OK, I'm sure there is a logical answer to this question but at present it is evading me.
So for all of us who decide to take the ADT path for a few months to stabilize our PCa and then hit it with the big guns such as a month (or more) of IMRT and in my case a follow-up of HDR Brachy Boost therapy, Why do we need to follow up with more of the dreaded ADT?
If ADT is only a suppressor of PCa, why are we using ADT after we have supposedly killed the PCa?
If it is a "just in case we didn't get it all" reason, then why are we using a drug that is still only going to suppress this disease? Why are we not following up with some short bursts of Chemo to really finish the job?
I guess I'm just trying to rationalize the need to keep on that ADT more than we have to. From my understanding, Chemo tablets are available that at least are designed to track down the PCa cells and kill them rather than suppress them and the SE's are more tolerable than ADT.
I look forward to any replies as I'm certain there will be a very reasonable explanation.
Thanks for the replies in advance.
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Mike58
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"why do we need chemo..." I don't understand-- who's this "we" you are asking about? You don't need chemo, only ADT. You need ADT to kill off the androgen-sensitive cancer cells.
Hi TA, I always appreciate your wealth of knowledge in all things to do with PCa and I guess people like me with these types of questions must be frustrating at times.
I think between yourself and others who have replied, that my question may have been answered. Since being on this journey I was always under the impression that ADT only locks up the PCa into a dormant holding pattern, while the RT kills it. Now I have learned that this is not necessarily correct.
RT doesn't kill the PCa, but only disrupts its ability to multiply and that ADT then starves it to death. Makes a lot of sense.
I guess I was simply looking for another alternative rather than being on the ADT treadmill, which quite frankly after reading so much on this forum, does frighten me somewhat.
As always TA, your presence on this forum is 100% crucial for all of us, so please excuse some of the queries I may make from time to time, - they may seem a little ordinary by many, but to someone (who is not fully educated in this field as yet), and who is grasping for answers, we need people like yourself and the others, to just give us peace of mind.
"RT doesn't kill the PCa, but only disrupts its ability to multiply and that ADT then starves it to death"
Not exactly. RT kills many cancer cells directly, and many more die through mitotic catastrophe over time.
ADT kills almost all cancer cells directly, especially the ones that are radioresistant. If any survive both, they may be killed off by the immune system (bystander or abscopal effect).
On forums like this you see a lot of complaints from the few that have something to complain about. You are not seeing the experience of men who do just fine.
Fantastic answer TA, really appreciate it and makes me feel a little more confident.
I guess it's a bit like the Hotel Reviews on TripAdvisor, we only tend to go straight to the negative reviews and forget about the 95% positive ones ... 😜
Radiation does not kill the cancer cells, rather it damages the DNA and makes it very difficult for the cells to reproduce/divide/grow which they tend to do prolifically. By suppressing the testosterone, not only are we greatly hindering the cancer's survival by not letting it divide , we are also starving the bastard.
Ok. I’m sort of understanding the radiation part of this but still not sure why we are using ADT after radiation and not Chemo tabs. Isn’t the goal to kill off this curse and not just put a lid on it?
Thanks for sharing that article. It was quite enlightening but also a little misleading. It starts off by saying .... "The chemotherapy drug docetaxel is very well tolerated" but then the rest of the article goes on to say just how bad the side effects can be. So after reading it, I am thinking that perhaps ADT is more tolerable than Chemo!
Statistics show it's a more effective treatment, especially if the ADT is started before the radiation treatment and carried through. Simple reason. And you may need chemo if the cancer has metastasized before treatment.
Thanks Don, Yes you are correct, it seems that ADT running for a period of time prior to RT is a good idea and afterward as well.
Like everyone though, we are looking to try and return to normality (if there is such a thing) as soon as possible and that can only happen if the PCa has been destroyed and after the effects of ADT have worn off, which can take as long as you have been on it.
So if the treatment of PCa is going to be over an 18 month period and is successful, then It probably means that the entire process from go to woe and to then being back to some sense of normality will be 3 years - Yikes!!
