When To End An ADT Holiday

[6357axbz]

Just had a lengthy conversation with my MD Anderson MO who agrees with my Houston Methodist MO, i.e., it’s probably better, after an ADT holiday, to allow PSA to reach 0.5 so a PSMA scan can be used to identify any metastices, then zap the met(s), then go back on ADT to put the cancer back into remission. The difference between this approach and going back on ADT before PSA reaches 0.5 is that the data is telling them that the next ADT holiday will last longer.

[GP24]

In this recently published trial they did end the ADT holiday when the PSA level rose ≥5 ng/mL for patients with radiotherapy. I would wait until a PSA value of 3.0 ng/ml to see all mets there are. Except micromets of cause.

Embark trial: urotoday.com/conference-hig...

[Concerned-wife in reply to GP24]

We were advised 2.0 by Duke. ( husband had SBRT, not surgery).

[GP24 in reply to Concerned-wife]

I had to wait for a PSA value of 3.0 ng/ml to detect mets. But you can decide for 2.0 ng/ml as well.

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

[Tall_Allen]

The EXTEND trial found:

jamanetwork.com/journals/ja...

They waited until PSA reached 20 ng/ml before ending the vacation in oligometastatic (<5 metastases) men, and those who had metastases radiated were able to take a much longer vacation.

But...

• Is this a real vacation for you? That is, has your testosterone sufficiently recovered so that it makes a difference to your QOL?

• Does it apply to you? Have you had >5 bone metastases?

• Is there a long-term deleterious effect in giving your cancer a chance to spread?

[6357axbz in reply to Tall_Allen]

TA, to your bullet points:

Bullet #1: T never recovered past approx. 55 but that had no impact on my QOL

Bullet #2: I only had 3 bone Mets. (I was a participant in Dr. Tangs Extend trial.)

Bullet #3: I doubt there is a definitive answer to you question. Has it spread to any significant degree? Would continuous have driven my cancer to resistance? Assuming any spread was small is that worth nearly 2 years off ADT and the toll that takes on your bones, brains and heart? We are in uncharted territory here

[Tall_Allen in reply to 6357axbz]

So if there is no QOL benefit on your intermittent ADT, why are you taking that risk? We know that continuous does not drive PCa to resistance any faster than intermittent. And there is no evidence that the toll it takes on one's body is any different - the long-term side effects are exactly the same.

[j-o-h-n in reply to Tall_Allen]

To T_A, I sure as hell can't answer that question for "axbz" but I can wish you a festive and bountiful meal for Thanksgiving. - save me the Pope's nose.

Good Luck, Good Health and Good Humor.

j-o-h-n Wednesday 11/22/2023 10:34 PM EST

[Tall_Allen in reply to j-o-h-n]

Thanks, happy Thanksgiving! What is the Pope's nose? It sounds like something a Jew shouldn't eat.

[j-o-h-n in reply to Tall_Allen]

It's the part that goes over the fence last..........(a delicacy)....

Good Luck, Good Health and Good Humor.

j-o-h-n Wednesday 11/22/2023 11:38 PM EST

[Shams_Vjean in reply to j-o-h-n]

You guys are reminding me of what my best buddy’s dad said at every Thanksgiving dinner: “Hey Adele, gimmie the tookus!”

Happy Thanksgiving to All!!

[j-o-h-n in reply to Shams_Vjean]

Thanks Shams_Vjean,

Yep it "Took Us" quite awhile to determine who gets it every year. We settled on, she gets even years, I get it odd years.........(BTW Best part)....

p.s. I Cant' pass this up: Do you know if Adele would get the Dreidel?

Stay well and keep that sense of humor......

Good Luck, Good Health and Good Humor.

j-o-h-n Thursday 11/23/2023 1:56 PM EST

[Shams_Vjean in reply to j-o-h-n]

Whatever Adele wants, Adele gets…

[j-o-h-n in reply to Shams_Vjean]

and Adele wants you........(her husband Harold is too busy eating the tuchus)....

Good Luck, Good Health and Good Humor.

j-o-h-n Thursday 11/23/2023 5:48 PM EST

[fireandice123 in reply to Tall_Allen]

I’ve noticed the QOL benefits have lessened with each vacation. It was quite noticeable during my first vacation. I felt quite good. Not so much with the subsequent vacations. I didn’t feel markedly better. A little better yes, but it was nothing dramatic. And I have to say the ADT SEs have not been as bad each time I resume ADT. It’s making me consider whether the vacations are worth the risk.

[6357axbz in reply to Tall_Allen]

First of thanks for your thoughts TA. Always valued and appreciated. However this post is about ADT holiday exit strategies, not the relative merits of CADT versus IADT. But to answer you questions I did feel better being of the lupron and abiraterone, i.e., a QOL benefit. Also both my well respected oncologists, whom I’m sure you know of, feel the toll the drugs take on one’s body is less with IADT.

[Tall_Allen in reply to 6357axbz]

I was reacting to your only allowing PSA to reach 0.5, whereas in EXTEND you allowed PSA to reach 20. That is about your holiday exit strategy.

[6357axbz in reply to Tall_Allen]

when I participated in Dr Tangs EXTEND TRIAL he told me PSA of 2 was my target. Perhaps that was because my cancer never produced high levels of PSA??? Anyway, during the period after I stopped ADT and my PSA starred to rise it was COVID time, early 2020, and I had an appointment with my then MO Dr Tu. He was out sick but I insisted on being seen by another MO cause I had travelled all the way from Florida. That’s when I first saw Dr E. She changed my target to anywhere from 0.5 to 1.0 and arranged for me to get a GA68 scan at UCLA (that got me booted from the EXTEND trial).

