Time for a vacation, but worried about IADT

[PGDuan]

Decision time is approaching but should I take an ADT vacation? Any new data or articles to support decisions on intermittent ADT?

I'm looking forward to an improved QoL but just worried about giving the beast room to come back.

I've been undetectable (<0.01) since treatment started 11 months ago and have a PSMA PET coming up to confirm nothing is visible.

As backstory, next month I'll complete the "triple play" treatment plan that included ADT + Docetaxel + Nubeqa + SBRT after recurrent low volume/high risk PSA. At the start of this round my PSA was 0.9 with a 4 month doubling rate and 2 "possible" hot spots on a rib and vertebra. The rest of my history is in my profile but I previously completed RALP and adjuvant EBRT with 18 months Zytiga for recurrent PSA after the surgery -- and I was then undetectable for 15 months after the Zytiga. Initial dx at 52 was PSA ~11, Gleason 4+3.

Thanks for any input 🙏

[treedown]

For me I liked being off the drugs for over a year. It did let me take my mind off my disease even with a steady increase to 2. I am still deciding if that was a good thing or not.Now I am going back on ADT and PET scan found 4 spots on my spine that I am radiating next week. That said, nothing was a surprise and I am doing well in general. Its not hitting me as hard as the first time. Maybe ADT will change my emotions but kind of taking it in stride at this time.

[Hidden in reply to treedown]

son of a gun! Knock it out!

[Tall_Allen]

The open question is how long it will take your T to recover. Good luck.

[6357axbz in reply to Tall_Allen]

TA, do you see a slow T return while on a ADT holiday as a good or bad thing? On the one hand one purpose of the holiday is to benefit from increased T. On the other hand if T is slow to return your body gets a longer break from the drugs with less fuel for PCa and, therefore, less likely hood of progression.

[PGDuan in reply to 6357axbz]

I had been thinking about this same question.

A few months ago I asked my doctor if I should take something to moderate my T after coming off the Nubeqa and Degarelix. I was thinking that a "moderate" level of T might be the best path -- feel better but not as much fuel for the PCa.

He wasn't too keen on the idea. He said its best to enjoy the holiday, let T get back to normal, and then if there's still PCa its best to know so it can be treated.

[6357axbz in reply to PGDuan]

I agree with your doc. I think I’m pretty much in the same boat as you.

[London441 in reply to PGDuan]

Exercise is a major factor here, cardiovascular and especially weight training. It can’t be overemphasized. It helps your T to recover faster and better, and helps keep the Pca at bay along with the co morbidities the ADT puts you at greater risk of.

Hopefully you were already doing it since exercise also lessens and often negates ADT side effects, thus minimizing the contrast between low and high T.

Too many guys basically hope for relief solely from stopping ADT. Especially since we are older this is not a good bet. T levels were naturally falling already and recovery can be very slow.

I would look at any vacation as an opportunity to get stronger and fitter. The same effort will produce better results, and provides a kaleidoscope of advantages should you need to return to ADT later.

[PGDuan in reply to London441]

100% agree; thanks for the perspective. I'm still pretty fit, surfing quite a bit. Just finding it harder and harder to get going...

[Tall_Allen in reply to 6357axbz]

Good question. It all depends on how you feel. Some guys feel like their old selves with T of,say 150, while others need T=700 to feel back to normal.

[Jac_J in reply to Tall_Allen]

Well, I just did the experiment over the last 3 months.

PSA Nadir of 8 after Docetaxel and Eligard. Stable at that range 8 - 9 over 18 months.

Testosterone over same period around 0.2.

After 2 month break of ADT Testosterone still < 1 and PSA around 9.

After 3 months break T of 630 ng/dl, PSA 27. A little concerning.

I did another blood test today and expect increased PSA and T levels.

I will resume Eligard tomorrow.

I have always been of the opinion that ADT vacations/intermittent are the worst of all worlds. T does not recover fast enough for most people but PSA will almost always rise alarmingly.

I would like to pursue BAT therapy but being in the back water of Australia no MD's that I know are willing to put their balls on the line to help me. So, if any one knows someone in Australia please pass on their details.

[6357axbz in reply to Jac_J]

I’ve been off Lupron for a year and off Zytiga (abiraterone acetate) for 8 months. PSA still undetectable. T around 50. PCa behaves differently in most of us.

[Jac_J in reply to 6357axbz]

Yes I see your T has remained effectively castrate hence no impact on PSA. Hope it remains that way.

[Teacherdude72]

This is the first time I have heard of a vacation from Nubeqa. Can anyone tell more about this?

[Brundo]

My father is in the same boat. He started Xtandi almost 3 years ago and has been undetectable ever since. He wants to go on ADT vacation , but we are afraid. His dr. mentioned it long time ago , but never said anything else after that...

