Adverse effects of ADT for aggressive tumors

I've discussed this question with my own oncology team (at a major research Cancer Centre), and they told me that when some prostate cancer cells evolve castrate resistance, many others continue to be castrate-sensitive, so it usually makes sense for someone with advanced prostate cancer to stay on ADT to slow the overall growth.

These days, we usually combine ADT with an ARSI (especially the one of the -lutamides), which will first delay the evolution of castrate resistance (sometimes by many years), and then slow down growth even in the cancer cells that have eventually evolved castrate resistance.

Thank you. In that case the needles are ready and I’ll worry about it at some time in the future. Appreciate your response and your time.

I can’t understand why people use Firmagon. It is frequently painful or uncomfortable for those getting that injection. It has to be done every month. You can get a Lupron shot that lasts six months and you get no side effects at all except maybe a sore Injection spot, Something I never noticed. You can also take Orgovyx, A once daily pill that does the same with absolutely no physical issues related to taking it. Get your doctor to change your ADT drug. And no, you do not increase your testosterone by taking ADT, At least not enough to offset the helpful effects of ADT Lowering testosterone.

As for whether you need it, Yes, ADT does make a difference and in your case I would think that adding a second drug like abiraterone or one of the lutamides will give you the best chance of a longer overall survival.

It sounds like you need to find yourself a new oncologist. You want to make sure they are a Genito urinary oncologist, They specialize in prostate cancer, unlike medical oncologist, who work with all different types of cancer. You should consider going to a center of excellence and getting opinions on what you should be doing, because it sounds like you need surgery or radiation pretty darn soon.

If you really have cribriform then you need to get moving on treatment. At a meeting I recently Attended they discussed the fact that if you have a Gleeson 3+4 but also have cribriform, your cancer is actually much more aggressive than a 3+4, Especially if the size of the cribriform is greater than .25 mm. You don’t mention your gleason score or a decipher score, both are very important, Much more than worrying about whether or not your PC is creating its own testosterone.

Firmagon due to the management of prior cardiac liabilities. Gleason score is 3+4/7.I do not have a decipher score. The slowness of pace has been a source of frustration for 7 months now. It's absolutely unforgivable. My concern is that if I ask to be referred from the regional cancer center in Waterloo, ON< that it will take a few months again before admittance or consideration. Not sure that's an option... The other source of utter frustration is, on the one hand, they say that every tumor warrants it's unique approach, and yet, they always proceed with a cookie-cutter approach. THey seem quite annoyed when one asks questions...

There are some other people here who live in Canada who can give you some help with getting faster treatment. Unfortunately, in Canada, there are very few GU Oncologists. I’ve only heard about one in the Victoria/Vancouver area, Don’t recall exactly which city There are however places you can go in Canada, where they will be much more attentive to your problems.

Hopefully someone else can respond soon with some really useful information for you.

In Canada Orgovyx (as an alternative to Firmagon) became widely available only last spring, because Pfizer waited to get Health Canada approval until after it had done the big markets like the U.S. and EU.

While it's relatively inexpensive even at full retail (CA $315/US $220 per month, the same as Firmagon) it's not in the Ontario drug formulary yet, and most private insurerers won't cover it until it is, so doctors might be reluctant to prescribe it (I'm fortunate that my former radiation oncologist registered me in Pfizer's patient-access programme before he retired).

That’s great info. My feeling is that in our “advanced” years what the hell is $$ for except your own comfort, convenience and longevity?
I have nothing to compare it to, but I have been on Orgovyx for almost 6 months with only mild hot flashes to show for it. An incredible drug as far as I’m concerned - almost as transformative as oral penicillin has been for strep.

I'm in https://connect.mayoclinic.org/member/00-5f1d090c7f9cb13c363032/ camp...

High risk PCa generally necessitates aggressive approaches to treatment, mono-therapy is not in that category!

From the clinical data you describe, doublet therapy, perhaps triplet therapy may be a topic to discuss with your medical team. They can also go over the which ADT and which ARI choices, their reasons why and considerations. As others have said, Orgovyx has advantages over Lupron - lower CV side effect profile, no flare, faster and higher sustained castration rates, quicker recovery of T, the hot flashes and fatigue may be less severe. Same with the ARIs, which ones you take with prednisone, crossing the brain blood barrier, interactions with other medications...

Here's one article, you can find others https://dailynews.ascopubs.org/do/would-you-use-doublet-therapy-and-not-triplet-therapy-patient-newly-diagnosed-mhspc

In my case, I chose triplet therapy given my clinical data - GS 8, GG 4, 18 months to BCR, PSADT and PSAV

Also, read through the NCCN guidelines - https://www.nccn.org/patients/guidelines/content/pdf/prostate-advanced-patient.pdf, they can also guide your discussion with your medical team, which, if not already, should include a radiation oncologist and medical oncologist, with expertise and experience in treating Advanced PCa.

When you say "apparently contained..." by what criteria do you say that, have you had imaging, conventional or PSMA? I ask because conventional imaging is not very sensitive and even PSMA imaging has its limitations given micro-metastatic PCa.

Kevin

All great information. I'll just add that the second generation ARSIs (the so-called "-lutamides") have had stunning results for situations where they're tested and approved, both for delaying castrate resistance and for delaying progression after castrate resistance.

In my layperson's opinion, the main reason still to take a first-generation 30+-year-old ARSI like Zytiga would be either that you live outside the U.S. and there's no -lutamide approved yet for your cancer situation, or you live in the U.S. and your insurance will pay only for the older stuff (which is out of patent, and thus much less expensive).

Here in Canada, at least Apalutamide, Enzalutamide, and Flutamide (maybe more) have Health Canada approval, though Enzalutamide's approval was just last year, so it might not be in the provincial formularies yet.

I've been on ADT + Apalutamide (Erleada) for mCSPC since 2021, and consider it my miracle drug. 🙂

Thank you so much…