A friend of mine had treatment for oligo metastatic disease and has been placed on ADT treatment for 2 years afterwards before he started a ADT pause. (Supported by his medical team)
He has been off the ADT for a little over a year now and his PSA has steadily increased to around 4,0. (He still has his prostate)
The issue is that no new metastasis shows up on the scans nor do the old bone lesions show any signs of recurring PC. He do not suffer from any of the medical conditions that could cause elevated PSA.
(He also had several PSMA pet scans during the last year all showed no signs of PC activity)
What could be the cause? His medical team have no answers of the cause.
His doctors want to put him back on ADT now but he is in doubt if its an idea to wait for visual signs on scans of recurring PC.
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MiRob
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True TA. But he is in doubt if it’s an idea to wait for visual signs on scans of recurring PC to find out if this/these spots could be treated with radiation therapy before going back on ADT. Your thoughts? Thank you
The idea was use the “open window” before being placed on ADT to remove any few PC spots found if possible. (Oligo metastatic belief. And only if max 2-3 spots show up) Some at The Mayo Clinic share the same beliefs.
It is a bad idea. I would rather go back to ADT and maybe later have a new ADT Holliday. Believe me this was discussed here multiple times.
To wait for the cancer to show up on the scans in order to radiate it is a bad idea. You should actually be happy that nothing shows up and go back to ADT and maybe later have a holiday again.
I have the #1 Uro/Onco at UCLA (Dr Rettig) tell me that nearly 3 years of Neoadjuvant and adjuvant ADT (Lupron and Abi) with WPRT radiation in between is enough after BCR.
Pulled me off, and told me if PSA comes up, I get a PSAM/PET and they'll radiate any spots that come up.
I agreed, Ive had enough of psychological and metabolic effects, heart problems from ADT.
So do I go with online discussions? Or a Dr that studies PCa for a living?
I understand your thinking. I was also said by my medical oncologist that if my PSA starts to rise I will get the PSMA pet scan (he actually said pet scan) and we will radiate the spot.
I agree with TA if it is safe to radiate the metastasis why not, but I personally after my prostate SBRT irradiation rather try to escalate the system treatment.
My current MO would agree with you my old MO wouldn't but I personally think that until I feel fine without radiation or operation I will probably try to avoid it. Therefore I don't know but you are facing this decision therefore consultant multiple doctors.
I can say that with the SBRT irradiation of my prostate I possibly have now to the radiation resistant cancer in my prostate but I am still not sure in full consequences. Maybe it is a plus maybe it is a minus.
The plus could be that we are saving up drugs for the future treatment. The minus is that I am facing the side effects of the radiation.
Every treatment has potential problems and advantages. I maybe feel safer when I add a system treatment because PC is a systemic disease.
I believe nobody really knows and we are just experimenting on ourselves.
You know best your situation therefore you should decide for yourself.
I didn't check it but it is always interesting to see what the AI said.
Navigating prostate cancer treatment decisions involves balancing efficacy, side effects, and quality of life. Here’s a structured approach to your situation:
### 1. **Trust Your Specialist, but Stay Informed**
- **Dr. Rettig’s Expertise**: As a leading uro-oncologist at UCLA, his recommendation aligns with current evidence and personalized care. His plan reflects modern approaches:
- **ADT Duration**: For high-risk cases, 18–36 months of ADT combined with radiation is often standard. Stopping at ~3 years may balance long-term control with minimizing toxicity.
- **Advanced Imaging**: PSMA PET scans allow early detection of recurrence, enabling targeted treatment (e.g., metastasis-directed radiation) rather than indefinite ADT.
- **Guideline Alignment**: The National Comprehensive Cancer Network (NCCN) supports intermittent ADT or stopping therapy in select patients to reduce side effects, especially when recurrence can be managed with salvage therapies.
### 2. **Addressing Your Concerns**
- **Quality of Life**: ADT’s psychological/metabolic effects and cardiac risks are valid reasons to pause treatment. Your doctor is prioritizing your well-being alongside cancer control.
- **Recurrence Plan**: The strategy to act only *if* PSA rises (with imaging and targeted therapy) is proactive and avoids overtreatment. Studies (e.g., STOMP, ORIOLE trials) show promising outcomes with metastasis-directed therapy for oligorecurrent disease.
### 3. **Online Discussions vs. Expert Guidance**
- **Online Variability**: Forums often highlight extreme cases or outdated practices. Treatment plans are highly individualized, and anecdotes may not apply to your case.
- **Evidence-Based Care**: Dr. Rettig’s approach is likely grounded in the latest data. For example, the EMBARK trial (2023) supports intermittent ADT in certain scenarios to reduce side effects without compromising survival.
### 4. **Next Steps**
- **Clarify Monitoring**: Ensure a clear PSA-testing schedule (e.g., every 3–6 months) and confirm PSMA PET access if needed.
- **Cardiac Monitoring**: Address heart risks with a cardiologist; lifestyle changes (diet, exercise) may mitigate metabolic effects.
- **Second Opinion**: If doubts persist, consult another specialist (e.g., at MD Anderson, MSKCC) to validate the plan. This can ease anxiety and reinforce confidence.
### 5. **Key Takeaway**
Your doctor’s plan reflects a nuanced, patient-centered approach. Stopping ADT does not mean “giving up”—it’s a strategic pivot to prioritize quality of life while remaining vigilant. Trust in your care team, but advocate for regular follow-ups and open dialogue about any changes in your health.
I was diagnosed as de Novo polymetastatic pc and the doctors wanted me on intermittent ADT injections but I refused that patient centric approach and I am still alive after almost 7 years. I decided for myself.
no, he is referring to something else. Kwon likes to use the Choline scan, even today. Not sure why, when there is something a hell of a lot better. But he does wait for scans to pick it up. I think he figures the Choline scan picks things up quicker. But it is also more inaccurate
My strategy is to delay radiation therefore I am on ADT. Actually I had prostate radiation but to the radiation most resistant strain survived and now I am Bicalutamide and re-irradiation of the prostate is either not possible or it is very toxic. I am happy as it is now. I definitely don't want to stop Bicalutamide and reradiate my prostate if I can avoid it.
I learned this disease grows at very low PSA values and spreads ahead of PSA and radiological progression. After having had four PSMA PET CT over seven years I wonder if my remaining cancer is PSMA avid; or is it that I do my imaging before 0.1? I rely on several comparative imaging methods and second radiological opinions - no singular imaging method and no singular radiology opinion. Also, I utilize liquid blood biopsy testing for a third leg of investigation.
many opinions of course. As I commented I do comparative imaging. To date not FDG for prostate cancer; just did one for my melanoma but it is different. Based on my efforts and consultations I would likely chose Choline over FDG - yes I am aware of what some say. Also in contradiction, I get imaging at very low PSA values because I am not willing to let cancer grow in size (and volume) to where darn near any imaging might work. But then, I walk a different path which to date is serving me very well. All the best to all of us looking for this beast to determine treatment strategy.
I find liquid blood biopsy testing - looking for circulating signs - very informative. These can present ahead of PSA and imaging. I've had three to date - first two NED. Third, surprisingly and fortunately, provided a heads-up on very unexpected metastatic melanoma; giving me a true curable opportunity.
I had laser ablation in 2018 and my PSA started to go up. All the MRI were negative but the PSA pet scan show it. The Biopsy was positive and had SBRT. My PSA for now is low (.58)
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