I was diagnosed around Thanksgiving 2018. That's 5 years and 2.5 months ago. I think 2.5-3 years is a good guess on how long before you start feeling better. It does take time for ADT to wear off after the last shot - typically around 4-6 months. I don't think anyone who has been through this will say everything is "normal" or "like it was".. there will be a new normal to become accustomed to - but the choice has already been made so no use fretting over it.
Early on in my treatment I asked my MO the same question. His answer was 'Because we have done clinical trials, and men with int. unfav. to high risk prostate cancer have better outcomes with ADT after RT than without. 'Why?' is the wrong question'
Glad I’m not the only one who wasn’t sure about this matter. And I’m glad people like yourself have given me some clarity on this issue. Thanks for your input
Thanks for the question and follow ups this sort of confused me as well. 5 months ADT, seed Brachytherapy, finishing up the last of 15 LINAC radiation sessions next week. Have a follow up with primary urologist and am anticipating adjuvant therapy will be brought up. I’m intermediate unfavorable .. primarily due to a high PSA reading 18, with 2 of six biopsies one lobe only being Gleason 4+3.. CT scan show no met .. though PMI pet scans not used here… Japan. At this point I’m 7 months on lupron and bicu.. and not sure if another 3 months or so of HT would be beneficial. I think my doctor will leave it up to me..will find out in a few days..Would like to stop but don’t want to if there is a potential gain from continuing a little longer. Overall HT has been ok .. totally manageable but would like to get some testosterone back and focus on working out and being healthy.! Good luck to you and all.
Love your answer and appreciate you replying. It’s people like yourself that I and others like to know about. Simply because you have said you found the ADT manageable. That is good to hear. I hope I can be like you, especially considering I am heading overseas (including a visit to Japan) for 8 weeks.
Overall health is pretty reasonable. My only real exercise is walking 2km a day. Not much other than that. I don’t take any medication, I don’t have any symptoms. My PSA has dropped from 8.1 to 4.7 in 6 months with no treatment. My free PSA ratio has risen from 7 to 12.5% in the same time. My latest MRI shows no change from the last one 6 months ago. No Mets.
So you can sort of see why I’m struggling with the idea of going all out on ADT prior to an overseas trip. But I’ll do what I need to do to be responsible with all this as well.
Your first shot at eradication is always your best one. Hopefully you’ve been persuaded by data-not folklore-about the efficacy of ADT as a part of a curative approach in a space such as yours. You ALWAYS want to hit it as hard as you can early, early only happens once.
This is why doing a full recommended course of ADT with the radiation is wise; many men cut it out or stop short due to side effects fear. Then they may well wind up battling chronic disease and on ADT for life. This is not wise, and should obviously be avoided if the opportunity is there.
It is risking recurrence later to gain a bit of quality of life on the front end and escape horrible side effects-ones that in reality may be quite mild or not experienced at all. Don’t do it.
Since you’ve not yet had any ADT, your concern about side effects is rooted entirely in what you’ve heard, read etc. 6 months isn’t that tough for most. Even longer can be quite manageable if you lift weights, which you should definitely be doing as an older person anyway.
Those who do dedicated aerobic and strength training on ADT minimize side effects, or even eliminate them. I did.
The muscle wasting aspect of ADT is indeed the most onerous. Those who don’t lift risk substantial muscle loss, fat gain, brain fog and all the rest. They are generally the ones making the noise about side effects.
Intervention-on aging itself, not merely ADT-with exercise is the key, one of the very few things within your control. Great luck to you!
Along with IMRT and brachyboost , I had 19 months ADT. After 9 months I no longer had the mind set to exercise. I did some manual labor at times. Being weakened by ADT made things more challenging. Now a year after ADT has worn off Testosterone is up into lower range of normal. I feel pretty good most of the time. PSA. 0.1. So there is light at the end of the tunnel. Keep the Faith
You and others like you are the reason why we love this forum. It just helps us, as you put it, - see the light at the end of the tunnel. Thanks for your reply
This is great advice.. I cannot stress enough the benefits of exercise as well. Movement of any kind as well as basic muscle resistance..e.g, pushups pull-ups, and or dumbbells if possible pays huge dividends. I must say every one is different but I’ve handled all treatments so far with minimal negative side effects. No blood, no pain.. except the catheter part, no inconstinence,no bowel issues, a couple of emotional sad feeling moments and outbursts but oh well. Defiantly some weight gain 4-5 kilos but my cravings for food have increased since HT as well as a 2 month broken finger incident which sidelined workouts a bit. Concerned about breast increase but not bad most most like due to the 5 kilo weight gain which in reality is probably 8kilos minus 3 kilos of muscle. Going into this I was fairly healthy working out and a bit young so maybe that helped. Sex drive disappeared but the plumbing seems to be fine. I guess I need to see how the long term effects play out but I would not miss the opportunity to do everything you can to fight the disease as mentioned. Good luck to all.
