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Intermitten or Continuous ADT

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Posted 6/22/2022 3:37 PM (GMT 0)
I would appreciate all opinions about "intermittent ADT" from everybody who has been on a long journey with PCa or has knowledge about it. We are undecided of which way we should go. My dad's first diagnosis was in Oct 2019 with 3 spots seen on 3 ribs.
07/2018 psa= 3.4
07/ 09/ 2019= 34
07/19/ 2019= 43.4
09/18/2019= 55.6
Started Casodex and Trelstar Nov, 2019.
02/07/2020= 0.44
Since 08/2020 psa has been undetectable.
He switched to Xtandi/ Trelstar Dec. 2020. He's 90 years old and he said the main side effect is hot flash. He's been getting Trelstar shot every 3 months and taking 2 Xtandi per day (instead of 4). Thanks in advance for inputs.

Post Edited (TN1932) : 6/22/2022 1:36:04 PM (GMT-6)

Posted 6/22/2022 4:40 PM (GMT 0)
TN1932,
You're dad is getting the standard of care, which seems to be working well for him, and can continue work for a long time. It's not uncommon to use the lower dose Xtandi for older patients to minimize side-effects while still providing good protection.

I'm inclined to say don't fix what's not broken. Typically, by the time men start feeling better from an ADT break it's time to go back on ADT due to rising PSA. (I've never taken an ADT break, so I don't have experience with intermittent ADT).

If your dad's main concern are the hot flashes something as simple as having a fan handy can help a lot. My flashes have greatly reduced over time.

I guess the bottom line is that your dad may get some short term relief from iADT, but he'll have to decide if it's worthwhile to break from what's now working.

There are guys on the forum who have done iADT, so they can give a better perspective.
Posted 6/22/2022 7:55 PM (GMT 0)
I was on iADT three times, but with Lupron or Lupron like drugs. I got 8 1/2 years.

Once it was determined that I was castrate resistant and metastatic, Onco said no more iADT.
We added Xtandi and kept the ADT.
Said we'll go as long as we can on what we have.
Posted 6/22/2022 8:02 PM (GMT 0)
mattam,
I think the selling point of intermitten ADT (for my dad) is prolonged time before castration resistance. But from what i understand, there's no clear conclusion about intermitten ADT and prolonged time before castration resistance. If it's just for the purpose of reducing side effects, my dad probably will decide to keep it going without breaks.
Posted 6/22/2022 8:18 PM (GMT 0)
alephnull,
Thanks for the summary of your journey. My dad is castration sensitive but metastatic. Even though the 3 spots seen on ribs were not biopsied to confirm, but they were gone after he started Casodex/Trelstar. So his urologist thinks it's PCa metastasis.
Posted 6/22/2022 8:50 PM (GMT 0)

TN1932 said...
mattam,
I think the selling point of intermitten ADT (for my dad) is prolonged time before castration resistance. But from what i understand, there's no clear conclusion about intermitten ADT and prolonged time before castration resistance. If it's just for the purpose of reducing side effects, my dad probably will decide to keep it going without breaks.

There has been an evolution in the use of ADT drugs the past decade. It used to be Lupron (Trelstar is very similar) was used until castrate resistance, at which time adding chemo was tabout the only option. During this period there was some experimenting to see if iADT could stretch out the effectiveness of Lupron. I do not know if much success came from these trials. Too shorten a long story, I will just say that drug trials have brought us to the point where it's known that the early addition of a second tier ADT drug like Xtandi to a Lupron type drug gives the most robust survival. This what your dad is getting.

I don't recall any guys on the forum doing intermittent use of these combination drugs. I don't think trials are happening for it, but I don't know.

Are the doctors suggesting the intermittent use of your dad's Trelstar and Xtandi?
Posted 6/22/2022 9:47 PM (GMT 0)
Yes, His urologist is suggesting iADT. I think his urologist is an old school guy; his use of Casodex/ Trelstar from the beginning is a proof. I convinced my dad to see another doctor (oncologist) in 2020, who introduced him to second tier ADT drug- Xtandi. But then he ended up returning to the first doctor and continuing with Xtandi.

Post Edited (TN1932) : 6/22/2022 3:55:27 PM (GMT-6)

Posted 6/22/2022 10:14 PM (GMT 0)
TN1932,
Well, that's a new one for me, and explains my confusion over the reason behind putting the treatment on hold. I was thinking your dad wanted a "vacation" from the treatment side-effects.

