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Hormone treatment duration

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Posted 3/13/2018 4:06 PM (GMT 0)
Medical oncologist with GU specialty spoke to my support group last night. In response to the question "How long does hormone treatment last?" her response was 18-24 months. I questioned if she was using men who present with widespread metastases at diagnosis and she said no, data shows this is the duration of ADT response. I was dumbfounded. Can anyone suggest what data or source she was using?
Posted 3/13/2018 11:40 PM (GMT 0)
To be clear: the question you were asking was in a man with metastases who is taking Lupron (or similar) to slow progression, how long will it be before castration resistance starts to become noticeable (i.e., PSA starts to rise or new mets are discovered)? His answer of 2 years (median) is right. For most men, it is more than one year and less than 3 years. It may be longer for those diagnosed at an earlier stage of progression (e.g., oligometastatic) and those who achieve undetectable PSA with ADT.
Posted 3/14/2018 1:05 AM (GMT 0)
Another person from the group asked the question and the GU MO is female. Just to keep the comment straight. She said that in response to my question if she were referring to men with presenting with metastases, she said no, not limited to them. Patients without metastases, rising psa after treatment with no visible mets. She made no qualifications as to the extent or spread of disease, amount of disease burden, stage, anything.
The question was "How long does hormone treatment last?" and her response was "18-24 months".
Posted 3/14/2018 1:25 AM (GMT 0)
It's an ambiguous question, and an ambiguous answer. It points to a deeper problem - communication. How can a patient, who knows exactly what he wants to know, ask a question of a clinician, who only speaks Medicalese, such that he gets an appropriate answer? Not everyone can bring me along on doctor visits to rephrase the patient's questions and interpret the doctor's answer. It's a wonder that anything gets communicated accurately in most meetings. Since we can't control whether the clinician makes an effort to speak our language, we have to make an effort to speak there's.
Posted 3/14/2018 7:14 AM (GMT 0)
In the introduction of many studies I have read it is mentioned that after two to three years the patient becomes resistant. However, there is no citation provided. When I mention this to other patients they usually reject that and tell me they know of patients which are ten years on ADT now.

I think it depends how aggressive the disease is and the existing tumor volume. Debulking the tumor should help. E.g. this study:"Although many clinicians hesitate to offer a local treatment to a patient who cannot be cured, the current analysis suggests that this is an important component of the optimal therapy that contributes to better survival.".

George
Posted 3/14/2018 12:01 PM (GMT 0)
Like TA said communication is the key now if somebody ask me how long ADT treatment lasted I would probably answer 18 to 24 months as that seems like what most RO and MO prescribe for their patients like in my case my Mayo team wants me on Lupron for a minimum of 2 yrs and then we will see from there. A lot of the guys on the ADT and SRT thread are getting it for 18 months so I'm wondering if this is what she meant?

Larry
Posted 3/14/2018 12:20 PM (GMT 0)
Larry,

if you have ADT adjuvant to salvage radiation or if you start with ADT since bone mets were detected after biopsy and bone scan, this are different situations. Adjuvant ADT to SRT should be 18 months according to the latest study results. But that does not mean you got resistant after these 18 months.

In the other situation you shall do lifelong ADT. In that case one would expect that the patient gets resistant within two to three years. But every patient is different. And he may have local treatments as well. If he gets resistant the ADT will continue and usually Zytiga will be added to that.

George
Posted 3/14/2018 12:53 PM (GMT 0)
My Decipher genome test and a positive node put me in a higher risk category but my Lupron duration was six months (along with radiation.) This was MD Anderson, I like to think of them on the leading edge of research and protocol.
Posted 3/14/2018 2:52 PM (GMT 0)
Leuprolide With and Without Flutamide in Advanced Prostate Cancer; E. David Crawford, 1986

Early androgen ablation for stage D1 (N1 to N3, M0) prostate cancer: prognostic variables and outcome;
G. K. Zagars, 1994

Immediate versus deferred androgen deprivation treatment in patients with node-positive prostate cancer after radical prostatectomy and pelvic lymphadenectomy; E. Messing, 1999 and 2006.

To find an answer to the question a one hour search online gave me these studies that showed disease burden at diagnosis has significant prognostic value for duration (Crawford), response to drug initiation has significant prognostic value for duration (Zagars), and treatment of the primary tumor and pre-metastatic initiation contributes to longer duration of survival (and hormone sensitivity) (Messing).
Each was the first or among the first to demonstrate the value of the factor studied. There appear to be dwindling studies of this type in recent years perhaps due to the reduced proportion of men with stage 4 at presentation.

