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How long should the ADT phase be in IADT?
  1. #1
    John Guest

    Default How long should the ADT phase be in IADT?

    In IADT, how long should one persist with the ADT phase, once the PSA
    is below detectable?

    --
    John

  2. #2
    Steve Jordan Guest

    Default Re: How long should the ADT phase be in IADT?

    On 8/12/10, John wrote:

    > In IADT, how long should one persist with the ADT phase, once
    > the PSA is below detectable?


    According to the estimable med onc Stephen B. Strum,
    "undetectable" is a PSA at or below 0.05 ng/mL.

    He recommends, once having achieved that goal, continuing ADT for
    at least one year.

    Sources:

    The Prostate Cancer Research Institute (PCRI) at:
    http://www.prostate-cancer.org/pcricms/

    and

    _A Primer on Prostate Cancer_ 2nd ed., subtitled "The Empowered
    Patient's Guide" by medical oncologist and PCa specialist Stephen
    B. Strum, MD and PCa warrior Donna Pogliano. It is available from
    the PCRI website and the like, as well as Amazon (30+ five-star
    reviews), Barnes & Noble, and bookstores. A lifesaver, as I very
    well know.

    Regards,

    Steve J



  3. #3
    John Guest

    Default Re: How long should the ADT phase be in IADT?

    After two attempts, one of them not very well put, and the other just
    a hint, I suspect that I'm not getting my point across - I can't
    believe that IADT folk don't care how long they have to wait to
    recover 'normality' (ie average testosterone levels) during the off
    period so it must be my lack of clarity. So here goes with my last
    attempt.

    I am now in my second spell of being on Zoladex but, looking back over
    my first period of being 'off' the ADT(zoladex), it took fifteen
    months before I recovered a reasonable level of testosterone and,
    thence, the feeling of being the real, male me. I was very frustrated
    by this and was left wondering if it would have taken less time to
    recover if I hadn't previously been taking zoladex for as long as
    fifteen months.

    Why does it take so long for the pituitary (and what follows between
    it and the testosterone factory) to recover?

    Is there a correlation between the length of the period of androgen
    deprivation and how long it takes for the testosterone to return?

    If there is, do we prefer short spells of 'off' and 'on' or longer
    ones? I would prefer short ones.

    So, is there a case for stopping ADT as soon as the PSA gets really
    low?

    And what are the longevity, and perhaps other, consequences of the
    choice of long or short on and off spells?

    __

    John


    _________________________________________________
    Prostate History of John, b 1935

    1991: Trans-urethral resection (TURP) following poor flow and
    rectal exam. Biopsy of fragments revealed benign hyperplasia.

    2006, June: Second TURP following return of poor flow.

    2006, July: Biopsy of TURP fragments revealed presence of malignant
    cancer, Gleason 4 plus 3. Subsequent PSA was 30.

    2006, Aug: Bone scan clear, MRI showed breaching cancer. Cancer
    committee' decided that prostatectomy was unsuitable due to scarring
    and damage from two TURPS. Recommendation was for external beam
    radiotherapy after three months of neo-adjuvant ADT with Zoladex.

    2007, Jan: Radiotherapy until end of February.

    2007, Feb: Decided to halt ADT in order to see clear result from
    radiotherapy.

    2007, May: PSA=1.4

    2007, Aug: PSA=3.3

    2007, Nov: PSA=7.8

    2008, Jan: Started course of Casodex to prevent flare'.

    2008, Feb: ADT recommenced with 12 week Zoladex implant.

    2008, April: PSA less than detection limit (0.1).

    2008, Sept: PSA less than 0.1

    2008, Oct: Twelve week Zoladex implant - the last after deciding
    to adopt intermittent ADT if the next quarterly PSA remained below
    0.1.

    2009, Feb: PSA less than 0.1

    2009, May: PSA less than 0.1

    2009, Aug: PSA less than 0.1

    2009, Sept: Testosterone =0.4 (European units)

    2009, Oct: PSA less than 0.1, testosterone= 2.1

    2010, Jan: PSA=1, testosterone = 6.2

    2010, April: PSA=13.4 (a second measurement, a week later, in order
    to confirm that the high value was real gave PSA=15).
    Testosterone=4.8.