I'm on Lupron/Xtandi and I personally would be hesitant for trying intermittent use. The researchers have barely had time to establish the drug combinations and the timing of their use, let alone any evidence for intermittent use. At least to my knowledge.

I may try to look up papers and trials on the subject, but there are forum members who are more skilled at that than me, if it interests them to do so.
Posted 6/22/2022 10:30 PM (GMT 0)
PS,
Your dad's urologist may be good, but I think his job is done. Your dad should be under the care of a Medical Oncologist experienced in prostate cancer at this point.
Posted 6/22/2022 10:50 PM (GMT 0)
How is his health otherwise? What is the estimate of longevity? I could see going intermittent with a PSA target say of 10. On ADT to very low PSA then a vacation till it goes up to an acceptable level then back on ADT. Will it make much of a difference on side effects? Only if he is off for 12-18 months. So is intermittent worth it? Who knows? When I am 90, I will be looking for the best quality of life.

BTW, who in the H#ll let his PSA climb so high? I am amazed he was even having PSA tests at his age. But if he was, why so high before anything was done? Hope I haven’t misread something.

Thank goodness he has you in his corner looking out for him.
Posted 6/23/2022 12:33 AM (GMT 0)
JNF,
You haven't misread. My dad did skip a couple years on psa test. His family doctor convinced him to do it again on 2018, when it came out 3.4. They didn't concern or do anything about it. A routine psa test a year later revealed a big jump to 34. He's doing pretty well considering his age. He's still driving and doing everything himself. The hot flash he's having now is not a big deal to him. However, I think there's a big decline in muscle strength due to ADT and his current inactive life style. I think my biggest question is if there's a relation between intermitten ADT and prolonged time before castration resistance. For my dad, prolonged time before castration resistance means he can stay on these drugs with minimal side effects (to him) therefore better quality of life.
Posted 6/23/2022 1:35 AM (GMT 0)
Thanks TN. At his age, don’t worry about becoming castration resistant from a practical standpoint. Theoretically, intermittent treatment probably delays this, but it all depends on the man. I have a friend that has been on Lupron more than 15 years and I have known others that the first shot had no effect. We know he is currently sensitive, just don’t know how long that will continue.

I was on ADT for three years and tolerated it well. Of course I was 30 years younger than your dad. If he is tolerating it well and controlled, why change? I would try to get on the lowest medication possible to maintain control. I might suggest only the trelstar for a few months and see the effect. Does he really need both drugs? Questions I would be asking the oncologist.
Posted 6/23/2022 1:40 AM (GMT 0)

TN1932 said...
mattam,
I think the selling point of intermitten ADT (for my dad) is prolonged time before castration resistance. But from what i understand, there's no clear conclusion about intermitten ADT and prolonged time before castration resistance. If it's just for the purpose of reducing side effects, my dad probably will decide to keep it going without breaks.

It may not make any difference because your father’s T levels may not recover after the ADT is stopped.
Posted 6/23/2022 3:15 PM (GMT 0)
JNK,
According to studies, taking both Trelstar/Xtandi yields better OS than ADT alone. He's already on the lower dose of Xtandi and he tolerates well with this low dose.
Posted 6/23/2022 3:18 PM (GMT 0)
Duck2,
That's true: may or may not. But if T level doesn't recover when ADT is stopped, then he doesn't need ADT, does he?
Posted 6/23/2022 10:24 PM (GMT 0)

TN1932 said...
Duck2,
That's true: may or may not. But if T level doesn't recover when ADT is stopped, then he doesn't need ADT, does he?


The main point I want to make is that your Dad is doing quite well; no need to change anything.
The second point is a bit more subtle. Yes, his T might not recover to 'normal' if he stops ADT, but it might slowly rise above the 'castrate' level (<20). One doesn't want to risk that.
Posted 6/30/2022 4:12 PM (GMT 0)
You have gleaned great insight and the collective "wisdom of the crowd" ~

With that being said, I endorse the shared idea of having a medical ONCOLOGIST guide your father forward.

Another consideration ~ it's never wrong to seek a second opinion, when in doubt.

