Intermittent ADT

[rocketphd]

I am 72 years old. I am six years out from my RP. I had prostate bed radiation when my PSA began to rise after RP. About two years After the radiation, a solitary metastasis to my right lung was removed using radiation. Apart from the lung metastasis, my scans have been clear. I am two years out from the radiation to remove the lung tumor. I have been on Lupron ADT for that two years and my PSA has been undetectable all of that time. The ADT side effects of any seriousness have been hot flashes and memory issues. My MO has recommended starting intermittent ADT at the end of my current 3-month Lupron shot. Could anyone comment on the long term effectiveness of intermittent ADT and the relief from side effects? Thanks.

[Tall_Allen]

There are no set protocols for intermittent ADT. The variables include:

• type of ADT used (e.g., Lupron, Lupron +Zytiga, Casodex, Estrogen patches, etc.)

• the duration of the "on" cycle

• the duration of the "off" cycle

• goals for off cycle (e.g., testosterone recovery, reduction in hot fashes, feeling better)

• triggers for ending vacation (e.g., PSA, PSADT, radiographic, pain, time)

• when to stop iADT (e.g., PSA no longer goes down sufficiently)

[6357axbz]

You may find this relatively recent study helpful:

New Protocol of Intermittent Androgen Deprivation Therapy for Patients With Metastatic Prostate Cancer: A Retrospective Study.

ncbi.nlm.nih.gov/pubmed/315...

[Magnus1964]

If you have not been on any ADT drugs I don't see the purpose of intermittent treatment. Why not a daily dose of casodex, xtandi or zytiga.

[6357axbz in reply to Magnus1964]

Don’t understand your response Magnus. The poster is on ADT. IADT is only relevant to patients on ADT, such as the poster.

[Magnus1964 in reply to 6357axbz]

Maybe I miss read your post. Is you doctor talking about intermittent Lupron shots? If that is the case maybe it is something I am unfamiliar with. But if you have not yet had Casodex, Zytiga or xtandi, it would seem one of these would be a good option.

From the article it would seem your doctor is trying something else. Intermittent therapy is a kind of last chance for the Lupron.

[6357axbz in reply to Magnus1964]

IADT is simply to take a break from ADT while it’s still working to give your body a break from the deleterious effects of ADT on your body. The literature on continuous versus intermittent ADT is sketchy.

[6357axbz]

FYI, I just began IADT over a month ago. From info I’ve received here I expect the hot flashes will continue until T increases. 6 to 9 months????Someone in this blog previously posted that intermittent should be tried before 24 months on ADT to increase chances of T recovery.

[Jimhoy]

Its not rocket surgery (a pun regarding your handle)!!

I read that as side effects vary, so do recoveries vary!

As for my story;

I had my last 3mo Eligard shot Nov 9th 2018 (PSA=<0.1 and T=18) with devastating side effects.

June 2019, I was still full blown ADT (PSA=<0.1 and T=19) All side effects unrelenting!

Nov 2019, I recovered a bit of T, now 103 and PSA now 0.1! No real noticeable decrease in side effects except for decreased joint pain but added verbal difficulties!

Jan 2020, and I can only assume that my T continues to recover because I have not noticed a hot flash in weeks. I an noticing some pleasing action with my junk (mostly night time / morning wood ( assisted with a nightly low dose viagra)). I also am finding women to be sexy again! So both above are proof that my libido is returning. My mood seams to be improving as well. These things could have also been improving to a lesser extent in Nov but I just didn’t really notice.

Short answer, in my case, its about 9 months to “start” feeling relief from my typical andropause symptoms. I can honestly say that my cognitive issues are not only still there but are worsening. but.... tick...tock....tick...tock, we’ll see what the next few months bring as next testing is in March.

Jc

[Hidden in reply to Jimhoy]

That pretty cool results .😎👍

[Stevecavill]

I’ve been on IADT for 7 years. On average 18 months on 18 months off. I was metastatic on initial Dx so did not have a prostatectomy. I’ve had stereotactic radiation twice. As far as I can tell the evidence for or against intermittent is unclear. So I’m happy to take the break from low testosterone, and my med onc is also happy with that.

[wuwei37405]

Intermittent ADT was a disaster for me. My PSA was 138. Went on Lupron for 8 months and my PSA went down to 2. Took a 3 month hiatus from Lupron and my PSA shot up to 68. Went back on Lupron but my PSA would not go down. The cancer had metastasized to my bones and liver. Now trying enzalutamide. Too early to tell if it is working.

