Approaching the end of a round of ADT? Something to think about.

I am six months away from the end of my 24 months of ADT that accompanied my adjuvant radiation. The three-month Trelstar shot I got yesterday marked the occasion. I talked to my oncologist and we agreed that it would be my last three-month shot. Sadly, that doesn't mean that I talked him into reducing my sentence to 21 months, but instead that we will handle the last three months with three one-month shots -- one in April, one in May and one in June.

When I went in for my appointment I took a copy of a research abstract with me and showed it to him. Here's a link: Randomized study evaluating testosterone recovery using short-versus long-acting luteinizing hormone releasing hormone agonists.

They were looking at the rate at which men recovered to T reference ranges after six months of suppression with either two three-month shots or six one-month shots. What they observed but failed to prove was that the men on the one-month shots recovered twice as fast as the men on the three-month shots. The reason they failed to prove anything is that they missed their accrual target of 100 men and with their 55 man sample the study was not strong enough to reach the required 95 percent standard. This is another study where it is important to remember that a study that fails to prove something has not, necessarily, disproved it. The take away from the study from a medical science point of view is that more study is needed. But the take away for you and me is that we probably want the last few months of our ADT to be one-month-at-a-time.

It makes sense if you think about it. A six-month depot of Lupron (or whatever) is designed to last at least six months (usually) but it may last seven months or nine or ten. The effect sort of drops off gradually and takes kind of a long time. Similarly a three-month shot (like I have been getting) is supposed to last at least three months but it may last four or five or six. A one-month shot lasts at least one month but it may go two.

So the idea is, if you want to square up the end of your androgen blockade -- so that you are nicely suppressed on the last day of your active treatment schedule and not suppressed at all the morning of the next day then what you want is to approach the end of your treatment with successively shorter-and-shorter acting treatments. (Exaggerating about the "morning of the next day" thing but you get the idea.)

Of course, lingering effects of declining LHRHa drugs are only one factor in testosterone recovery after prolonged androgen deprivation. The longer you are on ADT the longer it takes you to recover and the more uncertain the recovery process becomes. That difference isn't explained by the process I described above -- but it remains true that the lingering LHRH agonists don't help matters any, even for guys coming off of ADT after three years.

Another thing to bear in mind if you subscribe to the "saturation" theory is that the less time you can spend in the middle testosterone range the better. Once you get much above castrate levels any effect the testosterone will have on your cancer will kick in quickly -- the receptors will saturate at a level far lower than those needed to treat the symptoms of hypogonadism. While you are waiting for your T to drift up to a level where it does you any good any hormone-dependent cancer cells you may have are already in business.

I would think that for intermittent guys coming up on a "vacation" this might be something to talk to their doctors about.

I think my MO enjoyed talking about this study and my theories about it. When we were done he followed me all the way down the hall to the (dreaded) shot room, chatting away happily about new drugs that were coming out and patients he had seen for which some of the new drugs were little short of miraculous.

JNF,

Your doctors were probably right. I do think that if you had gone with lower duration shots at the end that it might have sped up the process a month or two but after, what?, three years of ADT it will take you a year or two to get back to baseline and a couple of months here or there isn't that big a part of the process.

In large part, my delight in my talk with my oncologist stems from the fact that for a Gleason 9 it is hard to get any part of your treatment plan to budge an inch. When I was a Gleason 6 I had a million options -- I could scarcely think about one option before I was crushed by the opportunity costs of all the others. I was out there all by myself twisting in the wind. But when my post-op came back Gleason 9 with positive margins, all of a sudden all of my doctors agreed on everything and they mostly just told me what was going to happen without much input from me. Yesterday, armed with my inconclusive study I made it budge. Victory!

Also, I have my patented bad attitude about ADT. If I can claw back a week of normalcy from the danmable stuff, and all I have to do is make myself into a pincushion for a couple of months, I score that as a big win.

This is a math problem that I used to be able to do before I lost brain cells from using exogenous substances. If we know the serum half-lives of the 3 month shot and the one month shot, the number and timing of past shots, and the minimum serum level necessary for androgen suppression, some clever person can figure out the dosing schedule that most quickly gets the ADT below the minimum serum level. Isn't Mel a mathematician? I'm sure there are a few in the forum.

- Allen

Tall:

I don't know the half-lifes. Also, I think the body processes it differently.

Dr. Lam gave me the choice of 1-month vs. 4-month shots and seemed to indicate that recovery will not be impacted.

Peter, et. al -- I will have had 1 year on HT. I hope that's it. I'll know after my next round of tests in 2 weeks. But, do you have any information about recovery time as a function of the time one has been on HT? I know the longer one has been on HT, the longer it takes to recover T. I have not seen this quantified

Mel

Along with the returning to normal testosterone levels, do you guys on HT use ED methods while you are on HT? I read about people simply not being interested in sex while on it, but I'm doing the bi-mix for rehab after surgery while hoping to regain normal function. Sorry if this is indelicate but I might end up in the same boat someday.

What about a couple of shots of human chorionic gonadotropin (hCG) to jumpstart the hypothalamic-pituitary-testicular axis? There is a guy in my group whose pituitary got stuck in the "off" position after a couple of years on ADT, and it worked for him. I think his doctor had him on Clomid (clomiphene) for a few weeks as well. This is all "off-label," but he said it was not expensive.