Hello, all. There is a lot of knowledge in this forum. Please let me ask this age-old question once again, to see what percolates up here. Many thanks for any wisdom on this.
It's the question of whether to stop ADT after six months, instead of completing the two-year course prescribed by my MO and RO.
5 1/2 months into ADT (Orgovyx/relugolix), I want to stop after finishing this bottle (month 6). I am high risk, localized (PSMA PET and bone scans found nothing, Gleason 4+3, pre-treatment PSA 44, current PSA 0.24) and I had RT, including lymph nodes. My MO says the evidence shows that finishing the two years of ADT will give me a significantly higher probability of surviving ten years. I'm 59.
But I see several recent studies that show it's not so simple. They indicate that six months is certainly a good idea but continuing to complete a full 12, 18, or 24 months may have no benefit when the patient's PSA has reached a nice nadir (0.06 ng/mL or 0.5 or 0.3, depending on which study you look at. I'm looking at 2022 study by Ayoub, et al, and a couple of 2012 and 2013 studies by D'Amico and by Zelefsky.) There are other relevant studies, one by Zaorsky, arguing for 19 or 21 months being optimal and better than 24 due to worsening quality of life. A review by Anderson (2022) says continuing ADT after six months has only a small benefit.
When I ask, "Can't I just go back on the ADT if my PSA rises?" My MO and RO say it isn't so simple. RO says the cancer cells, if any, will have gained ground on me by then. MO simply points to the data on long-term survival again.
I wish to stop because of fatigue and muscle loss and concern about other bad side effects rearing their heads. It is difficult for me to imagine completing two years. My MO says he will continue to support me medically if I take this decision, even though he advises against it.
My conclusion is that I am in a gray area. It's not clear cut. At this point it's a matter of placing my bet. Neither option is clearly the more prudent one. I am about 80% the way toward deciding to stop ADT.
Any tips, advice, wisdom, recent journal article refs most appreciated.
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JustJimmy
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I went with SOC. 44 IMRT to whole Pelvic bed and 2 years ADT. I didn't like it at all. In the beginning I thought it would never end, same for those 9 weeks of radiation. I got into a routine, walked, worked out and had a one day at a time mentality. Before I knew it my 2 years were finished. I'm now 8 months done and I feel great. I also feel that by doing the deed I've extended my life which I cherish so much.
You could get a Natera test (assuming you had a biopsy). It wouldn't be conclusive but it would be some evidence. I had one a few weeks ago. It came back negative, which is good but not conclusive. Now that you're off ADT, I would put more weight on a negative result if you got one. Taking the ADT off the table removes a question mark as to whether it might be keeping any cancer cells in a dormant state and not shedding DNA. Then again, even a positive result might only indicate that your immune system is killing any remaining cancer cells, so not conclusive. But interesting, nevertheless.
it does do better the longer you do ADT but there is always the question of whether you are just keeping the cancer in abeyance due to keeping testosterone at below castrate levels. Or whether the radiation really does kill the cancer off better with the ADT for longer periods of time. i'm not sure there is really truly a way to know that for sure other than the studies that seem to indicate a better result for a longer term of ADT. you could just make an executive decision and say I'll do a year. I mean, this stuff is up to you. Doctor of course are going to cover their ass and request you do the maximum.
Would you stop an antibiotic for a bacterial infection earlier than prescribed? Of course not. If you go "80% of the way," You would be selecting the most resistant 20% of bacteria and encouraging them to take over.
It sounds like you are following the POP-RT protocol. Resist the urge to tinker. It's not a "gray area" -- we have a protocol that is proven to work, and you want to imagine a protocol with no proof.
PCa is different, because whatever we do Darwinian selection always rears its ugly head and finishes us off - unless we pop our clogs before it gets that far! If we had a therapy which killed it off totally, like an infection, that would be great.. Just not available yet.
I agree that in terms of anti-cancer efficacy you follow the protocol - (while keeping overall health and comorbidities in mind). But the protocol offers no wisdom on what to do if the protocol is poorly tolerated. I have had really bad experiences with ADT/ARI's - PRES, hyperlipidaemia, weight gain, muscle loss, brain toxicity (spatiovisual impairment/cognition) the whole shooting match. Am 79 in April and I regard every year over 80 as a bonus.