[Horse12888 in reply to wuwei37405]

Wow, sorry to hear this. I would think that this means you became castrate resistant, because 3 months is a very short period of time for your T to recover and for the cancer to grow. Best of luck from here.

[RonnyBaby]

While it is always appreciated when some of the credible sources speak on relevant topics, I tend to be more general in my comments, basically trying to (hopefully) add to the discussions without submitting hyperlinks / URLs to studies, stats and more. Mine is a more personal feedback, based on what I've experienced and read and heard.

I am on an ADT holiday, which may be permanent (if I'm lucky). I had the worst of the SEs that ADT has to offer and quit when I became suicidal.

No doubt in my mind that ADT was necessary and beneficial BUT it wrecked my life once it started to run away on me.

First point to make - there is a lag time before ADT wears off, therefore the holiday isn't instant gratification - nor is it guaranteed.

Some patients will never recover from the ADT- the gonads are fried, so you never recover the 'T' that makes you whole again.

Most of thw SEs are based on the lack of 'T' to maintain the hormonal balance that is the more normal route we expect.

Hopefully, you will recover and benefit from an ADT holiday where the mix is significantly spent off, as opposed to on the ADT.

I, for example, quit ADT in July of 2018. It took more than a year for the hot flashes to stop and it was predicted that my return ti normal was likely to happen in the spring of 2020.

The rule of thumb was as follows - time on ADT = withdrawal time - to symptomatic free time.

Is this really true ?

Not sure, but it sure feels that way .....

[Horse12888 in reply to RonnyBaby]

Wow, that's horrible to read. I had the same experience (suicidality); it really is amazing that one can feel so shitty without being in pain per se. For me, it wasn't the magnitude of the SEs on a minute-to-minute basis, but rather the relentlessness. If could have felt OK for even a few minutes a day, or may even a week, I think I could have managed this, but the ceaseless pounding every second of every day without relief is what eventually wore me down and forced me to quit.

I too had hot flashes for more than a year after, but I started to feel decent again at about the 4-month mark.

Keep in mind that exogenous T is always an option, albeit not a frequently recommended one.

If I have to go back on ADT, I'm going to do it via high-dose transdermal estradiol (The Stampede Study). This isn't the standard of care in the US, as apparently it causes heart attacks in about 5%, but, as I told my onc, "I really couldn't give a SHIT about the SoC in the U.S.; I can't stand to be alive under those conditions. Also, let's keep in mind that I was BEGGING for a heart attack before I quit." She gets it.

[RonnyBaby in reply to Horse12888]

I'll have to do a sales job on my MO about the patches because I'm not advanced enough, yet - this Covid-19 breakout has delayed my PSA testing schedule, so there will be a delay before I get my next number, which I expect to be significantly higher than the last one - it's a gut feeling - I'm at 0.70 and I haven't finished the FULL withdrawal from the ADT but the rate of climb from undetectable to 0.7 was in about 1 year, with the last 6 months seeing it doubled twice.

I read that a reading below 2.0 is good and it is expected to be around 1.0 (nadir) anyway after radiation treatment.

Funny how the world is working - life as we knew it is about to be changed forever and we cancer patients are expected to put our treatments and appointments on hold in the meantime.

Either way, the grim reaper gets his due.

I wait for the next chance to get my testing re-scheduled - all the labs are or will be busy checking for 'covid' up here in Canada ....

[Horse12888 in reply to RonnyBaby]

Re: the patch, you don't want to be on ANY form of ADT until you need to be. High-dose estradiol (apparently) lowers T to castrate levels without most of the SEs. It's believed that the reason for the SEs from Lupron is that it lowers estrogen levels too, and THAT'S what actually causes the fatigue, etc.

[RonnyBaby in reply to Horse12888]

ADT is no fun for sure - I'm thinking I might be forced back unless I decline that option and either buy time or wait for something else to come along that avoids or minimizes the SEs. Your comment about estrogen is something I came across recently - that was a reminder that others told me about managing hot flashes as a way to deal with them - I hated the flashes - a constant reminder that my new normal included them .....

[RonnyBaby in reply to Horse12888]

You have a sense of humor of course !

[Horse12888 in reply to RonnyBaby]

I try.