Can Prostate Cancer "Take a New Trajectory"?

Since Xytiga/prednisone ended, in September 2021, I’ve been taking nothing at all. PSA < .001 since August 2019. Nothing ever detected in scans of the body. I hope the Pluvicto or LU works for you Mel. Best to you.

My surgical urologist & radiation oncologist agreed to “throw the kitchen sink” at it, regardless of any findings. Due to my Gleason & decipher, they didn’t want to wait. So they did radiation & ADT. I guess we’ll never know if it was necessary, but I can’t complain! So far, so good. Best to you, Surfer.

Just a wee caveat - BCR 17 yrs post RARP and 13 yrs undetectable PSA - then a 0.37 PSA last January led to PSMA PET which picked up a lung only metastasis. Yes, rare. At the 15 year mark he had a severe case of Covid - seems likely the Covid cytokine storm helped those micromets wake up. Getting off the meds seems like a positive step and good luck with your follow-up!

Radiation was to the entire pelvic area including that spot on the hip and all remaining lymph nodes. PSA was < 0.01 after radiation and has remained there for 2 years

Well...

As others have said, the prevailing "theory" is many who are high risk should be on continuous treatment - ADT + ARI, not allowing the PCa to get out of control. The contra to that is there is always the possibility of becoming castrate resistant doing that. How long before castrate resistance develops, all over the map, some in less than several years, a few go seven to ten.

Then there are the side effects, again, like the Bell Curve and statistics, some will experience severe ones that interfere with their lives, others will just live them.

I am high risk, GS 8, GG 4, short PSADT and PSAV, 18 months to BCR...

I have chosen not to do continuous treatment though one urologist, a Director of Urology at a NCCN Center here said I should (I fired him). I'm 11+ years into this journey, three of those on treatment, the rest off.

What has been the difference on versus of treatment? I've said this before, not much in what I do, rather how I feel doing it.

Many feel that localized PCa can be "cured." Many feel that once one's PCa is advanced, it is no longer curable, rather manageable. I'm in the latter camp.

That's not to say with the advances in treatment and imaging we won't get to a point where with individualized treatment, we can cure advanced cases.

For me, I am very comfortable coming off treatment because I don't walk away from my medical team, rather, we see each other frequently, every three months for labs and consults. We have decision criteria about what constitutes clinical data to go back on treatment:

For us, that is

Three or more PSA increases spaced three months apart.
AND:
PSA between .5-1.0

These criteria support acting on definite evidence, a trend in PSA increases, not single data points. It also increases the chances of PSMA PET imaging locating activity, which is for me, a key piece of clinical data in making a treatment decision.

You ask, can a cancer "change its trajectory?" Short answer from my foxhole, no. The GS and GG don't change, each time my PCa has come back the PSADT and PSAV have been very rapid.

In part, a factor in intermittent therapy [y may be the time off treatment before activity resumes along with say testosterone recovery, I mean, if testosterone doesn't recover and six or so months pass and PCa comes back, well, was there any utility in coming off treatment?

Kevin

My situation is similar. Since both Gleason and Decipher were high, Ive had prostatectomy + radiation + 2 1/2 years ADT. My PSA has been < 0.01-- but you never know. I've been off ADT for just 5 weeks. First PSA since coming up next month.

Given my cancer is high risk, I just can't understand why the Drs would want me to come off ADT. Why take the chances "just to see what happens"? Make zero sense to me.

Yes, it's a difficult and personal choice. IMO, the main reason people sometimes become castrate resistant when they're on ADT and ARSI long term is that the castrate-sensitive cancer was prevented from spreading much earlier (which would have been worse; you don't want any cancer forming new metastases). 😕

Thanks. Congratulations again on the low PSA.

After 2-1/2 years the Drs probably wanted to see if they've successfully stopped any growth. They'd rather you not go through the side effects, of ADT, any longer than necessary. Testosterone levels can be another signal. Three years after stopping ADT, my T level was 425. Urologist said that tells him that the fairly high T level was not feeding anything, since my PSA was still < .001. An ongoing guessing game, perhaps? I hope you go years and years without any recurrence.

You might Google AI your question
There's a Dr. Roy who is following this.
The follwing appeared in conjuntion w his name. But I don't know if he'd go along with all of or any of it. GOOD LUCK!!
After a patient completes a course of androgen deprivation therapy (ADT), testosterone levels gradually recover. A long prostate-specific antigen doubling time (PSADT) following this testosterone recovery indicates that any remaining cancer cells are growing slowly, which suggests a lower risk of biochemical recurrence (BCR).
This "flattening" of the PSA curve compared to more aggressive disease occurs when:
Residual cancer is less aggressive: The remaining prostate cancer cells are not highly proliferative, so they respond more slowly to the return of testosterone. Their slow growth leads to a longer PSADT and a less steep increase in PSA levels.
The initial treatment was highly effective: The previous treatment, such as radiation or surgery, successfully eradicated the bulk of the more aggressive, faster-growing cancer cells. What remains is a smaller volume of more indolent disease.
How a longer PSADT happens
Several factors influence the rate of PSA increase and lead to a flattened curve after testosterone recovery:
Return of androgen sensitivity: After a period of being suppressed by ADT, the PSA-producing cells—both normal and cancerous—become re-stimulated by the return of testosterone. In cases with less aggressive residual disease, this re-stimulation causes only a slow and gradual rise in PSA, resulting in a long PSADT.
Duration of ADT: The length of ADT can impact the PSA curve. A shorter duration of ADT (e.g., 6 months) often leads to a quicker recovery of testosterone to normal levels compared to a longer course (e.g., 18 months or more). However, regardless of the recovery timeline, the slow PSA kinetics following the return of androgens are what signals a less aggressive, or "favorable," recurrence.
Lower-risk disease characteristics: A longer PSADT is consistently associated with more favorable disease features. Conversely, aggressive cancers are characterized by a short PSADT and a rapid rise in PSA.
What a flattened curve indicates
A prolonged PSADT, or flattened PSA curve, is a significant prognostic indicator. It suggests:
Lower risk of future progression: Men with a long PSADT after testosterone recovery have a significantly lower chance of progressing to clinical failure or requiring further therapy.
More time before further treatment: The slower increase in PSA allows for a longer period of observation, potentially delaying the need for further, more aggressive salvage treatments.
Improved personalization of treatment: Monitoring PSA kinetics after ADT can help doctors recognize potential failures earlier and personalize management decisions, tailoring follow-up and future interventions to the patient's specific risk level.
This is for informational purposes only. For medical advice or diagnosis, consult a professional. AI responses may include mistakes. Learn more

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