So this is possibly the dumbest question I have asked. But the knowledge on this forum is worth tapping into even for people like me who struggle with all the complexities of PC.
So, - ADT suppresses PC but will not kill it.
Chemo on the other hand finds the PC cells and kills them.
So why do we put ourselves thru ADT side effects to just suppress this disease? Why don’t we all suck it in and do the full Monty with Chemo and kill this stuff.
From what I’ve heard the SE’s of ADT are in many cases worse than Chemo.
Just putting it out there. Sorry for my total lack of understanding of this entire treatment process but would love to know why we don’t first hit the PC with the big guns instead of the cap guns .
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Mike58
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ADT supresses the production of testosterone which PCa feeds on so it will kill some of the cancer cells but others become resistant and find other things to feed on. A second line hormone drug (ARI) such as Abiraterone or Enzalutamide blocks the uptake of testosterone by the tumours so adds to the starvation of testosterone.
Chemo kills any cells that are actively growing/dividing so works on active cancer (not stagnant cells). For this reason the current SOC is triplet therapy starting from diagnosis of ADT + ARI + chemo.
Thanks for your reply. The issue I have is that triplet therapy is not the SOC. It seems to be the last line of defense. ADT seems to be the first gun to use but as I’ve said, ADT seems to be a slug gun when an elephant gun (Chemo) is really needed
So - again why don’t we at least get Chemo treatment first, rather than ADT?
I’m certain there’s a good reason for it to be first but to date I haven’t heard any convincing reason yet.
Based on your profile you appear to have localized prostate cancer (has not escaped the prostate). This is an early stage disease and the types of treatments used include active surveillance, surgery, radiation, and ADT. Surgery and radiation are used to eliminate the cancer and ADT is used to suppress any cancer cells that may remain (escaped elimination) and prevent recurrence. Infrequently if your local cancer is diagnosed as aggressive then chemo may be added to enhance elimination. Hopefully you get 10+ years of cancer dormant survival and in some cases completely cured using these treatments. Chemo is not necessarily needed at this stage.
Chemo, Triplet therapy, ARPIs, etc are used in advanced metastatic PC. The cancer is established and not curable, aggressive systemic treatments are used to provide temporary respite from disease progession and death. At this point surgery and radiation are not effective at eliminating the cancer since it has spread and it is not possible to identify and target all the sites. Systemic chemo will knock the cancer down temporarily but not eliminate it. Eventually the cancer will mutate - develop resistance to systemic treatments.
You do not want to progress to advanced PC from localized PC.
Treatment strategies and options are based on RCTs conducted at the various disease stages and are selected in the clinic to give patients the best possible outcome given their disease stage.
I, too, was curious as to why Triplet treatment was not SOC! Thank you for asking and thank you to Benkaymel & skiiingfiend for such easy to understand replies.
No need to apologise for your lack of understanding this desease Mike. We all are confused at the start of this journey & learn from comments like the above.
I think the main answer is that medical standards of care generally evolve very slowly, and ADT has been around for a long time as an easily prescribed and delivered bandaid to kick the can down the road. That's why I sought oncologists who are leading edge in adopting new approaches.
Another reason may be that negative side effects of ADT are probably not as obvious to doctors as they are to patients. Several years ago at one of my support group meetings there was a guest speaker who had just inherited the product management responsibility for Lupron. When I asked the person about the weight gain most guys experience with Lupron, the person said they were not aware that was a side effect.
For my third recurrence of PSA, I'm planning (with my oncologists' concurrence) to get another round of chemo (cabazitaxel this time instead of docetaxel) instead of ADT. My prior docetaxel + prophylactic radiation of lymph nodes above the local area gave me 4+ years of undetectable PSA. For me personally, several years of freedom from ADT is well worth the side effects from chemo or radiation.
I believe that ADT is more of a targeted treatment where as chemo just destroys all cells. So chemo may be more 'effective' in some circumstances, but can can also be more devastating. You may get better treatment by trying the less destructive method first for as long as possible and when you become resistant, switch to the other treatment. It's not unreasonable to assume that maximizing less devastating treatment first could potentially improve the survival chances by leaving the chemo till later. I.e better disease management outcomes.
Chemo works better the earlier it is used because it can only handle the tiniest tumors. If you wait until tumors grow larger, it may be too late for chemo to be very effective.
ADT was more devastating to me than docetaxel was. Every patient is different.
My husband has been on abiraterone (Zytiga), prednisone and Eligard shots every 3 months. He just finished 28 treatments of IMRT radiation. He has had VERY little side effects. In fact, the radiation caused his urine stream to be thinner, but that’s already resolving. As for the ADT, the only thing it’s affected is his libido. And shrinkage of genitals. He’s 71 and was diagnosed with Stage 4 metastatic Gleason 9 prostate cancer in December. Small mets to ribs and clavicle. (3) and to lymph nodes and seminal vesicles. He hardly even feels like he has cancer and definitely minimal side effects to ADT so far. Part of me wishes he was on Triplet therapy, adding docetaxel, but on the other hand, it’s his body and he’s the one who would have to experience side effects. So, we’ll see what his PSA is next month to sew where he’s at.
Thanks Ron and MrG68. As most would agree, this entire PCa stuff is the most complicated issue to deal with and everyone is so different in their reaction to the various treatments out there. To some ADT is a walk in the park and to others its a trip to hell. To some Chemo is very hard to take and to others - not a problem. Two things I am learning on this forum that helps and that is Positive Thinking and Physical Exercise. Both good things to do even if you don't have any cancer issues.
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Chemo as first treatment
Testosterone and ADT break 
18 vs 24 mos ADT 
When ADT fails, we continue it anyway... why not Zytiga?
