Best length of Lupron Treatment for Advanced Cancer

My understanding is that it takes at least 9 months to get a meaningful response. Then the question is whether you go continuous or intermittent. My recollection is that the most recent studies indicated that for advanced high risk (which you are) do better with continuous. Then the question is for how long. I would expect 24-36 months.

I was treated just over five years ago along the protocols in the BOLLA study and received three years of Lupron/Eligard. Some would now say that could be reduced to 18-24 months for my risk level (G7). As you are a G9 I would expect at least 24 months on HT. As you are high-risk and advanced you need to be very aggressive right up front. No way would I think that 6 months would even be considered. Some of the newer studies like the STAMPEDE and CHAARTED are showing the benefits of adding chemotherapy early for high risk advanced cases. Is this something you have discussed with your medical oncologist?

As to monitoring PSA, I have done every 3 months. I haven't heard of high risk cases starting at 6 months.

Tall Allen is very knowledgeable on these studies and can do a better job than I can regarding your situation and I am sure he will join the discussion.

Hi Everyone,

One clarification, I rechecked my appointment schedule and my specialist has scheduled me for a PSA test every three months rather than the six month interval stated in my email above. My mistake. Sorry.

Thanks JNF and Newton for you responses. Good info.

Bob

I'm also G9 with poor pathology . After I had PSA recurrence again (see signature) post failed SRT I had (and am still undergoing ) ADT3 and concurrently had extensive IMRT to pelvic lymph nodes. I understand this is controversial but I opted for very aggressive treatment to try one more time for a cure. I'll be on ADT for 13 months so I have seven more months to go. That's less than 24 but more than six. My RO feels that is the right duration given my situation and the treatments I've had. l take the meds listed to help lessen the SEs of ADT. So it hasn't been too bad. If I have another recurrence I'll go on intermittent ADT. If I become castrate refractory I'll have to resort to other treatments.
Bob

Thanks for clarifying that the ADT was adjuvant to salvage radiation, which I assume included all pelvic LNs.

Here's what we know so far... At least 6 months of ADT is better than no adjuvant ADT at all. Less definitively, it seems that at least 12 months may be even better. Anti-androgen therapy may be as good as Lupron. We don't know yet the optimal duration with any confidence.

Here's an article reviewing our knowledge to date:
Combining ADT and salvage radiation therapy improves outcomes

You wrote: "Some studies claim that six months of Lupron treatment results in better long-term results than two years of treatment, whereas other studies claim two years is better than six months. "

You would have to show me the studies you are referring to, but I have never seen any study that showed that 6 months is better than 2 years of adjuvant ADT. The study that showed that 2 years is better than 6 months (DART 01/05) pertained only to high risk men treated with primary radiation therapy and not to men treated with salvage radiation.

There are randomized controlled trials in the works to determine the optimal duration of adjuvant ADT with salvage radiation, but we probably won't have those results for another couple of years. Until then, we have to rely on judgment, RO experience and tolerability of the SEs of ADT. I think most ROs looking at your pathology report, would advocate longer use of adjuvant ADT. There was a lot of cancer there to clean up.

- Allen

So you understand that the study you quoted does NOT apply to the salvage situation, right?

Also, when surfing the net for info, you have to be very careful. For example, that study was dated 2006 and included men treated at Cleveland Clinic from 1996 to 2003 with primary, not salvage, radiation, or with surgery. I've never seen anything showing that adjuvant ADT with surgery improves survival, so mixing that group in certainly obscures their conclusions. As far as I can tell, it was never published in a peer-reviewed journal, and that peculiar admixture of treatments may explain why. Most of the radiation patients would have been treated before dose escalation became prevalent and were treated with radiation doses that are now considered to be inadequate for cure. That's why DART 01/05 was undertaken - to see if adjuvant ADT improved outcomes in the era of dose escalation. They proved that for high risk patients receiving dose-escalated primary radiation, 2 years was significantly better than 6 months.

- Allen

Hey Bob....just out of curiosity, what are the significant side effects you are having?

For some side effects, there are some trips and tricks and even some drugs to help alleviate them.

