I've been told by several ROs that RT is more effective if given together with ADT, and I think that's pretty widely assumed to be true.
I'm wondering, though, if what is seen to be a synergy may instead be only a statistical error.
Temporary ADT can lead to permanent testosterone loss in up to 30% of men. So when we compare sRT-only patients to sRT+temporary ADT, what we're really looking at is a mixed cohort, a part of which are effectively being treated with sRT+permanent ADT.
The effect would seem to be that in the 30% of the sRT+ADT cohort, the lifelong loss of testosterone could make the apparent effectiveness of sRT+ADT appear to be artificially higher than it would be if you had a hypothetical cohort who had sRT which was later followed by a temporary course of ADT.
It seems like the answer to this could be teased out of existing data if we excluded the guys who never got their testosterone back from the data.
What do y'all think?
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The RCTs, being randomized, were indifferent to whether testosterone recovered. Whatever happened in the treatment group also happened in the control group. The only variable was the duration of ADT.
The decision depends on a lot of factors, including what your PSA level is now, how risky your cancer is, and what is your goal (I think prevention of metastases is the best goal). I think that your high Decipher score is important.
Early sRT, i.e. low PSA at start, ADT is a very convenient way for the RO to evade embarrassing queries like: "Doc, when will I see a PSA decline". Since 2019 there are 3 studies that claim ADT does nothing in early sRT if not worsens OS by increasing CV incidents.
Late sRT, probably already metastatic, it is primarily systemic treatment with sRT assuming the role of the long shot.
So Carlos, you've been on my tail..... oops trail..... Did my ex-wife put you up to it?
BTW are you from a Latin country? If so, do you know the four words every 6 year old learns if they lived in any Latin country around the world? If you do, don't tell me..... LOL
I had a 0.97 Decipher after a recurring PSA of 0.13 only 6 weeks post RP...my case required immediate suppression of the tumor for months while I healed then sRT (salvage) to treat the fossa...I dont think you are in this same boat...in my view your case is more positive than mine. I wish my Decipher was 0.66, which is what I was expecting with a GS of 4+3. Some things to think about;
First, it appears that LTADT (long term) used with LDRT (low dose radiation) significantly lowers your OR (odds ratio) of both PCSM (mortality) and MET (metastasis). This podcast may help answer your specific question regarding whether ADT with sRT (salvage) is effective at treatment for prevention of progression of PCa (both MET and PCSM)...I believe that they are. Check this out;
But, will you benefit from ADT treatment? I did not know that your Decipher test can help your Doctor determine if this is the case? Why take ADT if you will not benefit from it? Check out MIN 16:03 and 17:25 from this podcast;
Next, why take ADT; why do you need it before sRT? In my case I had to heal, get dry, then be treated...why would you consider taking it? Between my initial 6 months ADT and the following 15 months of ADT treatment I had a 'vacation' of 3 months...in that time period my TET roared back to 300 before I restarted ADT...after 15 months I am now almost 6 months post ADT treatment regime and my TET is 3.0 (that is three)...it is not coming back as fast. Now, it may take 2 years to return, or may never come back; free ADT for life (hurrah)! The 30% of non-TET return you are referring to is for men treated with long term ADT...check this podcast out for the effect of ADT on TET levels;
Finally, try to slow down your PSADT by taking Sulforaphane supplements, or eating Broccoli sprouts, or both. Sulforaphane has been widely studied and it slows down PSA growth...I have a lot of podcasts on this issue but check this out (Min 6:27);
Last, whether there is a need to take TET (testosterone) to zero is a new and growing debate in PCa treatment; is it necessary? I have followed the SOC that states the lower TET the better the outcomes...this may not be the case. Check this podcasts (there are more posted at my Hub);
Hope this helps...sorry for the long reply. I have stepped in so many holes and twisted my ankles enough to wish the same not happen to anyone...know this. The loss of TET will bug you. You lose visceral arousal...you mentally know what you would love to feel, but that sensation is gone...it will also destroy your penile tissue (more on this if you need it)...
So in summary if you need ADT, if you can benefit from it, if it will make a difference in your treatment, take it! It does work for men like me and can save your life. But, if you dont have to be under ADT dont do it Brother...Rick
Very much appreciate the thoughtful reply. I’ll go through those links tomorrow morning. I feel like I’m probably in the gray area where ADT could make a difference or might not. That’s one of the reasons I want to get a read on whether reported efficacy of ADT together with sRT may be boosted by a statistical artifact. Most recent PSA was 0.11, and hopefully holding steady or still drifting down. BTW, I’m assuming the damage to penile tissue with ADT happens even if a VED is used, right? And probably with all castration drugs.
