall_Allen in reply to boness]

Thanks, that helps a lot. You said "zapped the lymph nodes," which I assume means zapped the entire pelvic LN area. OK- so, in conjunction with that radiation, ADT has to be long term - 2-3 years- to clean out all the cancer still floating around down there.

prostatecancer.news/2017/12...

But maybe you can get away with less because of the Zytiga.

[MateoBeach in reply to Tall_Allen]

Thank you Allen. I too am sorting this issue out for myself.

Reviewing case: T3b N0M0 in 20007 Gleason 4+3 PSA 4: RARP, + margins and SVI.

Docetaxel 6 cycles the prostate fossa SRT. BCR 2 years later PSADT < 3 months. Provenge w 6mo ADT. when PSA hit 5.0 started Casodex w/ dutasteride (intollerant of Eligard). That failed in 2019 and stopped those. (PSA .25 & rising in 2019).

Ga-PSMA PET in Aug 19 showed 2 PLNs in left pelvis no other lesions.

Had left hemi-pelvic LNRT with boost to the two nodes. 6 months ADT (dugarelix + estradiol patches). PSA dropped from .25 pre RT to .135 post and has continued to bounce in that area (.185 max 3 mo post) and now trending down at .128. This, even as my T levels slowly increasing from 11 to now 98.

Repeat PSMA scan at LA VAH 2 weeks ago with DCFPyL showed no new sites. One PLN was gone and the other appears smaller, irregular and the SUV max also down by half: from 7.5 to 3.8 (though comparing different ligands and isotopes).

So my question is about the expected time to nadir from PLN SRT. Can this be expected to be up to 2-3 years as with primary "whole" prostate treatment?

Secondly, (after reviewing your linked discussions), Does ADT with SRT and Oligometastatic PLN RT act by impairing the cancer cells ability to recover from the DNA damage and repopulate? And if so, should ADT theoretically be continued until all viable cells have attempted to divide and been unable to recover (nadir)? My cancer is apparently very slow-growing despite early PSADT of < 3mo.

I stopped my ADT at 6 months because I am considering a "compassionate use" treatment with Lu-PSMA-I&T combined with Veyonda (similar to LuPIN trial) and was advised that being off ADT may improve PSMA expression for the first such treatment. But now I have very little PSMA visible, one weak node and presumably micro-sites not visible ( below sensitivity threshold) on the scans.

[Tall_Allen in reply to MateoBeach]

Are you asking if ADT should be restarted now? Yes. You have to kill the cells you can't see. It does, as you say, finish off those cells sub-lethally killed by radiation (from pelvic RT and Lu-177), and it creates an abscopal effect (immune activation against cancer antigens). I can't predict how long it will take, but most would allow 2-3 years.

[DarkEnergy]

I've been diagnosed (09/18) PSA 1000+, with extensive mestatisis from pelvic to spine. In fact, a tumor from inside the prostate grew large enough to invade the bladder wall, causing severe pain during urination with blood in urine.

After just a few days of Casosdex, my symptoms rescinded, no pain or blood. Then a week afterwards started quarterly Lupron injections, soon followed with daily Zytiga 1000mg.

Current PSA <0.02...

So, my point, obviously my Prostate Cancer is very depended on Androgens, With many discussions, my Dana-Farber doc says ADT for life!

IMHO, ADT vacations are overrated, unless you can survive testosterone replacement therapy without progression.

Are all the prostate cancers the same, NO! But, know the risks, that's all I'm saying...

[timotur]

I don't believe there have been studies comparing 18 to 24 mos. If I remember, there were studies addressing 18 vs 36 and 6 vs 24 mos. The 18 mo regimen was clinically equivalent to 36 mos. The 24 mo was superior to 6 mos. So the thought is 18-24 mos on Lupron is the SoC for a nmHSPC patient as adjunctive to radiation or to treat a BCR after RP. I would lean toward 24 mos if high risk (>Gl 8 or Stg3/4), and 18 mos if lower-intermediate risk.

I'm at 14 mos on Lupron and stopping at 18 mos since PSA has been n/d the past seven mos. I started at high risk t3bN1M0 and PSA 29.

[DarkEnergy in reply to timotur]

So, you did RP? Thus, the whatever time interval to cease Lupron is in play.

Actually, forgot to mention I still have my Prostate, so a bit different with treatment strategies.