This is a question I've struggled with for a long time. I went through 3 years, mostly because of the Bolla study. My oncologists have referenced that one routinely. The study saying 2 years was way more effective than 6 months is good. However, there's still a gray zone between 2 and 3 years. Hopefully, some day this will be resolved too. Tall Allen has helped me think through some of that, and challenged my oncos.

My present med onc is Dr. Maha Hussain at University of Michigan Cancer Center. She is quite conservative, which is an approach I like even if it's sometimes frustrating. Her last comment about it, at my 2 year point, was that with my G9 5+4, cT3 case, we need to be as aggressive as possible. She said she'd rather find out 10 years from now that 3 years was too much, than that 2 years wasn't enough. Hard to argue with, I guess.

So I've been enjoying the side effects of this for 3 years, just finished in March. I'm on now to the recovery phase, which can apparently take months, years, or never. My PSA has remained undetectable for 3 years now, so I'm pleased with the effect of my primary RT and ADT2, though of course I can't know for some time yet if the radiation was really effective.

Embarking on that 3rd year was a very hard decision. It's done, but it may have destroyed my Testosterone system for the rest of my life. Time will tell. Two years will take much longer to recover from than six months would. It's a real crapshoot. All I can say, is if you decide on two years you can do it, and the time will pass. The hot flashes are an ongoing warm reminder that your testosterone is nicely suppressed. So, there's that....

Bob656 said...
Jpen44,

Fatigue is the most onerous. I'm tired all the time, even after sleeping. Previously, I had so much energy, few people could keep up with me.

Increased urination frequency and hot flashes, (about four flashes per evening which completely wake me up with so much perspiration I have to towel dry myself before going back to bed.)

Other than this, that's the most noteworthy side effects.

Thank you for asking Jpenn44. It's good talking with people going through the same thing.

Similar side effects I had for the first six months or so (six month injection), woke up every hour sweating and going to the bathroom to pee. Another SE of Lupron I still have is a ravenous appetite - I swore I would maintain my weight but I gained 20 pounds anyway. A lot of it I think was stress eating during salvage radiation last November/December. My RO prescribed veneflaxine which really helped (after she doubled the dose) moderate the hot flashes. Also taking temazepam lets me get a good night's rest. Hate to be taking these drugs but I have to get quality sleep or suffer the consequences of adding to the tiredness.

I did two years of ADT3 along with my adjuvant radiation. ADT3 is a GNRH (ant)agonist plus an anti-androgen plus a 5ARi drug, or to use the common brand names, Lupron/Firmagon plus Casodex plus Avodart. I'm not sure how many oncologists include the Avodart these days but mine uses it, or at least he did four years ago when my Hormone Therapy started.

As the Tall one said, there isn't a lot of definitive research about the optimum duration and what research there is will often not technically apply. There is, for instance, not a lot of research (maybe none) about the duration of androgen blockade with adjuvant radiation after surgery. (My post-op pathology was much more alarming than expected.) So, I read the research for ADT along with primary radiation, figuring that what is sauce for the goose might be sauce for the gander.

In particular, when I was about a year into ADT I found the study that failed to show that 36 months was better than 18. You can bet I discussed the heck out of that one with my medical oncologist, trying to convince him that I could maybe get six months off my sentence for good behavior (of my PSA). He wasn't buying. His take was that failing to prove there was a benefit was not the same as proving there was no benefit, especially in a somewhat underpowered study. He felt that there was likely to be a small benefit and that a stronger study would eventually find it.

As for the side effects, my hot flashes were pretty minor so I didn't get into that but I am told that there are treatments that can help if you find them intolerable. As for the fatigue the first thing to try would be exercise. Staying active and adding some heavy lifting to your daily routine does seem to help with the fatigue, and even if it doesn't it gives one the satisfied feeling of having earned that afternoon nap. For a lot of guys antidepressants also help. I was on two of them -- fluoxitine (Prozac) and bupropion (Wellbutrin). You could also ask about modafinil if you have trouble staying awake. It's a really good drug for the ADT sleepies but it is expensive (in the US at least) and insurance doesn't like to pay for it.

So, hang in there. Regardless how long you decide to stay on ADT you'll make it through. Plan on an additional half that time to recover after the hormones wear off.

The estradiol patch changed twice weekly I found substantially reduces hot flashes. Compared to my first bout with lupron this round has been a cakewalk!
Bob