Hi Mike ......yes , radiation + primarily adjuvant ADT gives superior results vs no ADT. However, as this presentaion showed, MOST of the benefit of ADT comes in the 1st 10-12 months of ADT for high risk men......perhaps even shorter time for your 4+3? Also, studies are fairly conclusive that the time on adjuvant ADT is the main factor, and neoadjuvant time on ADT of much less value...here is that presentation....
Thanks - yes I think I'm going to be on 18 months at least for my 4+4.
6 months prior to RT and 12 months after. I believe, and correct me if I'm wrong, that it will be another 18 months after ending ADT that i will be back to normality. Maybe that is overstating it - I hope so!
Recovery time is better the younger....you already know that I'm sure!!! I would ask about the 6 months prior to RT..... studies show less benefit than if extending post RT!!!!!!!!!!!!!! In fact , little benefit pre RT !!! Seem s main benefit is shrinking enlarged prostste prior to RT....and I don't think 6 months is required!!! 1-2 months from what I recall....Google and pubmed.org do provide tons of studies on any question you will likely have.......too bad we can't just rely on Docs for answers to evrything!!! They seem to be too busy, or just plain uninformed re many questions......hope you have found Docs that devote majority of time to PCa cases....I have not been so lucky so far!!!
when I look at that study graphical results re ADT duration and efficacy..... not hesitant at all to stop at 12 months if ADT is really screwing with QOL !!!!!!!!!!!!!!!!! There is no guarantee that the additional months will help much, but there is a guarantee that reduced QOL will continue that much longer!! Just the way I view things...others disagree passionately!!! And, I am already low bone mass density...ie I'm osteopenic witha greatly incresed risk of serious fracture...the ADT will make that situation even more dire....current 7% risk of hip fracture will only increase...risk of any serious fracture is already 13%, and that risk will increase in all likelihood. The real specialists are constantly remnding fellow Docs of the balance between QOL and cure possibility.
glad to see im not the only one concerned about the trade off between long term QOL and continuing ADT . Im on Eligard (had a 6 month shot in Nov) and currently in middle of 45 days of RT. The QOL issues from the Eligard are too much and I want to stop prior to the 2 plus years the doc wants . It will be in my system 10 months anyway and my PSA is already down from 17 to 0.21.
Suggest you show that study to your Docs and ask about stopping ADT at maybe 12 months...though would have been better if more done during/after RT and less done pre RT.
Showed it to my urologist...he was interested!!! A prof at U Michigan mentioned this observation re incremental benefit of ADT at 12 months vs 18 months vs 24 months ...in a 2019 video !! In the end, your decision, not a Doc's !!
Like you I had a lot of questions and reservations about going on ADT. I was 4+3 when first diagnosed. After joining this forum, I sought a second opinions, and had more test done. I ended up at MSK in New York and second test put me at 3+4. Hey, decipher test was ordered to determine the aggressiveness of the cancer and returned as non-aggressive.. this qualified me to get into one of their clinical studies programs where I was given 5 sessions of high dose RT treatments during June 2023. No ADT pre or post RT. Two follow up appointments have shown my PSA 0.58 and I feel great.
I realize everyone’s experience will be different dependent on your test, results and scores, I just want to share my story and I hope that helps you on your journey..
See, this is the thing with you guys over there in the USA. Quite often you go for 2nd opinions. Over here (Australia) we rarely do that, except of course to get different opinions on initial treatment from a urologist and a RO. After we have made up our mind on what we are going to do, we don't tend to get any more second opinions.