So keeping physically fit as I possibly can (healthy weight, weekly gym, daily 2K, weekly 5K) and enjoying each day as it comes is my primary goal. And I have agreed with two experienced oncologists that intermittent ADT, hitting it each time PSA exceeds an arbitrary figure (around 1.0) is a good alternative to the "protocol" given my experiences and my wish for good QOL.
It is worth just taking a glance at the abstract of these straws in the wind:
Intermittent versus continuous androgen deprivation therapy for advanced prostate cancer. Marlon Perera et al Nature Reviews Urology volume 17, pages469–481 (2020)
Intermittent Androgen Suppression for Rising PSA Level after Radiotherapy. September 6, 2012 N Engl J Med 2012;367:895-903. DOI: 10.1056/NEJMoa1201546. VOL. 367 NO. 10
The use of intermittent enzalutamide dosing in the treatment of metastatic castrate-resistant prostate cancer. Journal of Clinical Oncology. Volume 38, Number 6_suppl. doi.org/10.1200/JCO.2020.38...
Thank you for this information, Doc. My medical oncologist and radiation oncologist were dead set against my suggestion that we move to intermittent ADT of just the kind your oncologists agreed to. The MO said after I quit ADT, if the PSA rises he would treat this a fresh case of possible recurrence and not consider it as time to start up on ADT again as part of a predetermined plan. He had good reasons, namely, Why make and stick to a plan? When the PSA rises, you decide what to do then (watch it for a while, see whether it goes back down, perhaps get a scan, etc.) I can see the reasonableness of both sides on that issue. Thanks for citing those articles.
People come to this forum for help and understanding. And because the forum is indexed on Google, they might find a post or threads from this year or last year or whatever that attract their attention. I find this problematic because sometimes people are treating this forum as a dialogue with friends and friends want to be helpful and kindly. But the information is sometimes than helpful.
One of the problematic topics that persists and discussion of our topic is the idea that one can be cured of prostate cancer after it is metastasized. And that taking a holiday from debilitating drug therapies may be a legitimate option, in some circumstances. It's not.
Generally speaking, my understanding is that once we have metastatic prostate cancer it's more or less a terminal diagnosis. The literature doesn't even support the idea of it being maintainably chronic yet, although one can hope. And there's always the confusion between prostate cancer that is confined to the prostate, that is to say not metastatic, and metastatic prostate cancer. Lazy journalists and fundraisers like to confuse the two.
Non metastasized prostate cancer is something that one might very well live with until the end of a normal lifespan. But this is not the case with metastasis. It's an ongoing battle. And some people have a longer horizon and some people have a shorter horizon. And science seems to be moving forward and one becomes optimistic. But it's still always there and always pursuing its own agenda.
I'm fortunate to have reached 3 years so far, in reasonably and good health, although with fatigue. If I didn't have the advanced therapy regime I enjoy, I probably wouldn't be writing here today.
With this perspective then, my decision making is focused on what I can do to maybe extend the success of my current therapy. It's a framework that does not include any fantasy about returning to normal as in "life before diagnosis".
Please remember, only about 25% of patients with prostate cancer die of it while 75% die with it and die of unrelated causes.
You say taking " a holiday is not legitimate". Perhaps you did not mean it quite like that, but it is just wrong to say it. I don't believe anyone here is indulging in fantasy about "life before diagnosis", we are all trying to navigate difficult and sometimes unanswerable questions to which is there is rarely a dogmatic response.
It really is up to each individual to decide what they wish to tolerate in terms of s/effects, time and money spent on doctor visits, tests etc in exchange for extra years, or months of life.
DANGER WILL ROBINSON! Doctor Skeptic is sharing dangerous misinformation!
** WRONG** "Please remember, only about 25% of patients with prostate cancer die of it while 75% die with it and die of unrelated causes." ** WRONG**
This comment only applies to men with prostate cancer that is not metastasized. I emphasized in my earlier post above the importance of making this distinction when a diagnosis of metastasis arrives. (The statement I'm criticizing is just crazy confusing anyway, because we don't know what the start point is. All prostate cancer starts in the prostate, duh. And then some prostate cancer occurrences are diagnosed before metastasis and some prostate cancers are diagnosed after metastasis, or very much after metastasis, even at Stage 4.)