    2010, April: Three week Casodex antiflare treatment commenced.

    2010, May: 12 week Zoladex implant.

    2010, July: Oncologist suggests that the PC has mutated to more
    aggressive form.

    2010, Aug: PSA=1.1, 12 week zoladex implant.

  4. #4
    Steve Kramer Guest

    Default Re: How long should the ADT phase be in IADT?

    I understand your situation and questions, John. I'm afraid there are no
    set answers. The number of studies that would (and will) have to be
    conducted and the lengths of them... well, it is just a daunting task to
    consider even the average possible permutations. Remember, modern ADT
    hasn't even been around as long as some previously diagnosed and now
    considered cured prostate cancer patients. Any studies that would have pat
    answers now would almost have been started when the ADT of the day was
    Estrogen.

    What we know is that some go on ADT for a couple of years and when they come
    off, their T comes back fast. Some go on for less than a year and it takes
    another year to come back. Some go on ADT and when they come off, T never
    returns - or at least the side effects of ADT last indefinitely in these
    individuals.

    We are all different people with different DNA and the study of prostate
    cancer, while amazingly advanced considering what it was in 1970, is still
    in its infancy. There will likely be a cure before they have an answer to
    your dilemmas.

    <John> wrote in message news:[email protected]..
    > After two attempts, one of them not very well put, and the other just
    > a hint, I suspect that I'm not getting my point across - I can't
    > believe that IADT folk don't care how long they have to wait to
    > recover 'normality' (ie average testosterone levels) during the off
    > period so it must be my lack of clarity. So here goes with my last
    > attempt.
    >
    > I am now in my second spell of being on Zoladex but, looking back over
    > my first period of being 'off' the ADT(zoladex), it took fifteen
    > months before I recovered a reasonable level of testosterone and,
    > thence, the feeling of being the real, male me. I was very frustrated
    > by this and was left wondering if it would have taken less time to
    > recover if I hadn't previously been taking zoladex for as long as
    > fifteen months.
    >
    > Why does it take so long for the pituitary (and what follows between
    > it and the testosterone factory) to recover?
    >
    > Is there a correlation between the length of the period of androgen
    > deprivation and how long it takes for the testosterone to return?
    >
    > If there is, do we prefer short spells of 'off' and 'on' or longer
    > ones? I would prefer short ones.
    >
    > So, is there a case for stopping ADT as soon as the PSA gets really
    > low?
    >
    > And what are the longevity, and perhaps other, consequences of the
    > choice of long or short on and off spells?
    >
    > __
    >
    > John
    >
    >
    > _________________________________________________
    > Prostate History of John, b 1935
    >
    > 1991: Trans-urethral resection (TURP) following poor flow and
    > rectal exam. Biopsy of fragments revealed benign hyperplasia.
    >
    > 2006, June: Second TURP following return of poor flow.
    >
    > 2006, July: Biopsy of TURP fragments revealed presence of malignant
    > cancer, Gleason 4 plus 3. Subsequent PSA was 30.
    >
    > 2006, Aug: Bone scan clear, MRI showed breaching cancer. Cancer
    > committee' decided that prostatectomy was unsuitable due to scarring
    > and damage from two TURPS. Recommendation was for external beam
    > radiotherapy after three months of neo-adjuvant ADT with Zoladex.
    >
    > 2007, Jan: Radiotherapy until end of February.
    >
    > 2007, Feb: Decided to halt ADT in order to see clear result from
    > radiotherapy.
    >
    > 2007, May: PSA=1.4
    >
    > 2007, Aug: PSA=3.3
    >
    > 2007, Nov: PSA=7.8
    >
    > 2008, Jan: Started course of Casodex to prevent flare'.
    >
    > 2008, Feb: ADT recommenced with 12 week Zoladex implant.
    >
    > 2008, April: PSA less than detection limit (0.1).
    >
    > 2008, Sept: PSA less than 0.1
    >
    > 2008, Oct: Twelve week Zoladex implant - the last after deciding
    > to adopt intermittent ADT if the next quarterly PSA remained below
    > 0.1.
    >
    > 2009, Feb: PSA less than 0.1
    >
    > 2009, May: PSA less than 0.1
    >
    > 2009, Aug: PSA less than 0.1
    >
    > 2009, Sept: Testosterone =0.4 (European units)
    >
    > 2009, Oct: PSA less than 0.1, testosterone= 2.1
    >
    > 2010, Jan: PSA=1, testosterone = 6.2
    >
    > 2010, April: PSA=13.4 (a second measurement, a week later, in order
    > to confirm that the high value was real gave PSA=15).
    > Testosterone=4.8.
    >
    > 2010, April: Three week Casodex antiflare treatment commenced.
    >
    > 2010, May: 12 week Zoladex implant.
    >
    > 2010, July: Oncologist suggests that the PC has mutated to more
    > aggressive form.
    >
    > 2010, Aug: PSA=1.1, 12 week zoladex implant.