[Hidden]

It’s risky! Imho … To vaca or not to vaca? Personally , I would not stop adt until at least five years clear .. I did the orch after two yrs of Lupron . I continued on tak-700 for over 7 yrs until I stopped it eight months ago . Men dream of T returning again . I won’t feel T again unless I inject it . My doc thinks that it is crazy for patients to inject T . I started out in k failure seeing how bad pc can be . Out of my four medical oncologist none suggested a vaca for me .. old school says if adt is working don’t stop it . You just might be very different than I am ? Stronger than I was? . It took me an orch and 7 yrs on adt to finally drop it . My new mo just told me that all it takes is one bad pc cell to start up the engine again . We are told that we can have 2-3 million pc cells at any time hiding from any scans .. A vacation in theory sounds great . I can’t tell you how many a fine fellow do so ,and then get an immediate uptick and regret it . It’s your life , to do as you please .. I wish you luck !

[Magnus1964]

I am not a fan of ADT "vacations". You are only giving new lines of cancer cells a chance to find a work-around to the drug. If an ADT drug is working stay with it.

Magnus

[Nusch in reply to Magnus1964]

Also not after IMRT/VMAT to prostate bed and pelvis, two years of ADT and undetectable PSA to find out if cured or not?

[Magnus1964 in reply to Nusch]

There is no "cure" for prostate cancer. Stopping ADT will only give the cancer a chance to return. It will do that anyway but why give it the opportunity to do it now.

[6357axbz in reply to Magnus1964]

stopping ADT May support growth of ADT sensitive cancer cells which could suppress growth of resistant cells which could result in a ADT recharge once it’s restarted. That was, more or less, the premise originated by Robert Gatenby

[Magnus1964 in reply to 6357axbz]

But any new cancer cells may find a work-around to the treatment. Therefore, restarting the treatment may prove ineffective.

[6357axbz in reply to Magnus1964]

or it may delay resistance. That was Gatenby’s premise.

[Nusch in reply to Magnus1964]

There are different opinions about cure, even in this forum. Saying this, cure for me would also mean long year remission or slow growth to survive.

Why do you stop ADT, when you don’t believe in cure?

[Magnus1964 in reply to Nusch]

You don't stop ADT as a "vacation". You only stop ADT when it fails.

[Nusch in reply to Magnus1964]

Hm, but iADT is quite popular isn’t it?

[Magnus1964 in reply to Nusch]

I don't know how popular it is, but I would not recommend it. Just one persons opinion.

[Boonster]

The thing about ADT is this: sooner or later, the cancer cells not killed by ADT will gradually become more and more numerous.

We become castrate resisent even if we keep on ADT. The resistent cancer cells will keep growing even when the amount of testosterone in the body is reduced to very low levels.

I'm hoping the adjuvant SBRT I had along with 2-3 years of ADT will put me in long-term remission. ADT will not be enough, but the combination of SBRT and ADT just might be.

[slpdvmmd]

Given you history I agree with the no ADT vacation side of the argument. Your story also drives home the risk of Gleason 7 as a 4+3. I think we are all individuals but my testosterone has been pretty much undetectable for 5 years now. I have continued to lift weights, hike, backpack, ski (works as instructor in the winter) and do surgery two days per week despite the lab value. I think you just can't allow yourself to stop!!

[PGDuan in reply to slpdvmmd]

Thanks for the input. With this disease we're always learning new things.

To be honest, I thought IADT was kind of straightforward -- that IADT had been established as "noninferior" to continuous ADT. No better or worse than continuous in regards to overall survival, but some hope to recover and improve quality of life.

Still, like every decision point on this journey, the more I dig in the more I learn. Glad I got all this feedback as I'm thinking harder about it.

I just read this study (thanks to Tall Allen's website that linked to it). This study implied IADT may well be inferior, but not enough data to prove it.

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

Will get "second opinions" from a few experts and look for any other more current studies....

[treedown in reply to PGDuan]

The thing about IADT is being clear when to restart and if the insurance company and you Dr are on board with that. I will consider if presented as an option, which I doubt now, but I will be clear when I will restart ADT which would be earlier than I am doing so now. That said I am not sure either I would have been approved for it prior to hitting a PSA of 2 to co firm recurrence.

[slpdvmmd in reply to PGDuan]

Non inferior really distills down to there not being a significant P value.

[Magnus1964]

At what durations are the intermittent points.

[PGDuan]

Thanks - this is what I heard previously and will confirm with my primary oncologist and get second opinion(s).

[6357axbz]

Based on my cancer I would wait for my PSA to go from undetectable to no greater than 0.5. Then get a PSMA scan, probably Pylarify, to identify new tumors.

[6357axbz]

There are both advanced PCa (Stg IV distant metastatic) patients responding here as well as patients with and the curable kind of PCa. We need to be aware of who we are listening to.

[PSAed in reply to 6357axbz]

Excellent point.

[Magnus1964]

But at what time interval do you resume?