Don't forget this forum's name is the Advanced Prostate Cancer forum! And until maybe 5 years ago a diagnosis of advanced metastatic prostate cancer gave one a lifespan of a year and a half or two. A terminal diagnosis. Because of the new generation of therapies some men might hit four or five years if they are lucky. It's very uncertain. And it's even exciting because we don't have "endpoints" reflected in the statistics yet for men who have started advanced New generation therapies in the last few years.
It gets more complicated though. Because apparently up to 1/3 of men with advanced metastatic prostate cancer die of heart attack and related CVD problems. And what is meant by this is that these endpoints are caused by metastatic prostate cancer therapies and are over and above the heart attacks etc that one might get anyway.
It took me probably a year to realize that I was completely wasting the precious time I had left by attending regular prostate cancer forums, either in person or online. Because unless the forum says it's about advanced or metastatic prostate cancer, it isn't. And there wasn't a single person, layperson or doctor, that suggested the difference was important.
Your statement is a cliche repeated ad nauseam by lazy journalists. And the price that is paid is paid by men with metastatic prostate cancer who think that what is said about non metastasized prostate cancer is relevant to them. So often it's not. And precious time is wasted. And wasting time with misleading information on this forum is a crummy thing to do.
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P.S. - For members of this forum that didn't grow up in North America, the phrase "Danger Will Robinson!" is what the friendly family robot would say to one of the members of the Robinson family on the hokey TV show "Lost in Space". This was in the 1970s I think. The phrase is now a meme - sort of for people who might not know what a meme is 😂
"And that taking a holiday from debilitating drug therapies may be a legitimate option, in some circumstances. It's not."
It's possible I am shortening my life, but here's my brief history:
RP Jan 2012. BCR Jan 2016. Metastatic to 2 thoracic nodes 2019. Began ADT May 2020 with PSA 5.7. One month later, June 2020 PSA <0.064. Began vacation May 2021. June 2021 and forward PSA <0.064.
PSA undetectable until Oct, 2023. Negative PSMA scan June 2023. Dec 2024 PSA 1.00. So now approaching 4 years on vacation. So almost 4 years with no drugs, no docs, no side effects, no nothin'. Will be 84 in Sep. Patient at a leading prostate cancer center.
I think TA would agree with you, but so far he's been kind and hasn't sent me any hate mail.
For what its worth, I’ve been on ADT for over 4 years now. The first 6 months were the toughest and then I sort of got used to it. As you know exercise is the key to avoiding some of the side effects like weight gain and fatigue. I know my life will never be the same as it was but I’m still alive. I’ll probably be on this for the remainder of my life. From my position, 2 years doesn’t seem like a big deal but we are all different. This whole journey is a bit of a crap shoot for us all. In the end, we don’t want to have any regrets. I told my MO, as he was the only one in the room with a medical degree I guessed I would follow his advice. Good luck with whatever you decide.
A Gleason score of 7, 4/3 is on the more aggressive side. Mine was 7 3/4. To go off of ADT allows the cancer to grow. Even staying on the ADT you will likely find that over time the cancer will begin producing it's own testosterone. Going off of of ADT gives the cancer a foothold while you cant see it.Yes there are side affects, all of us who are on ATD have them. But it is the ADT that is giving us time now. Enjoy life, and find ways to help with the side affects instead of going off of what is giving you time.
This is my viewpoint of where I am, after being on Orgovyx 5 years now. It is working, and I praise God for every day.
Stage 4 with abdominal Mets. Entering 5th year on the same ADT therapy, with no changes in PSA or T. I’m staying on it until changes show growth in tumours or Mets develop elsewhere. Stay with it is my advice
So I was G9 at diagnosis in 2015, BCR in 2016 at which time (63yo, partner deceased, no offspring) I opted for QOL over duration. My PSADT is 10-12 weeks and I'm persisantly oligeometatstic, so much so that on my first SBRT my RO rang six weeks later thinking they had mistargetted.
Single therapy ADT (Zoladex) currently cuts my PSA from 4 to 0.3 in 3 months. Yes, the nadir has increased from undetectable over the last 8 years so the increase TA is concerned about is very mild in my case. My MO doesn't want to add darolutamide in case it invalidates future treatment optons. Gently, gently.
I am more taken by the Moffitt Centre work (Gatenby/Zhang) on evolutionary dynamics of cancer cells than any clinical study. Why? Partly my training as a mathematical statistican and information scientist. TA's comment above is about a monoculture elimination.