    --
    PSA 16 10/17/2000 @ 46
    Biopsy 11/01/2000 G7 (3+4), T2c
    RRP 12/15/2000 G7 (3+4), T3cN0M0 Neg margins
    PSA <.1 <.1 <.1 .27 .37 .75 PSAD 0.19 years
    EBRT 05-07/2002 @ 47
    PSA .34 .22 .15 .21 .32 PSAD 0.56 years
    Lupron 07/03 (1 mo) 8/03 and every 4 months there after
    PSA .07 .05 .06 .09 .08 .132 .145 PSAD 1.40 years
    Casodex added daily 07/06
    PSA undetectable since. Next Assay 10/10/10
    Illegitimati non carborundum



  5. #5
    John Guest

    Default Re: How long should the ADT phase be in IADT?

    "Steve Kramer" <[email protected]> wrote:

    A wonderfully wise and measured answer to my question.

    Thanks Steve.

    Over the past six months I have been involved in a seniors science
    group which is being taught something about modern genetics and,
    latterly, about genomics (which is to electronics as gene is to
    electron). In my working life I was a physics researcher so I am
    comfortable with science but I have to confess that genomics since
    Crick and Watson just flattens me with its complexity. The standard
    series of 'Dummies' books has done one on genetics and all I can say
    is that if dummies are expected to cope with that stuff, then I can't
    imagine what the experts get up to.

    When the group was asked, recently, what we might go on to do next, I
    won approval for us doing a bit on cancer. We have a superb leader
    who trained as a doctor, had a soldiering career in the artillery, and
    finished up teaching before retiring. He has agreed to do some talks
    on this, starting in November.

    I've been taking a peek at what lies ahead by trying to read a year
    2000 paper entitled 'Molecular genetics of prostate cancer'.

    http://genesdev.cshlp.org/content/14/19/2410.extract

    I struggle with the terminology and the complex detail but my attempt
    to read this stuff has given an insight into just how powerful the new
    genetics is in getting to grips with the processes involved in our
    disease. It fills me with confidence that these guys are going to
    sort out this stuff, although not completely in less than ten years.
    But a full understanding, and consequent therapies, must be close.

    --
    J

  6. #6
    Alan Meyer Guest

    Default Re: How long should the ADT phase be in IADT?

    On 08/14/2010 07:50 AM, Steve Kramer wrote:
    > I understand your situation and questions, John. I'm afraid there are no
    > set answers. The number of studies that would (and will) have to be
    > conducted and the lengths of them... well, it is just a daunting task to
    > consider even the average possible permutations. Remember, modern ADT
    > hasn't even been around as long as some previously diagnosed and now
    > considered cured prostate cancer patients. Any studies that would have pat
    > answers now would almost have been started when the ADT of the day was
    > Estrogen.
    >
    > What we know is that some go on ADT for a couple of years and when they come
    > off, their T comes back fast. Some go on for less than a year and it takes
    > another year to come back. Some go on ADT and when they come off, T never
    > returns - or at least the side effects of ADT last indefinitely in these
    > individuals.
    >
    > We are all different people with different DNA and the study of prostate
    > cancer, while amazingly advanced considering what it was in 1970, is still
    > in its infancy. There will likely be a cure before they have an answer to
    > your dilemmas.


