Lupron/Eligard: How long to stay on it?

I'm about to start Eligard, a 3-month injection, along with SRT. My RO wants me on it for at least 9 months. Other ROs I've consulted recommended stopping at 6 months. I haven't gotten a really satisfactory explanation for either recommendation. I understand that duration of ADT will vary according to the specifics of one's pathology, primary vs. secondary therapy, etc. What I'm looking for is evidence that supports one length of ADT treatment over another.

I posted a similar question on the ADT/SRT Journey thread, but want to open it up to a larger audience. Those with very different pathology from mine who are also facing ADT as part of their therapy may be interested in the topic and have something to contribute.

I've told my story here before... I was originally started on Lupron for six months to prevent my PSA from increasing while I regaining continence following surgery. That never happened, and ultimately I had to get the AUS, which introduced additional delays.

My RO wanted me on HT for "at least" two months before RT, two months during and two month's afterwards. He said there were only two studies that showed a benefit to adding HT to RT... one ran for six months and the other ran for two years.

When my ART ended he told me that the radiation would continue to kill cancer cells for an additional 8-9 months. My last Lupron shot would start to wear off after two months, for one year total. I decided to extend the HT with another six month shot so the HT would be working as long as the residual action of the radiation.

It was not an easy decision. My RO was okay with either 12 months or 18 months, but said two years was not necessary (and I agreed!). It was my intention to throw as much at the cancer as I could.

garyi said...

Lawyers
I’m emailing you a superb study that my iPhone isn’t letting post here.

Gary actually called me a wimp in his email. I'm appalled to learn how transparent I am.
No url for the study, but here's the cite: A Systematic Review and Framework for the Use of Hormone Therapy with SRT for Recurrent PCa. European Urology 73 (2018) 156-165.
It includes some discussion of short-term v. long-term ADH:
"In localized high-risk prostate cancer, long-term hormone therapy (2–3 yr) results in improved oncologic outcomes compared with shorter-term therapy (4–6 mo), even in the context of dose-escalated RT.
However, this is yet to be established in the SRT setting, and the Radiation Therapy and Androgen Deprivation Therapy in Treating Patients Who Have Undergone Surgery for Prostate Cancer (RADICALS NCT00541047) trial seeks to investigate the importance of duration of hormone therapy on oncologic outcomes, in addition to assessing the impact on short- and long-term toxicity."

Absolute evidence, when it comes to anything about prostate cancer, is an exceedingly rare commodity.

How did the specialty pharmacy come into the picture? May we assume that previously your husband had only parts A and B, and no part D coverage until the most recent enrollment period. The charges you quote sound typical for "has insurance" versus "no insurance". Typically if a patient has insurance then the charges are restricted by what the insurance allows (in this case, part B) while pharmaceutical companies and healthcare institutions in general charge exorbitant amounts "on paper" for those without insurance. What was your copay after the part D? They could be trying to push you into the donut hole.

Typically Lupron is injected in the doctor's office and is paid thru part B. I'm wondering what changed?

One of my sons requires regular infusions, which previously cost around $100 in the doctor's office. But when the doctor moved his practice into a clinic facility, the charge jumped to $1000 for the same service.

By the way, many of the guys here receive Lupron in addition to other forms of treatment, such as radiation or chemo, which is why you see shorter periods of administration. For men on long term HT it's a different story. Your husband is fortunate that the HT has lower his PSA effectively for two years now. His dementia is sad and unfortunate, but that is a different matter.

RobLee said...
How did the specialty pharmacy come into the picture?

I’m not on Medicare, but under my BC/BS Lupron/Eligard comes under the specialty pharmacy program and is supposed to be supplied by CVS Caremark. Big mess out here in the western Pacific, my PCP, who will administer it in her office, has to go through Caremark for preauthorization even though the supply will not come from Caremark, who won’t ship here under refrigeration.

Saipan:

I agree with Gary's post that absolute evidence when it comes to PCA is a rare commodity. Moreover, I found that every MO and RO has their own opinion about ADT.

Although my situation is different than yours, I consulted with two MO's and two RO's prior to my SRT. By then I had already decided I wanted SRT but I was very adverse to the ADT and I did not want Lupron. I got four different responses when I asked each of them about treatment. One MO and one RO recommended no ADT with the SRT, one because it would mask the PSA after RT and the other because of my low PSA and slow PSADT at the time. My MO wanted me to start with a six months shot of Lupron and no SRT, or SRT to the prostate bed only. Fortunately, one of the RO's I consulted with had spent his whole career researching and treating PCA and co-authored the RTOG 9601 study comparing 2 years of Casodex with SRT and SRT only. He recommended 4 months of neoadjuvant ADT with 50 mg. of Casodex and .05 mg of Avodart daily plus whole pelvic SRT. Even though his own personal PSA threshold for no ADT with SRT was .50, he felt some ADT was better than none in my case.

I ended up following his recommendation but did agree with my MO to stay on the ADT for a total of six months. Although I did experience some minor SE's from the ADT, in hindsight I had a relatively easy time completing the six months therapy and the whole pelvic SRT. The best part is that my PSA has been undetectable for the past four months now.

Best of luck to you.

Rick

I've been on it (Lupron) for about 15 months now, my RO & Urologist plan to have me on it for a total of 2 years. My RO had originally wanted me to have 2 years of adjuvant ADT but later reduced it to 18 months. Actually it will be 19 months adjuvant ADT because my first six month Lupron injection still had about a month left on it at the time of my last IMRT treatment.

It seems strange (to me anyway) that it is United Healthcare, your supplemental insurance carrier, rather than Medicare that has determined what would and would not be covered under part B.

Hi jowens51 I'm a new member, I have been on Lupron for a year. I also have United Healthcare
care improvement plus medicare advantage PPO. Last shot in 2017 was around $175. Had a shot
in Feb. but haven't got a bill from Doc. if it's 1500 I'll be looking into a new plan. so let us know.

echotango, call me ET

echotango: Please let us know how much you are charged for your shot. We are in Southern California with the City of Hope. My husband's doctor is really upset. Many of his patients are just foregoing their treatments. Some have very aggressive cancers and may just die. My husband's approval letter for 2018 clearly stated that the lupron would be billed through Part D. If your shot is still under $200, please let us know exactly what insurance you have, so we can switch. If we need to get off the plan and go to just Medicare we will. I don't know enough about all these things. Thank you, Janet

Hi Jowens512
Lupron shot was $2100 other charges $397. I have UHC Care Improvement Plus Medicare Advantage plan.
Annual notice of changes for 2018. I have a $195 yearly deductible for tier 5 drugs,then will pay a 29% coinsurance. I don’t have last years changes so don’t know what my coinsurance was. I’ll find out what my cost will be when I get a bill.My uro must be going under part B, by the way I live in SC. I’ll post a profile on here one of these.
days. Echotango