Gattenby et al posit an always mixed structure of cancerous cells. Eliminate the easiest to kill and you provide more fuel for the next hardest etc. In cancer treatment this is SoC.
Curiously I have for a long time come to the same view - Darwin always wins. If therapy could eliminate PCa early before any mutants appeared then Darwin would lose. Sadly that is not the case.
Three plus years ago, when I embarked on a self directed adaptive Bicalutamide scheme, I had no _whatsoever_ knowledge of Moffit, Gatenby et al. It was just the obvious thing for me to do.
Thank you for this information. By the way, I think you and I are reasoning similarly regarding family. If my wife were deceased, I would certainly stop ADT at six months. One of my main concerns is that I not die before her.
You must look at how many guys stop or take a break only to find the beast returns. It will, has anyone found a cure for this, no, definitely not.Your treatment is killing off cancer cells, it's not a bout of flu. You either take the side effects or you take the cancer, it's simple.
I started ADT at 56 years old, I'm 68 years old now, never took a break and never will.
Hi that’s a tough question. I have not read those papers but will try to find time over next few days.
Meantime there is the broader philosophical question about the balance between quality and quantity of life. The doctors don’t have to live your life and in the end you are the master of your fate.
The statement that “the cancer will have gained ground on me by then” is not very helpful. Each time it comes back, the real question is whether having breaks in therapy alters prognosis in the long term. (Probably minimal based on one NEJM article). The other key question is how much recovery of T and symptoms you will have between courses of intermittent ADT. You won’t know until you test it.
I will share my experience but I am older than you (79 this April). I had radical in 2009, local radiotherapy for recurrence and PET +ve bone mets 2012, and then in 2022 ADT and enzalutamide (side effects) then apalutamide (side effects) and stopped the lot after about 6 months. PSA started rising again December 2024 and is still only 0.4 having been <.01 and has followed same trajectory. I was not keen to have continuous therapy with ADT and ARIs and got second opinion from experienced oncologist. Final decision is that I am as likely to die with it than of it so am going to have intermittent ADT whenever my PSA hits 1 printing it stops working. I plan to ask for estradiol patches as these avoid some but not all of the effects of T suppression and is equally effective (PATCH trial). When or if that fails I will then decide whether to have abiraterone plus prednisone. Might have had a cardiac arrest before that happens. It’s all a juggling act and the trial evidence only takes you so far in making personal decisions.
While its true modeling p cancer intervention on treatment for bacterial infection differs, the point made above is that one must look at the biomarkers and radiographic evidence, using an expert to determine when to take a vacation.
Looking at the studies of sequences and the difference between mono doublet or triplet therapies may be instructive, using criteria of pfs, radiographic fs, and os.
Based on what Ive read, if one has bone mets, then one needs consistent doublet or triplet therapy.
Their is also, plenty of evidence that SBRT , darolutamide and ADT and/or docataxel will keep PSA down. One should also look into Xgeva or Zometa to reduce "skeletal events" from bone mets. If the thinking is genetic, then maybe genetic testing would indicate special meds alongside.
Looking forward to reading your comments. As someone who is almost 80 I do find that perhaps we may have already come to grips with our mortality and that makes decisions much easy.
Our senior citizen gym group have a New Year’s Day tradition. In the year you turn 80 you are given a baseball cap that says Limited Edition and the year you were born.
Ha! I have such a cap! I have come to grips with my mortality. I paid no admission price to this show, and when the usher comes to tell me it's time to go, I will have not grounds for complaint. It has all been free of charge. I'm very grateful.
I was pleased to read JJ’s question because I had been thinking along much the same lines, so thanks to everyone who has replied below.
I’m approaching 6 months on Orgovyx + Enzalutamide, ie combination therapy. I have had localised RT on my principal lesions. I’m approaching a PSA nadir, so I wanted to go to Enza mono therapy for a while, monitoring PSA.
When people talk about ‘stopping ADT’ do they mean stopping Enza etc too? I’m somewhat confused.
My onc won’t prescribe me Enza alone, by the way, and basically takes the view expressed by Tall Allen below that it’s belt & braces - and for as long as can be tolerated / it’s effective.
I am high risk localised G9(4+5). I have been following the SOC - 37 sessions of RT + 2 years of ADT which started in Dec '23. My PSA is <0.006.
