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How does the length of ADT get decided ?

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Posted 6/7/2018 7:14 PM (GMT 0)
My DH just went to his check up with the Onc. He got his next 3 month shot. His labs were great with an undetectable PSA. Yay!!! He is feeling good. The only SE would be reduced libido and some weight gain. He goes to the gym 3 times a week for a pretty rigorous almost 2 hour work out with weights and cardio. He feels that the gym him helped him handle the ADT. It isn't always easy to go but he has made it a priority.
When we were talking with the Onc. we were trying to figure out whether he would go 2-3 years. We were bummed to even be considering 2 years. The dr. couldn't really say what would make them decide he should go past 2 years. If DH continues just how he is doing and the PSA stays at undetectable at 2 yrs how do they decide he needs to go another year? Obviously, he doesn't want to be on it any longer than necessary but at the same time he wants to help to ensure success. In the beginning it was suggested ADT for 6-12 months. We feel like the goal post has been moved. 12 months is a long time.
Posted 6/7/2018 7:35 PM (GMT 0)
They throw darts.
Actually, only ROs throw darts. MOs read tea leaves.
I asked this same question here a few months ago, and that pretty much sums up the answers.
I liken it to how long your orthodontist told you you’d need to wear braces when you were a teenager, vs. how long you ended up having to wear them.
Posted 6/7/2018 7:54 PM (GMT 0)
Depends on the situation and risk level. I was on three years, but now it probably would have been two years. He is high risk and that would put him at least in the 18 month duration by most docs.

Have you discussed intermittent treatment? Consider 18 month and then a holiday. If the PSA rises, you will know the surgery and SRT was not curative and you will always have some treatment. If the PSA stays undetectable it may mean a long remission or cure.
Posted 6/7/2018 8:04 PM (GMT 0)
Yes, this issue has generated different opinions among the specialists. My Rad Oncologist originally prescribed two years for me, but then he changed his mind (to my liking) and we did 18 months. His change in thinking was based on a Canadian report/presentation at a major prostate cancer meeting (by now about 3-5 years ago). BUT, I believe that those results haven't been published in a refereed journal.

I did a little searching and the following summarizes the issue much better than the above:

https://www.pcf.org/news/18-month-adt-optimal-for-locally-advanced-prostate-cancer/

PS: Even though this summary looks good to me, it does not apply necessarily to the original question (how long should ADT be prescribed after an earlier prostatectomy).
My BAD!
Posted 6/7/2018 8:09 PM (GMT 0)
you send an email to TA for a listing of all the relevant studies.

;)

tea leaves is another method, but with tea bags being so popular, finding lose tea is not as easy as it once was.

Andrew
Posted 6/7/2018 9:43 PM (GMT 0)
Generally it is decided after a vigorous debate between the patient and his oncologist. I tried pretty hard to convince mine to stop at 18 months but I couldn't sell him on it. I brought in study abstracts and everything. I wanted 18 months and he thought I should do 24 months. We compromised on 24 months.

Here's a link to an article that talks about the optimal length of ADT to accompany radiation for high risk guys.

New Study indicates 18 months of androgen deprivation therapy may be optimal for locally advanced prostate cancer

The author thinks that 18 months is the emerging standard. She quotes two recent studies, one that found that 18 months is better than 6 months and another that found that 36 months is no better than 18 months. She has links to abstracts for the studies mentioned. You could print those out to wave at your oncologist during the discussion.

Good luck with that.
Posted 6/7/2018 10:11 PM (GMT 0)

PeterDisAbelard. said...
Generally it is decided after a vigorous debate between the patient and his oncologist. I tried pretty hard to convince mine to stop at 18 months but I couldn't sell him on it. I brought in study abstracts and everything. I wanted 18 months and he thought I should do 24 months. We compromised on 24 months. ...


At the completion of my IMRT treatments in April of last year, my RO initially wanted me to have 24 months of adjuvant ADT (and that was in addition to the 6 months of ADT I had already had by that time).

But when I met with him at a followup appointment in August, he was suddenly open to the idea of decreasing the adjuvant ADT to 18 months (which was fine with me), there really wasn't very much debate about it. I wonder if that was about the time the results of the study you mention came out.
Posted 6/7/2018 10:42 PM (GMT 0)
Sr Sailor, thanks for the link to the report on the RADAR trial. That takes some of the guesswork out of it.