Is that good? - probably not, because you have just demonstrated that your 2nd opinion was indeed a good one - I think Aussies are generally very accepting of what our RO's etc tell us and we don't often want to offend by getting a 2nd opinion. Yet I'm sure that to do so is not only wise but also isnt (or should not be) seen as an offence to the original Dr. After all we are talking about a life, not fixing a car!
Thanks again for your reply and all the best for your continued recovery.
Im in the USA but was brought up in the UK where you really didn't question the doc . Im getting a 2nd opinion while in the UK to be better informed about what my US doc is telling me .
Has anyone here done Artera AI? They look at your digitized pathology slides, and can predict if you will respond to ADT or not. They found (after looking at about 1 million pathology slides) that 34% of men will respond to ADT, while 66% of men won't. Pretty amazing result!
Hmmmmm. If anyone is reading this that is from Australia, can you let me know if we can even get copies of these pathology slides? I'd love to get a copy, even if its just for my records because there was no way I could decipher any of the MRI slides let alone pathology slides.
You'd have to ask your pathology lab. I think they keep your pathology slides for 10 years in cold storage. You could ask the lab to digitize them, or ask for a recommendation of where to send them that does (e.g. , a University). Also, once you have digitized (scanned) them, you send them anywhere to get a 2nd opinion (e.g., Johns Hopkins Univ.).
Perhaps at a University. Once you get your digitized slides (which can be large files, probably need a CD-ROM disc), you can send them to Artera.ai, which does artificial analysis of your slides and can predict if you would benefit from doing ADT or not.
Here's more for you to ponder while on your journey!
You make assumptions as to the efficacy of the Radiation Therapy, that assumption is that "all" the cancer was seen, and therefore targeted. Even the best scan/imaging "cannot" see it all, period! So the imaging, radiation plan is designed and mapped to what is seen. Safe margins are also provided wherein of cancerous tissue is present near a sensitive place, radiation just won't be given there, etc. So given the fact that all cancer might not be seen, and the fact that tissue needing treatment might be excluded (margin), it is an improper thought process to believe "drugs", ie, Androgen Therapy, is used "just in case"... It is NOT just in case. And studies have shown this improved efficacy in therapy when ADT is combined with RT, as with most multimodal therapies vs mono-therapies. The ADT helps two ways, it weakens the cells that will receive radiation, and it also weakens and kills remnant cancer cells over time that are too small to be seen in imaging and therefore not targeted in radiation treatment, or even those cells missed!
So what was the question?
If you want to deep dive into the pool of knowledge, the addition of a receptor inhibitor helps even more! But that said...
It all just depends, as noted above, there really isn't a "WE" in this because "MY" cancer, isn't "YOUR" cancer. There are dozens of cell types, and hundreds of genomic markers identified in PCa. Let alone the "What" and "Where" in regard to other characteristics and location, such as things like Intraductal, or spread to distant sites like bone or organs. So each of us are traveling the same direction, but ultimately on own own paths! And I agree as well, those who do well with their therapy, ie, 66% of first line therapy patients, and another 66% who've received secondary therapy who've done well, don't go online gloating about how well they're doing! So much information is skewed as a result... Be careful with Dr. Google!
Yes I know all about Dr Google, but I must say that AI is fantastic if only for it to simplify the pathology jargon that makes no sence. Your right about every individual is on their own journey with this stuff and what works for one may not for another.
Thanks for taking the time to reach out - appreciated and definitely some valid points.
it all depends on your Gleason grade and other factors. I had SBRT applied with image guided MRI at UCLA. Based on my Gleason grade, decipher test, etc. the radiation oncologist did not recommend ADT in my case.
I suspect a similar situation in your case. I assume if your doctor thought it was necessary he would have recommended it.
this has certainly been a question my husband and I have had recently
Had chemo first, then started Lupron/Elligard since 2019, bic started 2021, Oct’22 started Zytiga, Feb “23 started Radiation, still on Zytiga but only 250mg with low fat bfast
12/23, Radiation Oncologist wants him to stop all ADT, psa undetectable since last rad in April’2023, no Mets on last PSMA
Thanks for this and - Wow, what a journey you have both been on. But it looks like you are now on the other side of it all which must be a relief. Out of curiosity what was your husbands PSA score when he was first diagnosed back in 2018?