I had toyed with the idea of cutting ADT to 21m - i.e. last prostap injection in June '25. However, although I would love to get off ADT, I do tolerate it relatively well with no hot flushes, no weight gain and preservation of most muscle with a lot of exercise sessions. For the sake of 3m, I have decided to go the full whack and have the last injection in Sep '25. I would forever blame myself if I had BCR and had only done 21m. If I do the 24m and get BCR, at least I would feel I had followed the full treatment plan and given myself the best chance.
If, over the next 6m, new data comes out then I would think again.
Thanks for the reply, MarkS. Just in case you're interested in the 21/19 months optimum (rather than longer terms) suggested by Zaorsky: The articles I mentioned in my post are "Optimal Duration of Androgen Deprivation Therapy..." Int J Radiat Onc Biol Phys 14(3) Supplement, 2022 and a similar one that is on urotoday.com and found by searching for Zaorsky Optimal Duration of ADT.
There's another iADT trial for metastatic patients going on right now too. In addition to Dr. Choudury's A-DREAM at Dana-Farber, Google the "De-Escalate EORTC 2238 trial" to find it.
I'm not enrolled in A-DREAM, but I'm following the parameters under supervision of my team. My last shot of ADT was in August, last Nubeqa pill Dec 31st, with PSA and T testing every 6 weeks for the first 6 months, and scans in May or June. I'll keep everyone posted.
I finished my 24 months of ADT after RT. If you don’t like fatigue and muscle loss, there’s a well known detour: exercise, both CV and weight lifting, and diet. It’s not getting better, if you stop ADT and your cancer cells might just loving it. Just my opinion.
Thanks, Nusch. I am an exercise fiend, so I have that covered. Let me tell you how bad the fatigue was. Working full time (job on my feet doing what is equivalent to light gardening level of exercise) I was too tired to work out. I had been working out religiously for 25 years. So, the fatigue was very bad. I stepped down to part-time work a couple weeks ago, losing my health insurance policy, tightening my belt, etc. Now I have enough energy to work out. This is a consideration weighing in favor of continuing with ADT for a while longer.
If you decide to continue ADT, I would strongly suggest using supplemental estradiol patches or gel/creams to mitigate/eliminate hot flashes and mitigate/eliminate osteoporosis due to having essentially zero estradiol when chemically castrated.
Also, you may want to consider following the PATCH phase-III tE2 protocol, which demonstrated that you can safely and effectively replace Lupron ADT with estradiol patch ADT and have the same safety profile and survival probabilities as traditional ADT.
When doing estradiol ADT, studies have also found that blood glucose and bad cholesterol levels are lower, while good cholesterol levels are higher.
The main downside of estradiol therapy is mild to moderate enlarged breasts and breast sensitivity. You can look up the papers by Ruth Langley et al. on the PATCH trials in Google Scholar.
This is an excellent point. One thing weighing against this point is the two papers on nadir PSA being "low" (<0.5 or <0.3) by D'Amico and Zelefsky I mentioned. Mine is 0.24 at 5.5 months But those two papers by no means a refutation of your point. (The paper by Ayoub does not count against your point because it used a nadir of 0.06, which I assume counts as undetectable.)
Another consideration is that healthy prostate tissue also can cause there to be some PSA. My MO said this the other day when I raised a similar point to yours. He said it's possible that I am cancer-free now and have some healthy prostate tissue left after the RT causing a detectable PSA. There is no way to know, of course, so this consideration, too, is by no means a refutation of your point. (My MO wouldn't even agree that it's okay to stop now ADT even if the PSA were now undetectable, so in his view it's a moot point anyway.)
I just stopped Orgovyx after 10.5 months. I discussed the studies you referenced to support the decision to stop before the originally specified 18 months. My RO was very familiar with them and he started my meeting by saying "you can stop now". However, I had 28 sessions of RT including the nodes but - and the papers discuss this- I also had LDR brachy, and 6 months of ADT was not inferior to 18 months or longer. (He did not think 6 months was sufficient, BTW) I'm not where my files are located to give specific information so this is from memory. Check them and I think you'll see the shortened durations were due to the brachy.
Thank you for this info. The papers I mentioned were not for brachytherapy patients but for RT-only patients like me. The brachytherapy paper you must be thinking of is Yorozu, et al, "Results of a multicenter, randomized..." J Clinical Onc 41:6 2023.
As you can see from the responses, there is no definitive answer,..
My experience, my choices, in concert with my medical team.
