ADT vacation with bone mets?

[Jojoteacher]

Did anyone with bone mets get ADT vacation if the treatment was successful? My husband was diagnosed in 2023 with aggressive metastatic PC with bone mets. Triplet therapy and ADT were successful in reducing the main tumor and mets by a lot. According to him, in his last visit the nurse practitioner mentioned something about stopping ADT after 2 years (This is at City of Hope, so a very reputable cancer center). I think that he heard wrong and I’m planning to clarify with the oncologist when she returns from maternity leave. Has anyone been recommended / experienced some kind of ADT break with bone mets? Thank you.

[GP24]

If the mets were detected with a PSMA PET I think a break will not shorten overall survival. The studies about intermittent ADT did use bone scan so they included patients with mets which a PSMA PET detects today.

[Derf4223]

Sounds like my situation plus the 21 months of ADT+Abi. My oligomet "bone mets" were small PSMA-PET/CT scan spots, and were not biopsied. My PSA dropped to undetectable almost immediately and has stayed that way. Based on trials applicable to me, my MO has me pausing ADT now, and hopefully my PSA stays low indefinitely. If not, rinse and repeat.

[Fiddler2004]

Hi JoJoteacher. What was your husband's Gleason score at time of diagnosis? What is is current PSA? BAT therapy works for some (alternating ADT on for a period, then a "vacation"). However not recommended for others, especially if cancer is aggressive

[Retireddoc in reply to Fiddler2004]

BAT therapy is different from taking an ADT "vacation". It involves the IM injection of Testosterone while ADT is continued and is used for men with castrate resistant disease. See excerpt from a article by Denmeade et.al. in Prostate 2022 on the subject:

BAT is a new treatment approach for asymptomatic men with castration‐resistant prostate cancer. BAT involves administration of sufficient amounts of testosterone to rapidly achieve a higher than normal level (i.e., supraphysiologic) of testosterone in the blood (Figure 3). The normal level of testosterone in the blood of a 70‐year‐old‐man is 300–400 ng/dl. The testosterone level in a man on ADT is <50 ng/dl. BAT is achieved by injecting a long‐lasting (depot) generic form of testosterone known as testosterone cypionate into the muscle of the buttocks every 28 days. The dose of testosterone cypionate is 400 mg. This is considered a high dose of testosterone but this dosage is within the FDA‐approved dose range of this drug. The term “bipolar androgen therapy” was coined to reflect the fact that over a 28‐day treatment cycle, the blood levels of testosterone oscillate between the polar extremes of supraphysiologic (1000–3000 ng/dl) to nearly castrate (100–200 ng/dl). In order for this to occur, all patients should continue to receive concurrent ADT throughout treatment with BAT, and ADT should not be stopped when BAT is administered.

[Schwah]

I had three mets snd went on my first vacation after 28 months and then found another met 18 months into my vacation so went back on meds for a year. Now 27 months into vacation # 2. My latest PSMA scan was clean so for now my vacation continues.

Two key aspects. You need to do a minimum 28 months on meds the first go round and a minimum full year with undetectable PSA. No proof but I highly recommend SBRT to any mets to zap them.

BAT is a hail mary. Do not try it at this stage. A good percentage get way worse with BAT

Finally you will hear that vacations reduce survival. There is no evidence of that. One study showed a small decrease in survival with intermittent ADT, but not statistically significant. And no intermittent studies on patients doing doublet or triplet therapy.

Schwah

[Aldo62 in reply to Schwah]

Are there studies showing that some get worse with BAT? I have not seen that.

[Professorgary in reply to Aldo62]

From what I understand they can have a good idea by testing but few places can do these tests. I do know you need to be asymptomatic.

[Doseydoe]

I took a vacation for about 2 years. My PSA slowly rose over 18 months to 3.5 then over then over six months later it exploded to 48. I had a PET scan which reveiled 12 new mets including more bone mets on top of the three I already knew about. So, yes it can happen. I restarted ADT, Eligard and Xtandi and had to have radiation to the three major areas. My PSA is now down to 0.01 so perhaps taking a vacation in hindsight was not the best decision. Having said that, I enjoyed my vacation and travelled the world with strength and libido. Just my experience. DD 😎

[Concerned-wife]

some high ranking centers are suggesting this now. My husband was on vacation until recently. He is back on treatment waiting to hear if they can safely zap the one new met. If so, he can try another vacation in 6 months if PSA becomes Undectable again. Only given a 30% chance that this will then allow him a long vacation If no radiation of the Met, no other vacation recommended

This is uncharted territory..I think they are trying to mitigate the bad effects of ADT knowing they can catch measurable Mets with PSMA. We know PSMA doesn’t see micromets.

[EdBar]

I had numerous bone mets at dx that responded very well to treatment, I was undetectable for 6+ years. I was given the option to try intermittent ADT a couple of years in however I had a couple of really good oncologists advise me “if it works, don’t fix it”. So I stayed the course and I’m glad I did. 10+ years now since dx I’m now resistant but my PSA remains very low, and when it begins to rise I get a scan and hit it with SBRT. PSA has retreated twice using that strategy, and ya I’ve remained on ADT the entire time since dx.

Ed

[InqPers]

Yes, I'm on ADT vacation now (first time). In short Dx Jul 2021 RP (Gleason 4+3), immed biochemical recurrence (PSA of 3, 1 bone met, 1 pelvic lymph node), Triplet (ADT, Aby, Docetaxel), complete response (PSA <0.1). Also had IMRT to prostate bed, pelvis, and bone met. I was on ADT/Aby for 24 months and complete remission (negative PSMA scans and PSA <0.1) since Feb 2023, so I opted to come off treatment in Oct 2023. So far so good. Just had a clean PSMA and am getting my PSA checked again next week, so I've been on ADT vacation for 12 months so far. I'm one of those optimists hoping I got it, but if not cured, hoping for as long in remission as possible. Yes, this is uncharted territory, but I have to know if my aggressive approach has been successful. In any case I have not read that intermittent is worse approach, so giving it a go. I'm told that if ADT should be done for at least 18 months before trying a vacation. Hope this helps and good luck to you!

[Hailwood]

I have distant Mets but no bone Mets. I can live with the side effects as there has been no shift in my numbers or my overall health. I will remain on the treatment that got me here.

[Tall_Allen]

If a patient needs and wants a vacation and understands the risk, he can request one. Here are the data:

prostatecancer.news/2023/04...

[GoBucks]

There are trials now going on where guys who have responded well go on vacation. They are mentioned in this article. ncbi.nlm.nih.gov/pmc/articl...

Even though I was upstaged to gleason 9 and had bone mets I was a super responder. After 4.5 years of lupron + Abi I stopped in June 2022. Still blessed to be <0.01. Feeling much better. T recovery was not happening so I just started supplementing. Feeling stronger every week.