Does anyone know what the general or (even better) individual percentage benefit of ADT is.
My wife who had BC was able to input all her variables into a choice of nomograms, and out popped her individual percentage benefit of taking hormone ablation therapy. The percentage benefit was small so she opted for no endocrine therapy. The side effects of hormone ablation therapy are similar for men and women.
My second question, which is addressed to those who have taken hormone therapy, given your negative health etc experiences, would you still do so if you were in your late 70s?
I too am fearful Mike58. For all the more upbeat responses on here, I cannot block out the honest anecdotal comments. Apart from the males, I have read the comments on other sites where the wives said their husbands aged 10 years!
The ED, bone degeneration, loss of muscle mass, cognitive decline, mental wellness etc etc are truly scary and factually correct.
I know it doesn't cover all cases and is particularly relevant to certain groups but the 2023 Oxford paper re the ongoing Protect T research suggests that generally we all arrive at the same station and around the same time eventually, irrespective of which treatment we receive.
"They found that around 97% of the men diagnosed with prostate cancer survived 15 years after diagnosis, irrespective of which treatment they received."
NB. The study showed that: "A reassessment using more modern methods showed that a far greater number would now be considered intermediate-risk – and in around 30% of men, the disease had spread beyond the prostate already. This means that the participants in the study had higher grade and stage disease than was thought initially".
So it wasn't just the 'low risk' that survived 15 years. Although the problem is that pain and disability may arrive sooner along that journey for some.
"The trial also found that the negative impacts of radiotherapy and surgery on urinary and sexual function persist much longer than previously thought, for up to 12 years".
Hi Nordman, Yes you make all the points that many of us have tried to process. I note you are 78yo and pretty fit other than the latest issues you are faced with. I'd like to be 78 and be making decisions like you are doing now, so you can imagine how the 50+ yo's are coping! If I were 78, I'd just do RT and perhaps a 3 month stint afterwards on ADT. That according to the data should extend life by up to 10 - 12 years. Once you hit 88+ the QoL decreases dramatically anyway.
My wife has also been reading those posts on the womans forum about their hubbies who have PC. Mind you some are quite positive.
I think Tall_ Allan who has a wealth of knowledge about PC data, makes a very valid point when he says that the people who come onto this forum and have something to say about their experiences with ADT are 8 times out of 10 going to be negative, not for any bad reasons, but they are simply reaching out for some interaction with others going through a tough time. The other 80% (these by the way are my figures) don't get onto this forum and say what a walk in the park ADT actually is, - and so naturally us fellas trying to make decisions are bombarded with all these "negative" results about ADT and rarely read about the positive results. TA may not have said that in so many words but that is what he has indicated and it does make a lot of sense.
My dilemma is that Im hoping to go away on holidays for 8 weeks overseas and I'd love to take something that will keep a lid on the PCa while away but at the same time won't hinder my health too much while trying to enjoy a relaxing break. ADT injections are the severest form of the medication but maybe taking a small dose of Bicalutamide tablets might do the trick. Anyway, I'll be running all these options pass my RO soon.
Thanks for reaching out and I hope you reach a decision soon that you feel comfortable with. All the best
Here's what Cancer Copilot had to say on whether ADT kills or suppresses cancer cells.
Androgen deprivation therapy (ADT) primarily functions to suppress the growth of prostate cancer cells rather than directly killing them. ADT works by reducing the levels of androgens (male hormones) in the body. Since androgens, like testosterone, can stimulate the growth of prostate cancer cells, lowering their levels helps to slow down or halt the progression of the cancer. This suppression of hormone levels creates an environment that is less conducive for the cancer cells to grow and divide.
While ADT can be very effective in controlling prostate cancer, especially in its advanced stages, it doesn't typically eliminate the cancer cells completely. Instead, it's a form of management that can significantly slow the progression of the disease.
Thanks for that info. There is so much info out there about ADT, but the fact that it has been used for decades would indicate to me that it is an integral part of the treatment process otherwise it would have been done away with years ago. It still doesn't make the decision process any clearer though. Thanks for sharing
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