Which ADT medication is best?

NCCN advanced prostate cancer 2024- that’s what I understand, not 2007 NCCN data.

Please look at the 2025 guidelines, search for relugolix. Then you can see the part I quoted.
Perhaps this is where the OP's RO got his "studies showing a benefit from ADT using Lupron".
I totally agree with you that study from 2007 has little relevance in 2025.

“So, rather than overdriving the system and then locking it up, [Orgovyx] actually locks it directly so that the testosterone never has a surge at the beginning so that testosterone becomes lower much faster and stays lower during the course of treatment — what we call the sustained castration rate in these particular trials,” he said. “But, also interestingly, after you stop, it wears off more quickly and then the testosterone recovers more quickly.”

For example, researchers noted, in the Orgovyx and Firmagon patient arms 52% of patients (34 patients) and 16% (six patients) had testosterone levels return to baseline within 12 weeks of discontinuing treatment.
https://www.curetoday.com/view/orgovyx-manages-testosterone-reduces-side-effects-in-prostate-cancer
https://www.urotoday.com/categories-media/2013-centers-of-excellence/mhspc-coe/4121-nccn-2024-prostate-cancer-guidelines-update-relugolix-gains-prominence-in-treating-metastatic-castration-sensitive-prostate-cancer-rashid-sayyid-zachary-klaassen.html#:~:text=NCCN%202024%20Prostate%20Cancer%20Guidelines,Cancer%20%2D%20Rashid%20Sayyid%20&%20Zachary%20Klaassen

I started on Firmagon rather than Lupron in 2021 because

1. I couldn't afford a testosterone surge (the metastasised tumour had already compressed my spine and paralysed me from the ribs down) and

2. Orgovyx wasn't approved in Canada yet (we're a small market, so the drug makers leave us for round 2).

Almost a year ago, I was one of the first people in my city to start taking Orgovyx. What a difference! They both work the same way, but a daily pill doesn't knock me out for a few days every month with flu-like symptoms, or cause a huge rash and swelling at the injection site.

I have felt much better since I switched from injections to pills. Your mileage may vary.

I get my Firmagon shot every month. Some how I always forget that those few days after are not pleasent. Then it's forgotten until next time. Just got the shot the other day, not terrible but oh well. Still can't believe I keep forgetting, lol. Best to all.

I backed into my trucks bumper with my Chrysler 300 while adjusting the outside mirrors. = brain fog. 2600.00 Chrysler is repaired. I fixed truck bumper myself for 100.00. So much for todays plastic bumpers.

Yes, conundrum.
My understanding is that there can be an initial flare of testosterone when beginning Lupron and prednisone or something else (?) is often given initially.
I chose Orgovyx because the cardiac profile was a bit better, and the promoted "quicker on and off" was attractive.
It seems that the ADT recipe can be different from almost each MO or RO.
With Salvage Treatment, I was rx'd 4 mos; 2 friends received 6 mos each. All of us had a different RO at the same COE. And "by the book", I could have had a longer course of ADT .
So unfortunately you need to choose between the recommendations of 2 different MDs. Ugh. But that's why we are able to exercise a choice.
Best wishes

My radiation oncologist recommended six months of ADT to accompany 28 EBRT treatments, and recommended starting the ADT 1-2 months before starting the radiation.

He offered either Lupron injections or Orgovyx pills, and seemed to have no preference in terms of effectiveness. He mentioned the likely spike in testosterone at the start of treatment with Lupron, but didn't think that would be a problem for me. He also pointed out that once I get a Lupron injection, I'd be committed for at least a month, where if side effects were severe with Orgovyx, I could stop and it would get out of my system fairly quickly.

He also mentioned a possible cost issue. He said he had patients that had paid as much as $1200/month out-of-pocket for Orgovyx because their insurance balked at the cost. Turned out not to be an issue for me - I have a Humana Medicare Advantage plan, courtesy of my former employer, and my copay has been $75/month. I looked at a recent statement from Humana and they are actually paying just shy of $2600/month for my prescription!

I opted for the Orgovyx because I liked the idea of the flexibility of being able to stop if it got intolerable. I have just over a month to go, and I've experienced most of the side effects - sexual, weight gain, fatigue, hot flashes. They've been annoying, but nothing I couldn't put up with. I have a physical coming up with my primary care doc about a month after I wrap up the ADT, so I'll find out then if my liver, kidneys, blood sugar or heart have be affected.

While the RO told me six months of ADT was the standard with the type of cancer I have, it also sounds like the medical community isn't sure that's what's best for all patients. He invited me to participate in a clinical trial, in which I would be randomly assigned to a group that would receive no ADT, three months or six months. They want to study results across the groups to determine whether they can fine-tune the treatment time based on Decipher results, Gleason scores, etc.

@ecurb, experts in experience is how I refer to all the knowledgeable members on Mayo Clinic Connect. No one member here is an expert. But collectively we share experience, correct or calibrate evidence-based information, and exchange real experiences.

Experts are people who have PCa longer than it takes to become an MO/RO/Genito Urologist. Even my MO recently told me- We are in a grey area now as no one or any group of people have all the answers. It’s not an exact science. Sorry we differ in viewpoints. 😞