When to Commence ADT and/or Androgen Blocking Therapy?

[Biochem]

Greetings All -

New to this forum but have followed the Healing Well PC forum since beginning treatment in 2018 and later began to follow Prostate Cancer News, Reviews and Views which referenced this forum.

The details are provided below but my question is: At what ultra-sensitive (LabCorp) PSA level is it advisable to consider commencing ADT and/or androgen blocking therapy such as ERLEADA?

Routine screening at age 60 (2017 ) flagged my PSA at 4.0. I had a follow-up exam and biopsy and I was diagnosed (Gleason 4+4 = 8). I elected an aggressive treatment path - RALP followed by adjuvant radiation therapy given my high risk surgical pathology: pT3aN0MxR1, Gleason 4+4 (tert 5)=8, positive margin, extra-prostatic extension.

I have had a good run from finishing radiation in July of 2018 (undetectable (<0.006 or <0.014) until June, 2023). In December of 2023, I rose to 0.024 then bounced down to 0.019 in March and up again to 0.028 yesterday.

Given my adverse pathology, I am not content to wait until I am considered in biochemical failure (0.20?) or PSMA-scan-positive (not sure what the corresponding PSA level is for that). Presumably salvage RT is an option but I assume that means waiting until I progress to the point where I am scan-positive.

It could be that I will stabilize and/or bounce around somewhere in the 0.0## level but I'd like to know what's next if my numbers continue to rise. I am 67 now, otherwise fit and healthy and inclined toward a continued aggressive approach to treatment.

Does anyone know if androgen deprivation therapies and/or androgen blockers are considered when uPSA levels are rising but below what is considered a biochemical recurrence or identifiable on PSMA scans?

Thanks to all!

[Justfor_]

Post RALP, I have had no treatment until hitting PSA of 0.17. Only close monitoring and PSADT assessment. At that point, started this:

healthunlocked.com/prostate...

[Tall_Allen]

uPSA will only create anxiety. Try to get a conventional PSA test (lowest value <0.1) if you can.

[Hawk56]

As TA says, USPSA can create anxiety...just because we can measure, should we....? With PSA tests to a single decimal point, the definition of BCR was universal and acceptable, PSA >.2, with two consecutive increases.Under that definition, your an dyour medical team would be using your time during consults to talk about vacation, sports..

Along comes USPA along with imaging capable of locating PCa at levels below .5, some even possible at .2. That capability did not exist when we tested to a single decimal point.

The question is, what do we do with the data from USPA. As TA and others will say, it can vary for a number of reasons, When my urologist switched me to USPA in 2019, first test came back at .36, I was ready to hit the "treat" button. I asked, well, told, my urologist to to repeat the test two weeks later, .24, six weeks after that, .06. When I asked him why, he shrugged...

In 2020, it did more or less the same thing, we both just watched it rise and fall. Why, well, we had put in place decision criteria...

Three or more consecutive increases spaced 2-4 months apart.

PSA between .5-1.0

That criteria would cause us to image, and informed by clinical data, decide on treatment, if, when, with what, and for how long.

That decision criteria was met in 2023, we imaged, it showed a single PLN though we knew there was micro-metastatic PCa elsewhere. We discussed a treatment decision. My going in position was SBRT with si months ADT, Orgovyx. His position was SBRT plus 24 months ADT, Orgovyx, combined with an ARI, Xtandi. When I asked why, he said it was potentially "curative!!" I said given my clinical history, that is not likely so let's manage this as a "chronic" disease. We settled on SBRT plus 12 months of Orgovyx, hold the Xtandi and add if PSA doesn't drop to undetectable in first three months, it did. AT our nine month point he asked me to think about 18 months vice 12. He didn't have the data about a change to OS and PFS and I didn't have the data about becoming castrate resistant. We compromised, he agree to come off at 12, I agreed I would see him very three months and oif PSA came back (same decision criteria), image and go back on treatment, consider a longer period and adding the ARI. Was that the right decision, who knows, time will tell if it was a "good" decision!

The question you need to ask is would any treatment decision now change the outcome versus waiting for a longer period to have more clinical data that shows a definite upward trend and possibly imaging to locate any recurrence?

Given the clinical dat you describe, yours, like mine, is high risk and requires active and aggressive treatment. You may not be there yet. If your treatment decision is say doublet therapy, ADT +ARI or triplet therapy ADT+ ARI+Chemotherapy, waiting for PSA to reach a level where imaging can possible locate the recurrence doesn't necessarily change your decision. If you think you may want to know where the recurrence is so radiation can be in play, say SBRT if it shows one to three locations, then wait?

Based on the clinical data you describe, you may not be at a decision point on treatment, insufficient clinical data, treating now may not change the outcome versus waiting...

The eternal dilemma given the vast changes in treatment and imaging over the last decade and more in the medical research pipeline, over vs under treatment, balancing quality and quantity of our lives.

Let the forum know your decision after discussing with your medical team

Kevin

Clinical History

[vintage42]

"... treatment in 2018... At what ultra-sensitive (LabCorp) PSA level is it advisable to consider commencing ADT... I am not content to wait until I am considered in biochemical failure (0.20?) or PSMA-scan-positive... "

I would commence ADT now before BCR and possible mets.

I had radiation treatment in 2021. In early 2023 I had BCR (5.71) with met to a node, and the urologist said pelvic radiation would avoid need for ADT. In late 2023 I had BCR again (3.78) with met to a distant node. Then I practically begged for ADT. I wish I had known enough to take ADT after initial treatment, but that MO said it was optional at age 78 and it was OK if I wanted to skip it.

I have been on Orgovyx 6 months and Abiraterone 4 months with no discomfort. Wish I had done this 3 years ago; it might have avoided Stage IV.

[Biochem in reply to vintage42]

Thanks all for your well considered and thoughtful comments! Will report back, as appropriate, once I have discussed my options with my physician. Thanks again.