[timotur in reply to DarkEnergy]

I did HDR- BT + IMRT, and started Lupron two months prior to HDR-BT to shrink the tumor (see profile). I felt it was too late for RP since I was high risk +SV +LN. So I started Lupron in April '19 and will take the last monthly shot in September '20.

[Hawk56]

After surgery in March 2014. T2CNoMX, GS 8, ECE, SV and margins negative, 10% prostate involvement I had BCR 18 months later. SRT in March 16, that failed. With rapid PSADT and PSAV we went to Mayo in Jan 17 where C11 Choline scan showed four PLNs no bone or organ. PSA was 3.8

We decided on a regimen of 24 months of ADT, Lupron, six cycles of taxotere and 25 IMRT to the PLNs with boosts and wider margins around the 4 PLNs identified in the C11 Choline scan. PSA when we started was 4.8, so in less than a month had climbed considerable in terms of PSADT and PSAV,

With my response to treatment, we agreed to stop ADT at 18 months vice 24. We had discussed adding Zytiga but again decided not to given my response (PSA dropped to detectable with the first ADTA and taxotere treatments and stayed there, subsequent C11 Choline scans showed PLNSs clear).

Last treatment was May 18, by October T was at 135, by Feb 19 T was at 482. I have labs every 3-4 months, last one in May had PSA at .07.

There was not any specific studies about 18 vs 24 months through there were 18 vs 26 and 24 vs 6 but there is so much individuality in this disease. For Dr. Kwon and I we were comfortable with stopping ADT at 18 months and then actively monitoring.

I was prepared to go the 24 months but I was also aware of discussion about time on ADT and resistance so decided to reduce that risk.

You won't know until you decide but if you do, an active monitoring program is important along with an idea of what you will do if and when the PSA begins to climb. In my case it would be to get enough readings to determine PSADT and PSAV, image at a PSA level where it can reasonably be expected to locate the recurrence then based on the clinical data, determine treatment.

Fortunately, two years after finishing treatment, we have not had to do that.

Kevin

[bobdc6]

I did 18 months lupron plus casodex for my contained G 4+5. Finished Lupron on 1-19, when the 4 month shot timed out.

This was in conjunction with proton. So far, so good. PSA undetectable as of two months ago.

[RonnyBaby]

There is no consensus among MOs about ADT duration under certain circumstances.

18 or 24 ?

Some say that 2 years of continuous ADT may be 'too long' because the body will 'never' return to normal functioning of SOME components - in other words - a point of no return.

Some might want to err on the side of caution and do the 2 years - because it MIGHT be more effective than 18 months.

A bit of a pickle / judgement call.

In my case, I quit ADT pre-maturely (@ 16 mos) - my 'T' and PSA have recovered to within normal ranges - BUT a BCR is possible - we watch and wait as the numbers rise .....

[KJMinPhx]

I’m confused. From the title of this post to many of the posts, many people are talking about 18 vs 24 months of Lupron as if that is the choice. My MO at Mayo says stay on Lupron + Zytiga + p until it stops working, no vacations or stopping otherwise. Any studies on benefit of stopping early

[kensawyerwayland in reply to KJMinPhx]

I’ve been on Lupron 18 months. No side effects. After one year, raising psa led to radiation therapy, which was successful, as confirmed by latest scan, done because of another med, then treated with radiation again. I’m still on Lupron quarterly.

[Don_1213 in reply to KJMinPhx]

You're metastatic? In that case it's a different scenario. The 18 vs 24 or 18 vs 36 scenarios are where men are not metastatic, and are using radiation therapy as their primary therapy. Generally IMRT. The ADT/Lupron is believed to weaken the cancer cells making them more sensitive to the radiation. It is also believed that any circulating cells are also starved to death by the loss of testosterone - lessening the chance of future metastasis. In many cases this treatments goal is to "cure" the cancer by killing all of it via radiation and starvation.

People who are metastatic - especially with multiple sites that can't be treated with radiation are often treated to control the cancer - trying to limit it's spread and even shrink the existing cancer. ADT/Lupron does this quite well - until if/or/when the cancer mutates to one that doesn't rely on testosterone for food. In these cases - the prescription for Lupron and other ADT agents is often for life.

[j-o-h-n]

Ok boneSS tell us more: location? age? scores psa/gleason? treatments to date? Doctor's name(s) at MSKcc? Thank you!!! All info is voluntary but it helps us help you and helps us too.