    What I have read agrees with this, however I'll put in two additional notes.

    If I remember correctly, a correlation has been observed between length
    of time on ADT and time of recovery. It's not strict, only statistical.
    As Steve said, some men recover testosterone quickly even after a long
    time on ADT. But a longer time on ADT does, on average, require a
    longer recovery period.

    As I understand it, there is also a statistical correlation between age
    and recovery period. The older the patient, the longer it takes to
    recover T after the end of treatment.

    As for what to do, that's a tough question. My impression is that
    doctors are biased towards life extension, i.e., to extend life as long
    as possible rather than trade off time for "quality" of life. It seems
    like a natural bias in that patients and their families are more likely
    to get mad at a doctor if they get sick before they needed to, or die
    before they needed to. It also seems to me to be a reasonable bias for
    a medical person. It seems reasonable for a doctor to perceive his job
    as preserving your very tangible health and years of life, as opposed to
    preserving some intangible "quality", though the doc should listen if
    you disagree.

    Many doctors won't prescribe intermittent ADT at all, though that is
    changing since studies have shown that it does not seem to result in
    earlier deaths. Some do it, but are very conservative about ADT "on"
    periods. Some use shorter "on" periods but use finasteride or
    dutasteride during the "off" period to preserve that.

    If I were you John, I'd research that last course, and discuss it with
    your doctor. Perhaps a shorter period of heavy ADT can be followed by
    an off period with light ADT (finasteride or dutasteride) possibly
    providing a prolonged off period with fewer ADT side effects.

    Alan

  7. #7
    Alan Meyer Guest

    Default Re: How long should the ADT phase be in IADT?

    On 08/14/2010 02:59 PM, John wrote:
    > "Steve Kramer"<[email protected]> wrote:
    >
    > A wonderfully wise and measured answer to my question.
    >
    > Thanks Steve.
    >
    > Over the past six months I have been involved in a seniors science
    > group which is being taught something about modern genetics and,
    > latterly, about genomics (which is to electronics as gene is to
    > electron). In my working life I was a physics researcher so I am
    > comfortable with science but I have to confess that genomics since
    > Crick and Watson just flattens me with its complexity. The standard
    > series of 'Dummies' books has done one on genetics and all I can say
    > is that if dummies are expected to cope with that stuff, then I can't
    > imagine what the experts get up to.
    >
    > When the group was asked, recently, what we might go on to do next, I
    > won approval for us doing a bit on cancer. We have a superb leader
    > who trained as a doctor, had a soldiering career in the artillery, and
    > finished up teaching before retiring. He has agreed to do some talks
    > on this, starting in November.
    >
    > I've been taking a peek at what lies ahead by trying to read a year
    > 2000 paper entitled 'Molecular genetics of prostate cancer'.
    >
    > http://genesdev.cshlp.org/content/14/19/2410.extract
    >
    > I struggle with the terminology and the complex detail but my attempt
    > to read this stuff has given an insight into just how powerful the new
    > genetics is in getting to grips with the processes involved in our
    > disease. It fills me with confidence that these guys are going to
    > sort out this stuff, although not completely in less than ten years.
    > But a full understanding, and consequent therapies, must be close.
    >
    > --
    > J


    The "Bible" of molecular biology is _Molecular Biology of the Cell_, by
    Bruce Alberts, et. al. It's now in it's fifth edition. James Watson
    was one of the original authors though he dropped out after the second
    or third.

    It's a great book. It covers the entire field and has great
    explanations and illustrations. It includes a chapter on cancer but,
    importantly, it gives you the preparation you need in genetics, cell
    signaling, cell death, etc., that you need to understand the material on
    cancer. You'll need some understanding of biochemistry to read it, but
    not a lot.

    It's a big commitment to read its 1,392 pages, and it costs a bundle
    ($152 on Amazon) but, as a scientist, I think you'll find it
    fascinating. I recommend it.

    Alan

  8. #8
    colin Guest

    Default Re: How long should the ADT phase be in IADT?