When I did triplet therapy, the starting plan was six cycles of Taxotere, 24 months of Lupron and WPLN radiation, 45 Gya spread out over 25 treatments. There was discussion about adding an ARI.
As we progressed, based on my response to the ADT and Taxotere, we decided the ARI was not needed. After about a year, I discussed with my medical team coming off the Lupron at 18 months versus 24 based on various clinical trials looking at 6 vs 18, vs 36. They agreed. Keep in mind, my PSA was undetectable in the first three months, a key data point in determining statistically the probability of a durable remission.
That triplet therapy brought a five-year remission, T returned quickly.
April 23, PCa is back. Again, the discussion with my medical team. We agree on SBRT to the lone lymph node identified in the scan, what we don't agree on is the length of ADT to deal with the micro-metastatic PCa too small to be seen by imaging. My going in thought was si months, my oncologist's thoughts were 24 months + ARI (EMBARK).
After some thoughtful and deliberate discussion, we "settled" on 12 months of ADT (Orgovyx), only add the ARI is PSA did not drop to undetectable in the first three to six months and at 12 months, re-visit our decision and decide whether to continue the ADT to 24 months or comer off and actively monitor.
We did not add the ARI and came off treatment at 12 months.
Was our decision the right decision in either case? We'll never know what the additional time on ADT would have meant to the outcomes, What I know is we made the best decision with the clinical data we had, and my medical team and I were comfortable with our decisions.
As others have said, mitigating the side effects of ADT is possible:
Exercise
Diet
Managing Stress
If the hot flashes are extreme, talk with your medical team about medications to mitigate those.
I am in the camp that generally believes advanced PCa is not curable, at this point in time.
I believe it may be manageable with a wide array of treatment choices, though not for all (I had a friend pass this year after only 12 months from diagnosis).
Part of the decision also is the length of time off treatment and the rate of T recovery.
You have obviously made a big effort to have a better understanding of the benefit of extended ADT following RT. Have you discussed the Zaorsky paper with your Docs? I think it is undeniable that the marginal increase in benefit from longer ADT duration plunges as a man passes 12 months of ADT.....most dramatically seen when looking at overall survival curve. For remainiing free from detected metastases, longer duration of ADT is more beneficial...The curve actually shows lifetime ADT would be the best choice. Yet for overall survival, that is not true!!
I notice many in this conversation are referrinng to ADT use when already metastatic, but I understand your situation is that you are non-metastatic and concerned about the duration of ADT after "curative" radiation? Some of the top PCa Docs express their uncertainty about the 24 mo current SOC ...and new trial are underway testing the value of "just" 12 months. As to your particlar case there are some studies that have found a PSA nadir of I think < 0.2, or perhaps even closer to undetectable, are good markers for a successful long-term treatment......if you haven't reached that low nadir, maybe even more important to continue the ADT?
Deciding to do less than 24 months is in no way a guarantee that the pCa will metastasize/kill you!!
Thank you for this excellent reply. Right on point.
1. I was going to mention the papers to the MO the other day but just packaged the idea in terms of stopping early. He was 100% against it and we had a nice discussion. I should have mentioned the papers. I will ask for a phone visit.
2. Yes, I was given "curative" RT/ADT. My docs are aiming for a cure because the scans found no metastasis. I apologize if posting here is inappropriate but the forums for high risk PCa seemed dormant and I noticed that others in this forum had posted on high risk PCa.
3. Yes, what you said about nadirs, I agree. On the other hand, the Zelefsy and D'Amico papers say that there is something to the 0.5 or 0.3 nadir.
I'm considering going another six months for a total of twelve.
There are studies which point to a PSA nadir of undetectable as an important clinical data indicating better progression free survival when stopping.
In retrospect, had my PSA not dropped to undetectable in the first three months of both treatments, we would have added the ARI and gone the full 24 months.
The disease is too heterogeneous for any of us to give you any advice on stopping that would assuredly guide you, In the end, no matter how open minded you try to be, it is not only Darwin but confirmation bias that rules.
You want to stop, ok. There’s plenty of expert medical opinion that supports it. There’s also plenty of hard data that supports staying the full course.
However, past 6 months to a year at most, side effects often put a man in your position. They are indeed uncomfortable, but the health consequences of the resulting co morbidities are the real issue. Overall survival endpoint markers for a longer life on ADT mean little if you hasten the advancement of say, heart disease. Which of course kills 10 times more men annually than prostate cancer in the US alone.
