As the years of first-line ADT go by, I expect the day of initial castrate resistance most likely is drawing nigh. Seems to me BAT offers a possible way to delay that day, but I could use some input in surmounting the SOC views of my doctors (no long-term data, MI risk, etc.).
I have given them various studies and trials.
1. Is there anyone in the Midwest who is administering BAT, and who, by getting involved in my case, would probably be assurance enough for my doctors?
2. RCTs all seem to be for those already CR. Have I missed anything?
3. If my doctors are ok with BAT as long as they do not prescribe it themselves, is there an easy way to obtain a prescription for T-cypionate?
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cigafred
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1. Other than Denmeade's group at Johns Hopkins, I think Oliver Sartor (Tulane), and Michael Schweizer is doing it in Seattle per protocol for men who are mHSPC..
No RCTs for any situation, and the studies so far have been very small
My opinion is that the evidence for benefit so far is weak, and the danger is high. I don't think it should be done outside of a closely watched clinical trial.
There is a phase 2 BAT trial for CRMPC called COMBAT which combines BAT with a checkpoint inhibitor. Currently recruiting at Hopkins, Dana Farber snd UCSF: clinicaltrials.gov/ct2/show...
The BAT studies we have seen so far remind me of something Samuel Johnson said ~250 years ago (apropos of something quite different): "... is like a dog's walking on his hind legs. It is not done well; but you are surprised to find it done at all.”
The idea that BAT might resensitize mCRPC men to ADT seems to me to be clutching at straws. And yet BAT does work for a few. Cigafred has a better idea, which is to delay CRPC with BAT, & one would expect a better response in terms of time to CRPC. Better still, IMO, would be to use BAT from the start of ADT.
I would think the easiest way to obtain a prescription for T-cypionate would be via a urologist or other doc who specializes in TRT, since ADT results in the hypogonadism that is the medical justification for TRT. You have a medical condition for which T-cypionate is commonly prescribed!
While for decades it was unheard of to give T to a man with PC, I guess we can now say it is "heard of." Abe Morgenthaler (a urologist who specializes in TRT) started doing it mostly for men desperate for QoL benefits. He was not trying to treat cancer, but mostly to treat "cancer treatment." His results along with other research mean that TRT is no longer automatically contraindicated for PC patients by all docs. So of all the docs who treat low-T, you will surely find some willing to prescribe T for a man with PC.
The question is, what is the "right" T-level to shoot for, and for how long, for a man with PC? The willingness of one of these docs to prescribe does not mean he has any protocol to follow. So if your docs are "okay with BAT" does that mean THEY will design a protocol, or will you design it yourself with other input?
The only MO of note (to my knowledge) that started using it outside clinical trials as a routine follow-up to ADT/chemo was Bob Liebowitz (Compassionate Oncology), and that wouldn't really be considered a BAT protocol since his approach was just to keep patients on high-T, indefinitely, after a single 13-mo course of ADT/chemo.
The idea of just going off ADT and staying on high-T therapy sure has a lot of appeal, but not a lot of science or study to support it as a low-risk venture!
My approach 15 years ago was to search for an integrative medicine doc who was OK with the idea of incorporating T into my protocol. I did this by email & found someone right away. He prescribes my T-cyp, although my urologist subsequently offered to do so too.
Prior to that, I was told about someone in Cyprus who would send T if you stated that you did not have PCa. US customs were intercepting T shipped from Mexico, although one could obtain the shipment by stating that it was for personal use. The folks in Cyprus were shipping via a third country where interception was unlikely.
But more recently, when every middle-aged man in the country seemed to want T, internet sites appeared that got around the prescription problem. Anyone who wants it can find a way.
A word of caution. I switched to something very close to BAT in 2018 & belatedly discovered that the 28-day cycle did not give me any meaningful time on ADT. For over a year, I have been on a 2-month cycle which keeps my mets in check.
So , is your approach -- BAT on a 2 months cycle ? 2 months aaADT and 2 months high dose T from the start of taking ADT ? second question - Do you have any mets ?
I wonder if using the new pill form of ADT every 2 months would be safer than DES. Also the new pill form shuts T off and lets it back in really quick.
I think that aging men would probably want to limit office visits in these COVID times, so an oral form is attractive.
However, new drugs are expensive. My last shipment of 90 x 2mg DES cost less than $50 (including shipping).
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"The estrogenic effect of diethylstilbesterol protects one from bone resorption. Patients on diethylstilbesterol did not have any higher levels of bone breakdown than patients with benign prostatic hyperplasia or those who never received any androgen deprivation.
"Conclusions: Rapid bone turnover and resorption can be prevented with 1 mg. diethylstilbesterol alone or in conjunction with other modes of androgen deprivation. Therefore, diethylstilbesterol should be considered as monotherpy in men who require long-term antiandrogen therapy."
Hi Patrick, We have been considering BAT while hormone sensitive and were also thinking along the lines of 1 week T every two months. We will be discussing with our oncologist next vist. My husband is on Trelstar and Zytiga. I see you use DES. Do you find T is castrate again by the end of the month? Did you ever consider Casodex or another receptor blocker to get the shock of the sudden high T with a quick "removal" after a week? Thank you.
I once used a product that brought my PSA down to near zero after 3 months. I never measured low T - I didn't feel that I needed to. I felt pretty good throughout the 3 months. (& then I was back on T for 3 months. I repeated this for a number of years.)
With 2 mg DES & a 2-month BAT cycle, I feel profoundly castrate throughout the second month. Quite different from what I have experienced before. Some brain fog, etc. I may go back to 1 mg which I tolerated more.
I have not left the house in 4 months & am disinclined to visit LabCorp for a blood draw. At some point I will venture out. I am going to need some positive feedback before the year ends. LOL
When I was on the 1 month BAT cycle with 1 mg DES, I developed leg pain. Nothing showed up on a bone scan & I was refused an MRI. Eventually, a second bone scan showed the tiniest pinprick of white at S1. After many months of pain, my leg felt normal by the latter part of the first 2-month cycle using 2 mg DES. So leg pain is now my canary in the mine.
I never considered an antiandrogen.
With the Denmeade protocol, T is above 1,000 ng/dL at the start & slowly declines. I know from the past that with 0.4 mL (100 mg/mL) T-cyp, I am still above 1,000 ng/dL seven days later. Denmeade uses five times as much T-cyp, because he wants T above 2,000 ng/dL. That's a lot of T-cyp, and it lingers.
With T patches, e.g. 4 mg Androderm, one could use 3-4 patches, say, a day for 7 days and T would rapidly clear thereafter. This abrupt shift to castrate would be better IMO. The advantage lies in the shock effect, I believe.
But this is a quibble, since insurance clamped down on my use of Androderm 5 years ago. It is quite expensive and I was on it a long time.
Hi Patrick, Thank you for sharing these details. If we decide to use BAT as part of our strategy we would want to have the burst and then shut it down after a week or two and go with the shock effect. Since my husband has several mets (in remission on ADT), we are hesitant to let it diminish over a month (or longer) to castrate levels, hense the thought about a receptor blocker. Alternatively, perhaps T-enanthate would be a better option as an injectable since it clears so fater than T-cypionate (half-life of 4.5 days vs 8 days). I am doubtful we could get insurance to cover it, so compounded propionate or troche would also be on the table for us. Androderm probably further down on the list due to cost and number of patches. Warmly, Shanti
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Thanks Patrick.
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