Are there benefits of ADT Beyond 18 months?

[bigdoggatto]

Specifically, for high risk prostate cancer after EBRT plus LD brachytherapy, is there any evidence of benefit of extending ADT beyond 18 months?

[Don_1213]

The most accurate answer I can give - maybe and maybe not. Some studies say no, some say yes, some say maybe. The difference in overall survival doesn't seem to change significantly, but there is a possible small difference in the recurrence of PCa.

You had a fairly aggressive treatment - what what was your Gleason number? You mentioned your PCa was high-risk. Ditto on your PSA number before treatment? What's your PSa number right now (I assume you're still on ADT)?

You're also 77 years old - some of that decision should also depend on any other comorbidities, and how your quality of life on ADT is affected. Since ADT can cause other issues (bone embrittlement, cardio/vascular issues) these also have to be taken into account.

I think your question is a bit too simple without the additional information it's hard to make any intelligent response to it.

[bigdoggatto in reply to Don_1213]

Right, thanks for reply. I had PSA of 9 and Gleason 8. At beginning of treatment my RO's protocol was 24 months ADT plus the EBRT and brachy. Since then there was the paper looking at a couple of trials that suggests that 18 months, perhaps even 12 months, is optimal for the radiation treatment I had. I take Orgovyx and QOL sucks. Sure, I could stick it out another 6 months if needed, but if it doesn't provide any benefit then I'd like to quit. I'm a couple of weeks out from having a discussion with my RO, but at this point I don't know what he will have to say about it. I just want to be as prepared as I can be.

[Don_1213 in reply to bigdoggatto]

I certainly won't suggest a decision, I'll just share why I stopped my ADT after 18 months (had IG/IMRT, 45 treatments, prostate-bed and boost treatment - 83Gy.) I had originally been prescribed 24 months of ADT. (G10, PSA 2.4, non-metastatic.)

The side effects were being compounded by Covid - mostly that it closed the gym that I went to in order to fight some of the side effects of ADT. I also had cardio issues that might have been made worse by continuing the ADT. And my PSA while on ADT was basically "undetectable" - <0.10, And the paper saying 18 months was not inferior to 24 months had recently been released.

None of my oncologists/urologists had any disagreement with the decision.

The other consideration was - I was at the time 74 years old. I figured at best, I'd have 10 more years, and perhaps 5 of those when I can do physical things I like to do. How much difference in QOL would continuing ADT have? Well - it would at a minimum have 6 more months of undesirable side effects, some of which could counteract any additional life span I'd get from another 6 months of hell. And 6 months of not doing things I wanted to.

It was actually a pretty simple decision, and I continue to think it was the right one. Once my T started recovering, I started recovering some strength, and I go daily to the gym now. Things I viewed as never-again enjoyment (with ADT) became possible again. My T seems to have settled at 380-400 or so, not a bad number for 76 years old. With that my PSA increased slightly - it's currently hanging around 0.17-0.20 right now. It's been that way for over a year now, so it looks like that's the "nadir" going forward. The cardio issues seem to have stabilized and I'm slowly loosing some of the Covid weight.

That was my decision - yours has to be based on your disease and desires. Good luck with the decision!

[Max24 in reply to Don_1213]

Your story is almost identical to mine and gives me hope...thanks 😊 🙏

[Horse12888 in reply to bigdoggatto]

I was G4+5=9. Positive margins after RP, assigned 24 months along with EBRT. I quit after 12 because I was suicidal, and T recovered in 5 - 6 months, so a total of about 18.

Since then there have been studies showing that 18 months is not inferior to 36 months.

You're ~20 years older than I was at the time, which militates towards less ADT because your life expectancy is less.

[Tall_Allen]

Not beyond 12 months according to this:

prostatecancer.news/2022/01...

[bigdoggatto in reply to Tall_Allen]

That's what I'm basing my thinking on. I'll present this to my RO doc if he objects. Thanks.