On the other hand, I would not be talking about intermittent casually if I had a realistic shot at cure, which you may.
Intermittent means just that: off and on for life. It also means with each ‘break’, the respite from side effects is less as return of testosterone (if any) is lessened. The breaks also become shorter. Relief from sides becomes more placebo effect, possibly in exchange for giving the disease opportunity.
Yet this is all well worth it if you are metastatic. If not, your first shot at eradication is always the best one, and ADT can be the difference maker. Again, you obviously can’t know for sure.
What you do know (hopefully) is the state of your physical health. How much do you exercise and what kind? What co morbidities do you either have or are at considerable risk for? IMO these are a much better guide than anecdotal evidence and confirmation bias when making this all important decision.
They were for me: I stopped early in September of ‘21 and have been free of recurrence since I did.
Absolutely nothing can predict success or failure in this. Regardless, it is impossible to overstate how important a combination of both weight bearing and cardiovascular exercise is to your decision. Your ongoing fitness and strength is a more valuable metric in your favor any other.
Excellent reply, London. My health, aside from PCa, is excellent. I do weight lifting and some pretty plyometric (explosive bursts) calisthenics, plus long walks every day and plenty of yard work. This had been my lifestyle for about a decade, and before that I also did a lot of running. The ADT knocked almost all of that out of me. I didn't have the energy. I therefore stepped down from full-time to part-time work last week and am now back to my exercise routine, having enough energy.
JustJimmy. Its hard to weigh in without your bio info...dont know what treatment you had so its hard to pass on my research. If you can fill that in it would help.
But, if your PSA is not going down with ADT, and 0.24 as a nadir is high, then stopping ADT may not be in the cards. Of course, if you had Radiation Treatment (RT), then this may explain this PSA; again the need for bio info.
So if you can fill in your bio we can better aim our joint research at your questions. TNX Rick
Thanks, Rick, I did put the RT in the original post. I had pretreatment PSA of 44, no mets found by scans, went on ADT, had RT of prostate and lymph nodes, PSA kepts descending until current 0.24 of last week. I will look for the nadir ASAP. Perhaps I have not yet reached it.
Something that most do not consider or know about is that castrated men live significantly longer than noncastrated males, 13-14 years. The main theory behind this is that low testosterone causes it. And the longer you live, the more likely you will be cured.
Following up on what janebob99 wrote above, you might explore with your medical team the option of using high dose transdermal estradiol (E2) for ADT. The data on that option are just now coming out and it is admittedly still an off-label treatment. However given what the STAMPEDE team in the UK has presented on it in the last few months at ESMO and ASCO-GU, it is certainly something you could discuss with your MDs.
The were experimental (pre-clinical) data published a decade or so ago suggested that high dose E2 can reduce fatigue. Also, as a form of ADT, with tE2, you'll have few, if any, hot flashes and bone mineral density is likely to be better maintained than on the standard ADT drugs. And there is some circumstantial evidence that E2 may also be somewhat cognitively protective and preserve libido to some extend.
I can provide more information, but I prefer to discuss E2 with individually via voice or video, and not on chat lists with folks hiding behind pseudonyms. [Also I am a slow typist.]
Contact me individually if you wish to discuss the pros and cons of using tE2 at high dose (for androgen suppression) or at low dose (to mitigate side effect of the natural loss of E2 with standard ADT).
Thank you, Richard. I am indeed concerned about cognitive decline. My MO says he has patients who believe that ADT has cost them a few IQ points. Not that I am worried about it leading to dementia, but I very much do not want to lose any IQ points at all because my vocations and hobbies require all the points I have now. I will think about this and get in touch. Jim Ryan
I have been on Firmagon and Xtandi for five years and my PSA has been <.01 for the time period. Only thing I would even think about changing would be from Firmagon to Orgavyx. Even still I’m not willing to rock that boat.
UPDATE: I just spoke with one of my docs about a thought I'd had and which maley2711's reply here chimed in on: Why am I not continuing ADT until nadir is ascertained (hopefully just a few months) and then reconsider stopping? This makes more sense than stopping now, looking at the Ayoub article I mentioned.
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Newly detectable PSA after prostatectomy: RT + ADT planned; add Erleada?
PSA level six months Eligard
When to start ADT, 
ADT or no ADT