Hope this all helps...I am getting to be an expert on what not to do, after I do it...but yes ADT is immediately detrimental to penile tissue health. I have yet to post a podcast that goes thru all the negative impacts of ADT and will do that...basically, 6 weeks after you start ADT you have permanent venus leak...that is the end of your spontaneous erection recovery expectations...VED use will only keep your penis from getting shorter and thinner (you should be using a VED right now; see below). BUT ADT may save your life as well...that is why you should use it only if you absolute need it and only for the length of time you require...
Here are my initial notes on what happened to me and what led up to my IPP (inflatable penile implant). I only wish I had done it immediately after I had to proceed with sRT (salvage) and long term ADT. I would have saved a good portion of my size. And yes, size matters. It will bug you to see an atrophied penis 2-3 years down the road, when you finally get an IPP and see that you could have acted earlier and preserved more of what God gave you. But many, like me, held out that 2-3 years down the road we would recover...once your on ADT for more than 6 months your natural erections are most likely gone. Check this out...
So ADT can save your life, but it comes at a high cost...but then again what is your life worth? A heck of a lot! So, it makes sense to use it if you need it AND if it will work for you. Otherwise this is not a substance you want to use 'just in case.' Do your due diligence and if you need it pull the trigger...then I would suggest you get your IPP planned earlier rather than later...Rick
Thanks very much for the info. The decision process on this has really bugged me. medical advice on the use of ADT concurrently with sRT doesn't seem to include much discussion, if any, of the potential side effects of ADT. Also, the advice to use it seems compelling when you see graphs of relative risk, but if you look at it for an absolute risk perspective, it's not quite as cut and dried. Not a single doc (I've seen a half dozen) has mentioned to me the possibility of permanent penile tissue damage or the 30% chance of testosterone recovery.
I understand your situation is different and if I had a Decipher of 0.97, I'd probably buck up and git 'er done. But at 0.66, I'm not quite so sure. In December I met with an RO who advised immediate sRT with no ADT. He said if I did ADT, we'd have no idea if the sRT worked or not. I keep thinking about that. Several people on this board said he's an idiot. Now, he may be wrong, but one thing he's not is an idiot.
And he might actually be right. The question seems to boil down to "How much benefit is there to doing ADT concurrently as opposed to serially (if needed)?" And it's tough to find an answer to that. I can't even find out what the mechanism of the advantage that concurrent ADT provides, which is one of the reasons why I'm suspicious it may be, at least in part, a statistical artifact.
After all, if we had three cohorts, (1) sRT only, (2) sRT and short term ADT, and (3) sRT and permanent ADT, we'd expect three different OS and MET rates. If that's true, then we'd likely see an "unfair" advantage from sRT administered concurrently with ADT as compared with sRT used alone or serially with ADT. But who knows? I'm a noob and this isn't my area.
At any rate, I've got to make the call on this pretty soon. Probably this summer or fall at the latest. I appreciate your help on this.
Brother, your Dr was absolutely right; ADT will mask success from sRT. I had ADT before my sRT to give me time to heal...you are healed my friend. You dont need ADT...your PSA is very low in fact so why have it. Just get sRT if that is what you want. In my case I had a 4 month 'vacation' after my sRT during which time my TET recovered to 300 ng/dL AND my psa was ulta low! That means that the sRT worked! If I had been on ADT I would not have known...for me I had to continue with ADT as the studies show the OR of PCSM and MET were substantially better with LTADT plus LDSRT (long term ADT w low dose radiation)...you have the study.
Then, if I were you, after I take sRT wait. Why take ADT! See if your PSA comes back and what PSADT is...here is a podcast that says if its not less than 6 months (which yours now appears to be), then your chance of MET and PCSM is lower...
I dont know if there is a difference between absolute and relative risk...the studies show probabilities of primary end points in the populations noted for the time periods stated. There are corrections for all types of conditions which would skew the results, one being if TET never recovered and patients essentially never went off ADT...if the study did not correct for this then its bogus for sure...but I have seen in nearly a half dozen cases where studies show ADT after sRT prolongs life, reduces BCR and MET, therefore decreases PCSM...BUT for high risk PCa...Brother, I dont thin you are high risk.
That is my opinion...choose carefully and wisely what you do, then get that IPP done if what you choose will forever rob you of your God given properties...then take the risks and roll with the punches...Rick
Saw this post today; what I read corroborates this. Only high risk PCa patients benefit from ADT + sRT...I dont think you are high risk, but dont know all the details of your post RP...but take a look. Rick
Any such study lacking PSA stratification is flawed from the start. For another one, published a decade or more ago, they re-did the statistical analysis of the raw data, but this time stratifying by PSA to end up with totally different conclusions.
Perhaps Tall_Allan or one of you other experienced contributors could share the flip side of this use of ADT.
Assuming you did not have a surgery first but had radiation first is there any trial results that say you should benefit having short term ADT (6 months) with your initial radiation treatment if it appears that there is NO cancer outside of the prostrate.
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