If I remember correctly, there have been studies on the efficacy of short-term vs. long-term ADT in combination with SRT for high-risk PCa. But the precise protocol a doctor recommends -- 6, 9 or 12 months for short-term, 18, 24, or 36 for long-term, for example -- seems not to be grounded in hard evidence and to be more a matter of the the individual MD's judgment/experience. If I'm wrong about that, please set me straight.
Posted 6/7/2018 10:45 PM (GMT 0)

Kent said...
But when I met with him at a followup appointment in August, he was suddenly open to the idea of decreasing the adjuvant ADT to 18 months (which was fine with me), there really wasn't very much debate about it. I wonder if that was about the time the results of the study you mention came out..


That's a distinct possibility. The study was released early in June, two months earlier. He'd probably have seen it.
Posted 6/8/2018 11:23 AM (GMT 0)
I asked the same question of my team at the Mayo when I had to go on Lupron - this is what I was told each case is looked at individually the aggressiveness, outside involvement, and what you the patient wants concerning QQL, trying for a cure if there is such a option, or just taking your chances? After being undetectable for 6 months I asked my RO if I could try the 18 months and then a break but they encouraged me with the good results and my post-op report to go the full 2 years. For us guys that are old enough to remember when radial tires first came out we didn't want much to do with them didn't think it was safe I was working in a Dodge dealership them and the owner refused to put them on people's cars as he didn't want to be held liable if something went wrong. Now I think it would be pretty hard to find a tire that isn't reliable even after the Ford Explorer fiasco. I kinda wonder if that isn't the thot that goes along
with ADT treatment length? 2 years has proven it works so lets stay with it. JMHO

Larry
Posted 6/8/2018 1:48 PM (GMT 0)
And with my positive node (and high risk Decipher genome test) I only had six months of Lupron.
Posted 6/8/2018 3:48 PM (GMT 0)
I had an RP, RT, and HT pT3bN1

My HT was 24 months, took a vacation from it that lasted less than a year.

Determined BCR, now I'm on intermittent HT, 3 - 3 month shots, then stop and monitor
Posted 6/8/2018 6:21 PM (GMT 0)
Adjuvant ADT with salvage RT is different from adjuvant ADT with primary RT. When there is a whole prostate full of cancer to be cured, it is a different situation from destroying the remaining small foci of cancer after the prostate is removed.

That said, there is no one optimal answer. The only randomized trial with Lupron showed that at least 6 months is necessary. A retrospective study suggests that at least 12 months is better. There was a randomized trial of Casodex, which is much less potent than Lupron, that showed 2 years is better than none.

/pcnrv.blogspot.com/2016/08/combining-androgen-deprivation-therapy.html

There are other considerations. To some extent, radiation dose can be substituted for ADT duration. Also, since he had a positive margin, it reduces the probability that systemic treatment is needed.

He cannot stop it and later re-start it and hope to cure it, so it is a decision he will have to make up front.
Posted 6/8/2018 11:02 PM (GMT 0)
As it probably should be, these studies concentrate on more advanced prostate cancers. If it’s reasonable to apply these findings to intermediate risk cases is problematic.

After G3+4, surgery, persistent PSA, a one inch tumor remaining in my prostate cavity and 39 SRT fractions of 1.8 Gy per, I’m looking forward to the end of my six months of Lupron and seven months of Casodex, in 3 weeks. As TA says, there is no single universal answer. Each case is unique and we all could use a lot of faith and a little luck.
Posted 6/8/2018 11:29 PM (GMT 0)
One thing I have noticed, the more you complain about it, the more likely they are to reduce the treatment duration...You are lucky they are not talking about chemo.....
Posted 6/12/2018 6:33 AM (GMT 0)
Fairwind, the Onc did throw out that maybe DH should consider some Taxotere. Another reason we feel the goalposts are being moved without any evidence that the RT and ADT has failed. DH is saying no at this time.

Thank you kindly for your valuable insights. My husband's case has been so frustrating as the choices haven't been so obvious. We have been blessed that he has felt pretty good and the RT and the ADT haven't completely kicked his butt. His hard work at the gym, physically demanding job and healthy diet has helped his outcome we hope. I look back and think how naive we were to think he would be one and done with his treatment. We had no idea how many variables there were. We wouldn't have navigated this journey in the same informed way without you all.
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