ADT vs physical castration pros and c... - Advanced Prostate...

Advanced Prostate Cancer

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ADT vs physical castration pros and cons

Mascouche profile image
Mascouche

I understand that unlike a physical castration which cannot be undone , adt can be stopped.

But if someone has to be on ADT for life or chooses to be on it for life for fear of a recurrence of the cancer coming back or growing if it never enters remission, does a physical castration offer benefits?

Is the outcome from toxic drugs like Lupron (osteoporosis, high blood pressure, Parkinson, alzheimer, whatever else comes from long use of ADT) lessened by choosing physical castration?

24 Replies

Yes, there are benefits to physical castration. This thread will be particularly useful:

healthunlocked.com/advanced...

Personally, once you become "castrate resistant" - which for most of us is normally 2-3 years after diagnosis and ADT treatment, I see no point in keeping the testes.

For those with not-so-aggressive tumors and who are able to stave off "castrate resistance", there is the possibility of taking ADT vacations.

I had mine removed two days ago. Easy procedure. No regrets.

Mascouche profile image
Mascouche in reply to Pleroma

Not sure I understand what you mean. If your cancer becomes castration resistant, then what is the point of getting castrated since it won't help you control your cancer anymore. I would consider undergoing physical castration because the cancer is sensitive to testosterone, not once it is castration resistant. What am I missing?

noahware profile image
noahware in reply to Mascouche

The current treatment paradigm is that when you progress from CS to CR, and that simple castration (physical or chemical) fails to control the PC, then you proceed from androgen deprivation to androgen annihilation. So you would stay on "Lupron for life" even as you pursued further ways to block other sources of T and/or block AR activity.

Mascouche profile image
Mascouche in reply to noahware

Ok so if I understand, whether you are castration sensitive or castration resistant you should nevertheless still take Lupron or undergo physical castration. Which then leads me back to my original question.. :)

noahware profile image
noahware in reply to Mascouche

Well, yes, you "should" maintain a castrate state if you subscribe to following that paradigm of proceeding to androgen annihilation. The alternatives to that include trying BAT or SPT or some other attempted way of fooling your cancer into not killing you too fast... so that would be an obvious reason to NOT choose surgical castration (although you could add back all the T and E2 you wanted to, with shots or gels or patches).

For myself, I would choose castration over Lupron-for-life simply because it is cheaper and easier. One and done makes a lot of sense, with no "looking forward" every three months to the shot that perhaps helps make you feel a little less alive (even if its keeping you alive).

I have chosen to do ADT via transdermal E2 for now, as that should help avoid some of the problems that can come with either surgical or chemical castration. I also hope that possible vacations might delay a progression to being CR, which is not a given, of course.

Pleroma profile image
Pleroma in reply to Mascouche

"Castrate resistant" is a medical term which basically means that you have reached a point in your disease where your PSA begins to rise (typically doubling in a month - a sign of tumor progression) despite ADT. In other words, the cancer has become resistant to attempts to block testosterone (T) and has found alternate ways of flourishing despite being deprived of the main source of T. (There are a few other small sources of T emitted in our body - eg adrenals). Cancer cells will find other sources of nourishment over time.

The cancer will always feed on T if it were made available which is why we are on Lupron for life at this point. No vacations. That is how I understand it.

So my original thought was that physical castration makes sense when you have reached this event. But each to his own.

Tall_Allen profile image
Tall_Allen in reply to Mascouche

You are incorrect when you assume that just because you are CR that castration (chemical or physical) is pointless "since it won't help you control your cancer anymore." The opposite is true. Castration resistance occurs for many reasons, but the most prevalent reason is the "upgrading" of the androgen receptor (AR). That means that the cancer cells start producing many more copies of the AR protein on the cell surface. Because of that, even the slightest little bit of testosterone can activate the cancer. It becomes more important than ever to restrict the availability of testosterone.

An orchiectomy is no guarantee of a permanent remission of cancer. It does mean you will not need Lupron or other gonadotropin drugs. You may need ADT drugs.

You should never have castration (chemical or physical) "for fear of a recurrence of the cancer coming back." There are many advantages to having normal testosterone levels. Deal with what you know instead of fears about what may happen.

