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Intermittant HT -- how long have you kept it up and another question

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Posted 9/20/2015 2:27 PM (GMT 0)
I am hopeful that as of 12/1, I will be officially starting my second HT vacation.

I seem to be on HT for a year. The last time, my vacation lasted only 9 months (I was hoping for at least a year).

So, I have 2 questions for those of you doing this.

1) I assume that my 2nd HT vacation will last less (ie: < 9 months). Have any of you had lengthier (or even equal) HT vacations the 2nd time around.

2) How many HT vacations can one get before becoming HT resistant?

I guess I am just curious about the experiences of others.

Mel
Posted 9/20/2015 8:40 PM (GMT 0)
And if I might add a third question, at what point do you end a vacation? Anything more than undetectable? Or .03 or .2?

I have a friend who has been on an 8 year vacation!! But has had rising PSA for a couple of years, but his Uro wants to wait till he is at a PSA of 4. His logic is that HT has been very successful so far and no reason why it shouldn't be so again, but wait til you really need it. More frequent use might end up in a law of diminishing returns much as Mel has mentioned in Q 1 above.

Chas
Posted 9/20/2015 8:57 PM (GMT 0)
I think Dr. Lam and I decided on about a PSA of 5. I don't have my notes here, so this is from memory.

However, we definitely wanted to wait for my PSA to get above 2.5 or so in order to do a C11/Choline scan (they recommend a PSA of >2 for more accurate results)

Mel
Posted 9/21/2015 3:27 AM (GMT 0)
Our doc says to wait until it hits 4.
Posted 9/21/2015 4:56 AM (GMT 0)
I just checked and I did restart at a PSA of 5.26

Mel
Posted 9/21/2015 1:03 PM (GMT 0)
They've decided I won't even get the second vacation. Glad you are getting that!
Posted 9/21/2015 1:37 PM (GMT 0)
Mel:

In my case the first on period led to 0.1 psa and the succeeding off period was 8-9 months. Same for second cycle. Third on period was with oncologist rather than urologist and psa 0.01 achieved though longer time to this lower figure. For next on period radiation was added to mets in hip, spine and nodes and this led to off period of 20 months. All on- periods with Zoladex or equivalent and Casodex.
I am currently on new mix of Xtandi and Degarelix so past results cannot be compared when I suspend ADT in the future. So in my case a change of treatment has led to a longer off period which I hope will be true on this next off period.
I believe that the psa nadir is a predictor to overall performance, and time to nadir (shorter to ultra lo is better) is also of some predictive value though I cannot cite any research about that.
Kenneth Mitchell participates in some of the online forums and he has NEVER been undetectable in 15 years of multiple treatments so there are differences everywhere you look. Psa results provide a trend and any change of treatment means previous trend may be unreliable, even more so than psa is under other circumstances.
Posted 9/21/2015 2:02 PM (GMT 0)
Mel,

I guess I am one HT vacation ahead of you. After failed RP and SRT, I am 8 months into my third one year round of HT (Eligard), hopefully to be followed by a third HT vacation. My first vacation was about a year and a half, the second somewhat less. In terms of side effects, you also need to subtract from the vacation period the length of time it takes to recover any T after the last shot supposedly wears off. In my case that has been 6-8 months. My trigger point for starting/restarting HT has been a PSA of 9-10. As my PSA gets higher the doubling time shortens to less than 3 months, so waiting for another 3 month check could put it over 20, making both my onc and me pretty anxious, so I go back on the juice.

I had bone and CT scans with each restart of HT with no mets detected, just one enlarged lymph node that doesn't shrink when on HT, so that was disregarded. I have read with interest your exploration of enhanced scans to detect micromets that could be targeted with curative intent. My onc shrugs off my case as systemic with no similar possibilities.

Your second question is one that keeps me awake at night- how many rounds before resistance appears? No doubt it varies by individual, Gleason score, PCa variant and other factors. As much as I detest HT and its side effects, at this point it is the best of a bunch of bad and diminishing options. Here's to many more HT vactions!

All the best,
Posted 9/21/2015 2:12 PM (GMT 0)
I'm reading a book about a guy that has been fighting advanced metastatic PCA for 25-30 years and he has been on intermittent HT 9 times. He is not yet resistant.

It is all so specific to the individual and unpredictable.
Posted 9/21/2015 3:44 PM (GMT 0)
Very interesting.

Tar, you mentioned time to nadir.
I'm not sure if my time is great, good, or poor.

First time:
2/7/2014 <0.02
10/25/2013 0.02
8/5/2013 0.03
7/26/2013 0.03
5/30/2013 0,07
4/19/2013 0.57
3/1/2013 17.55

IN other words, I started HT the first time on 3/1/13 having let my PSA rise to 17.55.
As of 3/1/14, I basically started my HT vacation.

Now, second round, see below:

9/17/2015 <0.02
6/19/2015 0.02
3/30/2015 0.09
1/23/2015 0.24
12/1/2014 5.26

In short after 9 months, I restarted HT (Lupron/Casodex each time) on 12/1/14. This time we did not wait for my PSA to go to double digits.
It appears that the time to nadir is more or less the same.
I suspect I'll do one more PSA in 2+ months, and barring any major turnaround, I can start my HT vacation on 12/1 (currently scheduled for my next Lupron shot that day).

Any comments/analysis on this data?

Mel
Posted 9/22/2015 1:20 AM (GMT 0)
Mel,

My understanding is that, as long as ADT manages to bring your PSA down to undetectable, and you have no identifiable mets on scans, you're in a really good place. Having your PSA be at such low numbers (even at the point when you restart ADT) should mean that there are very few cancer cells in your body, thus minimizing the numbers of them who are undergoing mutations in response to ADT to statistically meaningless numbers.

Eventually (but no one can predict for sure, at this moment) there could be enough such cells to produce measurable resistance to ADT, but you'll know, since the PSA drop will not be as dramatic, your nadir will be higher than previous, etc. At that point, you can deploy the full arsenal of second-line hormonal agents, etc., and keep it at bay once again.


There is one possibility to look out for: quick, sudden rises in PSA coming seemingly out of nowhere (exactly what happened to my father last year), while on remission and ADT vacation. Our oncologist has said this could indicate a repopulation with a new stream of PCA cells in the body. Apparently, PCA cells spawn off specific stem cells, and when they do in such a rapid fashion out of nowhere, it calls for aggressive treatment right away, especially to minimize the possibility for resistance emerging quickly (since there are many more cancer cells that are being produced at this point, naturally including larger numbers of mutations).

Lastly (again, based on our conversations with the oncologist), not all PCA cells emit PSA. Some are PSA-negative, some are PSA-positive, and both usually co-exist during periods of increasing disease burden. The PSA-negative cells usually get to a state that produce PSA (reflected in fast increases in PSA numbers).

The possible presence of PSA-negative cells is why it is important to stop therapy (for people with known history of mets) only after using multiple testing methods: PSA tests, but also bone scans, and if needed, circulating tumor cells tests, and imaging scans. This is to verify that scans show marked improvement, and/or show that the cancer has been cleared from the body; a way to double-check PSA results.

But, in your case, seems like you are doing great with your continued response to ADT down to undetectable levels. Here's to another long ADT vacation, as you successfully fight off this beast!!

Arthur
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