And thank you timotur and Don_1213 for your replies. They were very helpful.

[garyjp9 in reply to Tall_Allen]

TA, in your referenced posting of 1/22/22, it says: '"Standard-of-care dictates 2-3 years of adjuvant ADT when enlarged pelvic lymph nodes are found by CT or MRI." If someone in that situation has a PSA that is currently undetectable, is there any evidence of a benefit to 3 years as opposed to 2?

[Tall_Allen in reply to garyjp9]

No, there are no trials of 2 years vs 3 years.

[bean1008 in reply to Tall_Allen]

I wish the studies would include people that are not having radiation but went from RP to ADT. I hit the two-year mark next month and I would love to get off the drugs and see if it helps with the terrible fatigue and quality of life issues

[Tall_Allen in reply to bean1008]

The studies are about adjuvant ADT (=used for a limited time after radiation). Your situation is called salvage ADT (=used permanently after curative treatments have failed). Whether salvage ADT can be used intermittently (i.e., with periodic vacations) is a matter of judgment.

[bean1008 in reply to Tall_Allen]

Thanks TA! You’re the best!

[TylexGP]

I am slightly different from you G9(4+5) with SVI, EPE and PNI as well Intraductal histology and BRCA2. T3b N1 I am 57. PSA is0.08. Due to all those factors I am very high risk; I will do 24 months. Just had my next 3 month Lupron shot today. One more to go.

[bigdoggatto in reply to TylexGP]

You are also very much younger than I am! Good luck.

[conbio]

Yea, I rummaged through all the data and recommendations and decided to stick with 18 months and stop there. As TA points out - there is some evidence that even 12-18 months may serve just as well. Certainly there is evidence that beyond 18 months is not necessary if you are doing EBRT and brachy as well. As I heard one urologist say - Why extend all these side effects if the benefit beyond 18 months is marginal?

[London441]

Sure it’s a personal decision, and the data does not indicate any significant advantage. What is definitely significant is the proven cumulative side effects and detrimental consequences of longer ADT use. Forward thinking oncologists are much more invested in considering QOL and overall damage to heath ADT causes than they used to be.

I was in a trial that had a 2 year ADT protocol. At a year, in my last meeting with my RO, he asked me ‘how I was doing’, This was in summer 2020.

I told them it was swimming hard upstream, and made sure he knew I was slightly baffled by the question. He said I appeared to be doing great and tolerating it well. I said absolutely yes sir I am.

And I was! But though I was younger than you and an athlete, with no co morbidities, I wasn’t going to lie and tell him it was sunshine and roses. It sucks, and we all know the reasons why.

Yet even though I emphasized I was perfectly willing to do the second year, he simply said ‘I think you can stop now’. This was even more baffling. When I ran that by my MO who was running the trial he concurred, more baffling still.

A 2nd opinion MO said the same thing. The message was basically, ‘we don’t have the data to support longer ADT courses, but we have plenty of data on its harmful effects’

I am 27 months post ADT and doing fine so far. If I need to return to ADT in some form in the future so be it. My late 60’s are unquestionably fabulous in the meantime.

I have talked to and heard speak a number of MO’s who are doing their best to take QOL and exacerbation of co morbidities into consideration more strongly, as I said. No one has a definitive answer on the efficacy of 12 vs 18 vs 24 months.

The emphasis medicine has traditionally placed on solely extending life is both understandable and erroneous. Strictly my opinion! ADT is a perfect example. Life span without health span is often just not worth it, and is not the type of longevity any of us should pursue blithely.

[esperandrich]

Almost the same as you; Gleason 8; 5 was highest PSA; 2 of 12 cores bioposy results; no spread detected; did 25 radiation treatments last fall including whole pelvis; LDR brachy along with 18 months of Lupron ending this month; recommended by RO and MO at UC San Diego.

