The A-Dream Phase 2 trial is taking a second look at intermittent therapy for mHSPCa. In the study they hope to answer the question
1. Can intermittent therapy (a break from treatment) for high responders (PSA < .2 over 18-24 mos) on ADT+ARPi be more effective than continuous ADT (the current standard for mHSPCa).
Two benefits they are looking/hoping for are:
1. Opportunity to recover from side effects of ADT (low-T, bone health, etc)
2. Extend the window of Hormone Sensitivity, the patient will cycle back on ADT + ARPi when PSA rises by a target level.
This study was done before and found worse OS than continuous ADT, This is a new study with an improved design.
My husband will be doing this provided his PSA is still undetectable at his next doctors visit in September. He meets all the criteria for this trial except he has never taken a secondary ARPI. His oncologist talked with him about doing intermittent therapy last week and my husband is willing to take the risk. He is eager and happy to take a break from the side effects of ADT.
Besides chemo and an immunotherapy drug (part of a Phase 2 clinical trial) in 2020, he has only been on continuous ADT. He first had monthly shots of Frimagon then for over 2 years, Orgovyx. His PSA has been undetectable since March 2021.
He will be closely monitored by his oncologist and will have his PSA tested monthly. Either he or I will post here as to how he does on this intermittent therapy. Hopefully he gets a long vacation before he has to go back on Orgovyx. 🤞🙏
Unfortunately, yes. Multiple bone mets as well as to lymph nodes. More than 6 bone mets so was not a candidate for any radiation, only drug therapy. He was diagnosed stage IV at initial diagnosis. The good news is he is still asymptomatic. He only has side effects from ADT.
Does the number of bone Mets determine if you can get radiation therapy? My husband has 4 bone Mets, possibly 5, but unclear from PSMA scan. He is starting radiation tomorrow for 2 spots on upper spine and one rib. When we get back from vacation he’ll get last bone spot and prostate radiation using SBRT. Why would number of metastasis determine if radiation was appropriate? We’re fairly new to this!
In general, the more bone mets the less likely that there is a RT treatment benefit (pfs, os) for newly diagnosed mHSPCa. RT will still be given to treat symptoms like bone pain or enlarged prostate interfering with urination or defecation. As always check with your doctor since drugs and treatments are evolving.
Yes, we were told the number of bone Mets precluded him having radiation therapy. I am not sure what the cutoff was but think it is 6. If you have too many bone Mets there would be too many places to radiate.
Thank you for posting this video. I found it very informative and pertinent to my own circumstance.
This is Great, but what if you have an oncologist who doesn't believe in this and now you've been on adt for 4+ years?? "Must have remained on testosterone suppression for metastatic disease continuously (without treatment breaks) for 540-750 days (approximately 18 to 24 months) from time of first dose of LHRH agonist or antagonist by time of registration. A period of anti-androgen treatment prior to LHRH agonist or antagonist initiation is not included in the 540"
Sounds interesting. I always thought that the first study was very flawed with allowing the psa to go to such a high level (20) before going back on hormone suppression drugs. I've been doing vacations a number of times during my 14 years of stage 4 prostate cancer. I've only let my psa rise to no more than 2 before going back on medications. It has been very enjoyable during these vacations to get over the side effects even though the testosterone doesn't come back much after all these years.
My original prescription of cyclophosphamide was 25mg a day. I was able to get almost 3 years off the adt medications. You have to limit the total intake of this drug because it could lead to higher incidence of bladder cancer. I took it again about 3 years ago and only took the capsule once every 3 or 4 days or so. I was able to get about 18-20 months off adt medications instead of other times getting 12-14 months vacation without using cyclophosphamide.
Dr. Richard Lam of Prostate Oncology (in Marina del Ray) suggested it back in 2011 to help extend off periods from the ADT treatments. Very low side effects. Still allowed testosterone to rise.
Still doing intermittent ADT but not with cyclophosphamide each time. According to Dr. Lam there is a limit that any patient should take because it could lead to increased risk to bladder cancer. I think I took it for about 18 months during 1st off period. Have taken it again for another off period about 6 or 7 years later.
Stopped going to Dr. Lam about a year ago. Direct flights to LAX were sporadic for Southwest airlines and it became impossible to see him and fly there and back the same day. He is a fantastic Prostate Oncologist and involved in research for their office.
Is Dr. Lam not willing to do appointments, remotely, for example by Zoom?
What number of cycles of 18 months did you do? From the above, I infer just twice:1st off period and 6-7 years later. I presume the 2nd time was under the care of Dr. Lam. Do you plan on trying another cycle? And what is the limit of the number of cycles?
If the concern, is for bladder cancer, how do you and do you monitor for that?
I apologize for asking so many questions. I am just incredibly curious about low dose cyclophosphamide.
Dr. Lam is still doing zoom appointments but wants to see you every other time. His office also added yearly surcharge to keep them as your doctors not reimbursable by Medicare.
I did 1st off period with cyclophosphamide after 16-18 months of ADT with psa very low (0.005) and used it for 18 months of the almost 3 year off period. Dr. Lam did urine test during that period to check for bladder cancer. Next 3 or 4 off periods didn't use cyclophosphamide and off periods were greatly reduced to 18 down to 12 months. I usually go back on ADT when I reach psa between 1 to no more than 2. Did cyclophosphamide again during 5 or 6th off period and it extended the period this time to about 18-20 months. After 5 or 6 years there should be no remnants left of the cyclophosphamide in your system.
I likely will use the cyclophosphamide again on my next off period from ADT. My local oncologist doctor is aware of this and will prescribed it.
Thank your for being so kind to share your journey.
Is the PSA of 1 to 2 at high end, something that Lam chose for you, as the cutpoint for restarting ADT? And do you still do double hormone blockade with Abiaraterone or did you switch to ARSI (darulotamide, apalutamide, or enzalutamide or)?
I think you stated your off period has trended down to 12 months?
Has your PSA nadir on treatment trended up or do you still get to undetectable?
I think you stated your on hormone therapy period was 12 months ?
Has that changed?
Is that Dr. Lam's protocol in general for intermittent therapy in mHSPC or for you in particular given your particular clinical story?
I looked at your history. You said your PSA Doubling Time was as fast as 2 months before chemotherapy. What has it been after chemotherapy? And did it change the trajectory of your on and off treatment cycles?
Sorry, for asking such detail. But I want to get on an intermittent plan and I am mHSPC also and your history is remarkable. "Waiter: I'll have what he is having".
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