[Tall_Allen in reply to 6357axbz]

Then as you know, your low PSA with bone mets puts you in a rare category. Maybe you cannot use PSA to tell you when to end vacations. And given the known virulence of low-PSA subtypes, you may want to give up on the idea of vacations or use PET scans to track progression.

[6357axbz in reply to Tall_Allen]

Hmmm, thanks. Would original dx with PSA at about 5.5, biopsy showing 11 of 12 sectors filled with cancer, G8, with three bone Mets (ribs iliac) qualify as low PSA expressing cancer?

[Tall_Allen in reply to 6357axbz]

I think it's low for 3 bone metastases, and apparently Dr E thought so. The upside is that it is responsive to intensive hormonal therapy.

[6357axbz in reply to Tall_Allen]

Thank-you TA

[j-o-h-n]

To 6357axbz, I sure as hell can't answer that question for you, but I can wish you a festive and bountiful meal for Thanksgiving. - save me the Pope's nose.

Good Luck, Good Health and Good Humor.

j-o-h-n Wednesday 11/22/2023 10:33 PM EST

[6357axbz in reply to j-o-h-n]

👍

[LongevityAT]

I wasn't on ADT long enough to have a strong opinion on vacations, but do want to wish you and everyone else a Happy American Thanksgiving. A time to give thanks for our lives, our families, our health and our (your) country.

As for the Pope's nose, I read about the history of that saying and it dates back a few hundred centuries. Interesting way to refer to the turkey's ass!

[Tjc1]

Here is what I asked. I was on ADT Only for 7-8 years maybe. It failed and I went metastatic. Went on Xtandi and things settled down . When I went to get my 6 month injection the doctors were not even open because of the ...you know, COVID. Seemed like a good time to go on vacation since it failed anyway. After 18 months PSA started creeping up slowly. The advice I got was go back on ADT . I did and it didn't make any difference. Numbers now although small are doubling in 6 months. Now, Xtandi from what I read here is good generally for two years. I think I'm on year 4. Good run. Is the Xtandi failing too! I'll be getting a PSMA Scan sometime in December.

To the question? Was it worth it to take that vacation. For me it was. The last 6-9 months off ADT I started feeling very good. It seems in my case the break did not do anything to make the ADT viable again in my opinion. Been back on ADT for 18 months and I don't like it at all. It doesn't seem to be doing much anyway.

Good luck, it's all a crap shoot.

[fireandice123]

When I’ve been on vacations there was no specific point, such as PSA level, to end a vacation. Rather when it was obvious that my PSA was on the rise I have more imaging before restarting ADT. CT and bones scans at first. Then PSMA scans as they became available. My MO, and my insurance co, required that I wait until my PSA reached at least 1 before having the PSMA scan. When the scans indicated my PCa was again active I resumed ADT.

[Hawk56]

Here's my story, a study of one, decisions I've made based on my clinical history. Have they been the right decisions, would the outcomes have been different if I did something else, I'll never know since I can't clone myself and use that clone as a control group.

I know this, I've made the best decisions weighing my clinical data, the advice of my medical team and the dizzying and vast array of clinical trial data.

My decision criteria after triplet therapy that started in Jan 17 and ended in May 18 with my Last Lupron 90 day shot was to wait until I had three or more consecutive increases spaced 2-4 months apart and PSA between .5-1.0. That would prevent me from acting on lone wolf lab results and a decent statistical probability of imaging locating the recurrence.

That criteria was met in April of this year, the Plarify scan showed a single lymph node, my radiologist recommended SBRT and systemic therapy given the micro-metastatic disease too small to be seen by the imaging. My oncologist agreed with the SBRT and initially thought 24 months ADT, Orgovyx and Xtandi as curative.

I looked at my oncologist and said I'm in the group that generally thinks advanced PCa is not curative, rather managed, especially given my clinical history. He pondered for a minute then agreed.

So, this time we did SBRT and Orgovyx. The radiologist and Oncologist agreed to hold the Xtandi pending my response to Orgovyx. When at the six week pomt it dropped from .77 to .16 then at three months to <.04 and stayed there, we decided to keep the Xtandi in reserve.

The "team's current thoughts" are to do 12 months of Orgovyx, if PSA remains undetectable, stop and actively monitor with the same decision criteria.

Is that the right decision, TA will say no...however, it is my decision, made based on my clinical history, my homework, the balance of quality and quantity in life and my medical team's support and agreement. I mean hey, last time the head of a NCCN Urology Department disagreed with my decision to do triplet therapy, said he would do lifetime ADT mono-therapy... He was of the mindset to do progressive and sequential treatments, each destined to fail, while I was of the philosophy to combine and bring forward in treatment to overwhelm an aggressive cancer. Was he wrong, was I right, I believe I was, think my clinical data supports my choice. That was a nice 4-1/2 year break off treatment.

Kevin

Clinical History

[Mgtd]

Similar story. My plumber said do a “Roto Router job” and my electrician said he would “zap it”. I trusted the electrician more so I had radiation.

Happy Thanksgiving to all.

[TCMG]

The question is what if the mets is located in an area difficult or risky to zap? Then what do you do?

[6357axbz in reply to TCMG]

chemo? Pluvicto?