    Hi John
    In my case the first time I came off after 2 years, my psa at the time
    0.1, back on after 12 months, the second time after 3 zoladex sessions
    and the psa had reached 0.3, again back on after 12 months.
    the oncologist suggests coming off zoladex at psa 0.5

    On Thu, 12 Aug 2010 19:28:38 +0100, John <> wrote:

    >In IADT, how long should one persist with the ADT phase, once the PSA
    >is below detectable?


  9. #9
    starrin Guest

    Default Re: How long should the ADT phase be in IADT?

    On Thu, 12 Aug 2010 19:28:38 +0100, John <> wrote:

    >In IADT, how long should one persist with the ADT phase, once the PSA
    >is below detectable?


    Just finished that discussion with my medical oncologist, before I got
    the "final" 6-month shot last week. I have been bumping along at
    <0.014, the lowest the lab reports for well over a year. Inital shot
    was 02/09 followed by 7560 GY via IMRT for a GL 9 4/5/with a tertiary
    3.
    His response was: I can cite you references for 2 years of IADT, but
    none for 18 months.
    We do intend to continue with Avodart during the off period. He looks
    at the rise. He initially said he would become concerned with a rise
    above 0.5, but it will depend on how fast, etc
    So - we're all different - linked by problems we have had with a
    gland. But that gland is different in each of us, and so is the
    problem. To attempt tp come up with a rule of thumb for all seems an
    impossible task.
    So, we go to the basic rule of thumb - everyone has 2


  10. #10
    Alan Meyer Guest

    Default Re: How long should the ADT phase be in IADT?

    On 8/16/2010 10:53 AM, starrin wrote:
    > On Thu, 12 Aug 2010 19:28:38 +0100, John<> wrote:
    >
    >> In IADT, how long should one persist with the ADT phase, once the PSA
    >> is below detectable?

    >
    > Just finished that discussion with my medical oncologist, before I got
    > the "final" 6-month shot last week. I have been bumping along at
    > <0.014, the lowest the lab reports for well over a year. Inital shot
    > was 02/09 followed by 7560 GY via IMRT for a GL 9 4/5/with a tertiary
    > 3.
    > His response was: I can cite you references for 2 years of IADT, but
    > none for 18 months.
    > We do intend to continue with Avodart during the off period. He looks
    > at the rise. He initially said he would become concerned with a rise
    > above 0.5, but it will depend on how fast, etc
    > So - we're all different - linked by problems we have had with a
    > gland. But that gland is different in each of us, and so is the
    > problem. To attempt tp come up with a rule of thumb for all seems an
    > impossible task.
    > So, we go to the basic rule of thumb - everyone has 2
    >


    That's an impressive doctor. He's able to cite references to explain
    his recommendations. He recognizes that the references don't establish
    that his recommendations are the best possible, only that they have the
    most published evidence and no one has evidence of a better plan. He's
    going to treat you during the off period using Avodart. He has a plan
    for the future if and when that fails.

    I wish every man on this newsgroup had a doc like that. We'd all be
    better off.

    Alan

  11. #11
    John Guest

    Default Re: How long should the ADT phase be in IADT?

    Alan Meyer <[email protected]> wrote:
    >>

    >
    >That's an impressive doctor. He's able to cite references to explain
    >his recommendations.


    I'd be even more impressed with an oncologist who explained exactly
    what process isn't complete until the PSA has been below detectable
    for a year or more - or one who explained whether research on this is
    in progress and where it has got to.

    --
    John



  12. #12
    Heather Guest

    Default Re: How long should the ADT phase be in IADT?


    <John> wrote in message news:[email protected]..
    > Alan Meyer <[email protected]> wrote:
    >>>

    >>
    >>That's an impressive doctor. He's able to cite references to explain
    >>his recommendations.

    >
    > I'd be even more impressed with an oncologist who explained exactly
    > what process isn't complete until the PSA has been below detectable
    > for a year or more - or one who explained whether research on this is
    > in progress and where it has got to.
    >

    John........our oncologist (radiation and research) put Ron on this regimen
    in 2004 and they had been doing research on it then........but I will ask
    him today if I get a chance.

    Now I need my coffee.....grin. Heather



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