With my best to you & your father ~

CYCLONE - # Iowa State University
Posted 7/1/2022 3:13 AM (GMT 0)
Sr Sailor and Cyclone-ISU,
Your inputs are greatly appreciated. He saw an oncologist for about 4-5 months and went back to his original urologist in Mar 2021. That oncologist didn't recommend intermitten ADT whereas the urologist is recommending it. I wish I could convince my dad to see another oncologist. I guess the older we get, the more hesitant we are to make any change.
Posted 7/7/2022 2:13 AM (GMT 0)
It sounds like he likes his current urologist. Being where I’m most comfortable and who I’m most comfortable with adds to the quality of my life. At that age (or even at my age)… I don’t know that I would be gung-ho on beginning at the beginning (again) to fight a fight I’ve already begun to fight once…especially after I’d already fought 3 rounds of a 12 round fight and I’m currently winning.

I cannot answer on the iADT. But if he’s undetectable now…and he’s with who he wishes to be with I see no reason to touch anything.

I hope you find the information you’re looking for.

Godspeed.
Posted 7/23/2022 5:55 PM (GMT 0)
Everyone is so different and I don’t think there is a right or wrong answer to the intermittent vs. continuous hormone therapy. So far, I’ve gone down the intermittent road and it’s gone something like this: If PSA becomes detectable…wait for some trigger point like .2 then I get the latest and greatest scans that are out there if I can (f18, PSMA, etc…) and if that shows something, possibly spot radiate, and then go on some form of HT…once PSA becomes undetectable, stop HT…I’ve been able to get a few years off HT each time with normal testosterone and I’ve probably been off therapy more than I’ve been on for 13 years as a g-9…I also keep track of my bone density as well while on and off therapy…

I’ve been fortunate to have a great team of doctors over the years…
Posted 7/23/2022 6:59 PM (GMT 0)
Jerry,
You have a very interesting and successful story. My plan was to stay off ADT as long as possible (maybe too long) and then go on ADT for life, which is where I am. I would love to go on a long ADT vacation but I feel like I already may have pushed my luck too hard. Time will tell.

Continued success to you.
Posted 7/23/2022 7:32 PM (GMT 0)
PS, I forgot to add that I didn't know spot radiation was going on back in 2011. Judging by guys on the forum I thought it was a more recent development. It would interesting to know the history of spot radiation for PCa bone mets. Maybe it's been going on for a long time?
Posted 7/23/2022 8:26 PM (GMT 0)
TN1932 ~

Since your father ~ age 90 ~ is on ADT ~ it's important to understand it can impact bone strength and density.

I have been on continuos ADT since diagnosis in 2013. I am on PROLIA to maintain bone density, I walk daily, and also take calcium supplements.

It's important to avoid "slips, trips, and falls" ~ especially if you live in an area with ice or snow in winter months.

Your father might ask about a DEXA bone density scan.

I have to have one of these occasionally. They are quick and non-invasive and quickly assess one's bone density.

Just another topic to mention today ~

My best to you and your father ~
CYCLONE ~ # Iowa State University
Posted 7/24/2022 2:04 PM (GMT 0)
Mattam - The spot radiation I’ve had were always done in combination with other therapies. So, I never really knew if it had any direct impact. The PSA would come down and scans would be better (healed lesions, etc…) but it might very well have been the same without the radiation. Probably not too common of a practice a decade ago, but I was young (mid 40s) and I think my medical oncologist at the time and I wanted to be as aggressive as we could while on treatment. From my perspective…even if the radiation didn’t do anything…it made me think I was actually doing something for those images that would show on scan…perhaps psychological…. There were no conclusive studies back then on spot radiation, combination therapies, intermittent therapy, etc… but we did our best to navigate as best we could and treat with the information we had.
Posted 7/25/2022 1:32 AM (GMT 0)
I'll suggest, since surely no one else here will, that he consider transdermal estradiol patches. I feel a bit like a broken record, but I'll keep mentioning this on such threads. These patches supplement a critical hormone, estradiol, that will suppress hot flashes and protect bone density. Those are two critical factors for men on long term testosterone suppression. Dr. Charles "Snuffy" Myers recommended them for his patients on long term ADT. He suggested fairly low doses, 0.025 - 0.050 mg/day, changed twice weekly. Here's a link to his video on the topic:
Transdermal Estrogen + ADT For ProstateCancer

I've been on them for almost 3 years now, and feel great. The main negative effect is gynecomastia, but that's a bit of an issue for half of the men over 50 anyway. I have some, but it doesn't bother me. If that's the price for feeling as good as I do without testosterone, I'm fine with that!

It troubles me that this approach is so seldom recommended. Our body needs some level of sex hormone to work properly, and surprisingly either testosterone or estradiol will do. Different effects of both, but they'll work.
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