In a retrospective study, compared with those treated with GnRH agonist (like Lupron), patients who received an orchiectomy had significantly lower risks of experiencing:

• any fractures (-23%)

• peripheral arterial disease (-35%), and

• cardiac-related complications (-26%) .

• no statistically significant difference for diabetes and cognitive disorders.

jamanetwork.com/journals/ja...

GnRH antagonists (Firmagon and Orgovyx) also have heart-protective effects:

auajournals.org/doi/pdf/10....

ascopost.com/news/june-2020...

However, in a randomized clinical trial, fat accumulation was higher for orchiectomy :

bjui-journals.onlinelibrary...

Chemical castration may get testosterone levels lower:

ncbi.nlm.nih.gov/pmc/articl...

alephnull profile image
alephnull in reply to Tall_Allen

Thanks Tall_Allen!!

I've been on ADT for over 7 years now.

Recently transitioned to Orgovyx, what a difference it has made.

But my hot flashes have returned, ugh.

My Onco says because my PSA isn't going back to my previous nadir 0.19, now about 0.7, that I might becoming CR.

If that is the case then I'll be strongly considering physical castration. As I probably shouldn't take those ADT vacations any longer.

Mascouche profile image
Mascouche in reply to Tall_Allen

The Jamal network study says that it does not increase the risk of diabetes or cognitive issues whereas the other study from bjui says that there is an increase in fat and insulin resistance.

I find this contradictory because insulin resistance is not only the main cause of the fat gain but also leads to diabetes and is a known contributor to degenerative diseases like Parkinson and alzheimer.

Tall_Allen profile image
Tall_Allen in reply to Mascouche

Maybe with 10 more years of follow-up they might find that.

CSHobie profile image
CSHobie in reply to Tall_Allen

TA, I really wonder if there was some bias in the study, about T levels being lower on Lupron VS orchie. I had Orchie, and I am on Zytiga. How can my T level be lower than what my levels are now? on Lupron. My tests have been showing T lower than 0.4 , Detection limit.

Tall_Allen profile image
Tall_Allen in reply to CSHobie

Research only predicts the group average, not any individual's results.

In my case living with this cancer monster for 10 years now I must concur if I had a chance over again I would choose castration in the first instance.ADT drugs & patches etc are very limited in this country along with the attitudes of the few ONC I have seen so far.

I'm 77 1/2, been on ADT 4 yrs. Had my physical castration done 2 months ago and have great energy. I have my psa checked every 6 weeks and I saw mine decline from 1.0 to .83 Maybe my MO could explain it when I see him next week. No regrets.

A conundrum to consider for sure... But these many paths all seem to lead to the same destination.

So IMO if you tolerate the drugs well, there may be little reason for the surgery to accomplish the same. And yet, surgery makes sense to not deal with the drugs and their SE profiles... Eventually for advanced patients the possibility of graduated progression to resistance is assured seemingly regardless of path chosen.

How dastardly this disease is... Just sayin!

I agree and I am thinking about how my QOL would be much better.

I had Lupron for about 6 months, then had Orchie. I feel more energetic, and less dull than on Luprolide.

I am happy with my decision, but I wish it was a clear cut win lose situation, regarding your questions: Is the outcome from toxic drugs like Lupron (osteoporosis, high blood pressure, Parkinson, alzheimer, whatever else comes from long use of ADT) lessened by choosing physical castration?

Your first reply, and by Tall Allen, shows you the clear benefits, I think are significant, but it doesn't happen immediately. The hope of reaping these benefits, is what made me choose orchie. Lupron certainly has its own SEs, it is just well hidden by prounounced SEs of having Zero T.

One more thing, talk to your Oncologist immediately about getting a Baseline Dexa scan. Do the full monty, Bone density, Muscle mass and fat measurement. Then discuss estrogen replacement, and monitor your BMD. If you have a lazy Onco like mine, who did none of the above, get someone else.

Mascouche profile image
Mascouche in reply to CSHobie

He is against estrogen replacement. Said something along the lines that it could cost him his career if he used anything treatment that is not in the hospital's SOC.

Oh dear, are you in Ontario?

Mascouche profile image
Mascouche in reply to CSHobie

In Quebec but it is likely the same in our neighbor province.

CSHobie profile image
CSHobie in reply to Mascouche

Oh yes, now I understand. We are probably both limited, in the treatment menu on offer.

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