Good Luck, Good Health and Good Humor.

j-o-h-n Sunday 06/14/2020 4:56 PM DST

[boness in reply to j-o-h-n]

Hi John. Prostate cancer found in Dec 2016 (age 64 at that time) both lobes. PSA was 8. Gleason score was 3+4 (MSK), second opinion was 4+5 (Johns Hopkins), third opinion was 3+4 (Yale). Radiation oncologist made the decision not to use Lupron at that time as scans didn't show any spread. Seeds and 25 radiation treatments. Several months later PSA up to 28. Aximum scan showed three spots on pelvic lymph nodes. Started Lupron, Zytiga and prednisone December 2018 followed by 25 radiation treatments again. PSA slowly went down to 0.05 nine months ago and then <.05 last two PSA tests. MO was concerned PSA went down slower than he liked. The side effects so far have been tolerable, but no one wants to be on these meds longer than they have to.

[j-o-h-n in reply to boness]

Thank you for that quick and detailed reply. I happen to be a "customer" of MSK in NYC. MY MO is Dr. Michael Morris. It may be a good idea to copy and paste your above bio on your home page (under your userID) for future reference by you and by members. I agree that no one want to be on these meds longer than they have to. Keep fighting there boness.. As they used to say "see ya in the movies"....

Good Luck, Good Health and Good Humor.

j-o-h-n Monday 06/15/2020 9:55 AM DST

[db1966]

I have been on Lupron since December 2015 with Zytiga also.

[TEBozo in reply to db1966]

continuously?

[Don_1213]

There was a study done in Canada - a well regarded study - comparing the outcome of 18 months of ADT vs 36 months of ADT. The conclusion was "18 months was not found inferior in results to 36 months.." and the primary lead on the study made a comment about why torture men with an excessive length of ADT, when what it's going to do is done by less.

The length of time to stay on Lupron was first determined by comparing 6 months treatment to 36 months treatment for high-risk patients following radiation treatment. 36 months was found to be superior to 6 months. 36 months became the "standard of care". A few years later another study was done with 24 months and 36 months. The results were found to be equal. Finally - last year 18 months and 36 months were compared. The current standard of care for radiation/ADT is 18 months.

medscape.com/viewarticle/90...

[boness in reply to Don_1213]

Thank you.

[Horse12888]

The studies that show 18 mos ADT is not inferior to 36 mos in the adjuvant setting make it impossible for me to imagine why any doctor would suggest > 18 mos (or why any educated patient would accept that suggestion). I would think this would be simple malpractice.

What happens in the case of a recurrence is another matter, but again, the studies that show that intermittent ADT is not inferior to continuous make it hard to understand why any doctor/patient would not choose IADT.

Where this becomes more interesting is factoring in the patient's capacity to tolerate the SEs. I was stunned to learn that there are people who don't experience any, but there are people on the other end who commit suicide because they can't stand living like that. I was far closer to the latter than the former. ADT had rendered by physically and emotion so miserable that it was only the presence of loved ones that kept me from blowing my brains out.

I'm surprised that this issue of QoL doesn't seem to figure into the equation of ADT prescriptions. If I were my doctor, I'm sure I would say, "Look, there are treatment options that aren't FDA approved, any may represent some level of risk, but given that you have zero QoL on ADT, I want you to read up on high-dose transdermal estradiol and bipolar ADT and then we'll work out something that doesn't make you wish you were dead."

[boness in reply to Horse12888]

I’m trying to get educated. That’s why I posted here.

[TEBozo]

My understanding is that there has been a study indicating that 18 months is the optimal time period and that 24 provides no additional benefits. I get to stop in August!!!

[Enshope]

Hi, Husband and I are trying to decide whether he stops Zoladex after a 19 month duration or continue with two more injections. Was Gleason 8 and had IMRT for 40 sessions, and began ADT in the beginning. Testing showed that the cancer was all enclosed within the prostate, nothing in seminal vessels or outside the walls. His PSA was last tested at undetectable. He hates the effects of the ADT...has become pre diabetic and now with Osteoporosis, horrible hot flashes and weight gain. He tried to keep exercising but has so much fatigue. Age 77 in the spring. We have read conflicting reports and doctors offer no advice so where do we find help in deciding about this? On one hand, we worry about resistance developing with longer use, against the possibility of recurrence if we stop too soon. It is like the devil if you do and the devil if you don't! If there are recent studies, we would like to read them.