My guess is that this lack of recent research into hormone duration, the extension of androgen treatments with current agents, research efforts in more efficient areas, and the smaller proportion of advanced stage patients at diagnosis leaves professionals with less data than they have in other areas of our disease.
Posted 3/14/2018 3:36 PM (GMT 0)

tarhoosier said...

My guess is that this lack of recent research into hormone duration, the extension of androgen treatments with current agents, research efforts in more efficient areas, and the smaller proportion of advanced stage patients at diagnosis leaves professionals with less data than they have in other areas of our disease.

Amen to that....

Many RO's and MO's take, what in my experience and opinion is the easy answer.....18 to 24 months. No risk to them. I suspect they aren't current on the latest studies (not that they shed much light on the subject), and aren't as familiar as they should be on the in-depth history of the patient in question. Instead of admitting there is no definitive answer, many fall back on the easy 18 to 24 one. Again, in my experience, this extends to the best clinicians....Mayo, Johns Hopkins, Emory, MSKCC, Dana-Farber....and so on.

Like tarhoosier, I've spent many hours researching this topic and issue, and discovered that like most everything with PCa, there is no clear answer. If there was, it would probably change with the next published study anyway. shakehead

Research as much as you can, then go with your gut, my brothers, remembering the physician "throwing the kitchen sink" at your condition, doesn't get hit with the sink or suffer the myriad of side effects. As for me, it's six months of 2ADT, period.

Now, the concept of having Tall Allen available for doctor visits, to rephrase our questions and interpret their answers, has a great deal of merit, and could be a new business venture for him! cool
Posted 3/14/2018 3:47 PM (GMT 0)
There is no real answer since it is very dependent on the person, the cancer and the method (continuous or intermittent). There are generally accepted ranges that come from studies as have been mentioned, but they are not predictive for all nor definitive for any. There is no way any doctor can look at a given patient and tell him when he will become refractive.

To me this is so simple to explain and I don't understand why very highly educated doctors can't simply say,..." it all depends on the individual, but a general range is from ....to......months. But, some men become refractive very soon and others may go many years. It just all depends on the individual. Everyone's cancer is different and we just can't predict when any man will become refractive".
Posted 3/14/2018 3:55 PM (GMT 0)
As an example, my wife was diagnosed with stage III ovarian cancer 30 months ago. Against my judgment she asked her surgeon/oncologist how the diagnosis would affect her life span. His reply was "I will be your doctor for years." I think it was a superb response.
As a doctor for women exclusively he has learned to tailor his responses accordingly. Perhaps MO's for men develop responses based on different experiences. I may be too generous here with this second element.

*She has been disease free for 24 months (no appropriate emoji)
Posted 3/14/2018 4:52 PM (GMT 0)

tarhoosier said...
...*She has been disease free for 24 months (no appropriate emoji)


Happy dance! Enjoy every moment.
Posted 3/14/2018 4:58 PM (GMT 0)
Looking at these responses, I see my comment about communication applies. Some of you are talking about how long ADT should be given (ie, how long it lasts) when it is given adjuvant to radiation (whether primary or salvage), and some of you are talking about how long the cancer remains hormone sensitive (ie, how long it lasts) when it is used for lifelong hormone therapy. Ambiguous questions get ambiguous answers.
Posted 3/14/2018 5:00 PM (GMT 0)
Tarhoosier—
Here’s to your wife, may she continue to reign disease free!
I just don’t get it how ROs who broadly agree that a course of SRT should be exactly 72 Gy, without much variation according to the specific pathology of the salvage patient, can so broadly disagree on the appropriate duration for ADT — 6, 9, 12 18, 24 months. And why is the recommendation always a multiple of three? As if 1 m and 4 m leuprolide injections weren’t available.
Posted 3/14/2018 9:47 PM (GMT 0)

Tall Allen said...
To be clear: the question you were asking was in a man with metastases who is taking Lupron (or similar) to slow progression, how long will it be before castration resistance starts to become noticeable (i.e., PSA starts to rise or new mets are discovered)? His answer of 2 years (median) is right. For most men, it is more than one year and less than 3 years. It may be longer for those diagnosed at an earlier stage of progression (e.g., oligometastatic) and those who achieve undetectable PSA with ADT.


I hear you, Allen, but some of the guys (e.g. George, SkyPilot) are reporting 18-24 month tx regimes, not “Stay on Lupron till castration resistance, which typically sets in around 18-24 months.” Maybe that’s for more aggressive PCa (G9, pT3 N1)?
Posted 3/14/2018 10:25 PM (GMT 0)
SP - That's scary I'm in both groups might as well bend over and mmmmmm naw but you are right we were talking about tx regimes.

Larry
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