MO was leaning towards 24 months but I showed him the info from Tall Allen on ADT with the above treatment and the studies referred to in that info (and RO said 18 months was enough and even 12 was probably OK). MO then agreed that 18 months was enough.

So far so good. However, everybody is different. When you bring it up to your doctor I suggest you print out and give the doctor the info from Tall Allen and the studies referred to in that info and see what the doctor says.

[bigdoggatto in reply to esperandrich]

I definitely plan on being prepared. Thanks.

[SimMartin]

I think it’s very a individual / onco joint decision. After AS I opted for HIFU as biopsied twice as G7 (3+4)when PSA rise to 8 from 5 in 3 months )

But that didn’t work and in 6 months biopsied G9 (4+5) and MRI plus PSMA/CT/PET and T2cN0M0. I have other comorbidities (post polio which includes breathing muscle loss and wheelchair user) so I am on maybe only 6 months of ADT - depending on my just today finished 20 sessions of 3 Gy each session of Moderately Hypofractionated RT

The risk/ benefit for me after discussing it with my oncologist seems a good trade off - for me at least, as longer term ADT might be much worse OS and QoL than going with the slightly higher risk of recurrence. Research isn’t clear yet of the difference but it seems it might be equivalent (assuming the PSMA is a true reflection as never infallible aa I discovered with my several biopsies)

Of course I am 72 and have other complex issues but even so it does seem that extended ADT might be not as definite or as big a risk limiting approach than shorter or even intermittent use.

Good luck it’s so complex and difficult decision and also so individual.

[bigdoggatto in reply to SimMartin]

Thanks very much.

[Teacherdude72]

Decision is very much up to you! We are all different.

I was G9, had EBRT and HDR to sessions with 24 months Lupron. ADT side effects for me were minimal. Then 40 months later psa doubled twice to just above 2. Back on ADT, Eligard 4 months then a 6 month shot that failed (psa rose to 2 in one month from 0.5) put on monthly Lupron and Nubeqa. Now 19 months in psa <0.02 and T <0.5. Energy sucks: only other SE is 3 hot flashes a month. Age at dx 67, now will be 75 in Feb.

[bigdoggatto in reply to Teacherdude72]

Sorry you've had difficult journey. Wishing you the best.

[Teacherdude72 in reply to bigdoggatto]

Thank you. Untold this is my second Cancer. First was at 27, testicular.

[bigdoggatto in reply to Teacherdude72]

Oh crap. Well you obviously beat that one!

I missed your 3 hot flashes per month comment. I have at least three per night. They come with severe stomach cramps, guaranteed to fully wake me up. I have a lot more during the day, but I can tolerate those. The night-time ones are literally killing me because I can't get a decent night's sleep.

[Teacherdude72 in reply to bigdoggatto]

Yep first cancer gone 40 years before Prostate attacked me.

First year on Lupron was a nightmare of hots and frequent pee breaks at night. Some how avoided stomach issues.

I had AC in the bedroom and dropped temp as low as possible. Tossed off covers when hot. Wife had extra covers of her own.

Talk with your oncology doc about your issues. Might have some help. Even your primary might help. I take magnesium, 500mg, nights and mornings plus vitamin D, 1000 units daily.

Best wishes and hang in there. Live life the best you can.

[janebob99 in reply to Teacherdude72]

I don't know if it helps, but I take 10,000 IU of VIT-D daily with no bad side effects. My VIT-D levels are near the top of the scale. I haven't had a cold in many years.

[cancerfox]

My situation is almost identical treatment and diagnosis-wise, and I stopped ADT after 13 months on the advice of my doctors. I think it becomes counter-productive after 12 to 18 months. ADT is an very miserable experience IMO with negative side effects, and it can also cause the cancer to become resistant to that treatment over time, so I'm just going to monitor my PSA every 3 months and see what happens. Good luck to you! 🦊

[bigdoggatto in reply to cancerfox]

Thanks, you too.