Doublet Therapy Holiday - Option for Oligorecurrent Prostate Cancer?

You ask..."Anyone take a break from hormone therapy despite being oligometastatic?"

In formulating responses, more clinical data may be useful.

You say:

Surgery in December 2019, pathology report?

IMRT - implies BCR to me, if so, again, what was the clinical data, his PSA tests after surgery...what were the dates of his SRT, did it include the pelvic lymph nodes, did they add short term ADT...

Over the course of the next few years his PSA began to rise at the start of 2024, what was it at the start of his SRT, at the end, and since.

He was treated a year ago for oligorecurrent prostate cancer (2 small spots on his spine) after his PSA reached 0.5 with SBRT. He has been on Eligard and Nubeqa for almost a year now as well and was tolerating it well enough with his PSA being below 0.1 for the last 10-11 months..what did his medical team recommend, a defined period such as 24-26 months or continuous?

There are other clinical data which can assist the forum in responding, age, overall health, any other co-morbidities, imaging result...

There is debate about intermittent vs continuous ADT for advanced PCa. In some clinical trials, EMBARK for example, treatment is discontinued if participants reach a n undetectable PSA in the first 3-9 months., That may be clinical data that points to a "longer" progression free survival period when stopping treatment.

My experience, clinical history attached, it has been possible for me to come off treatment based on my clinical response and enter an "active monitoring" phase with labs and consults every three months. We have decision criteria about when to resume treatment, three or more consecutive increases and PSA between .5-1 which supports a statistically better chance of imaging informing the treatment decision.

So, yes, it is possible" for your father to come off treatment, there are many variables in thatv decision, a discussion with his medical team.

Kevin"

I know people that have done it, Waited for their PSA to rise, and then found they had metastasis in many spots on their body. I know others that have done it and we were able to go a year or two before they had to go back on the drugs.

I had a 4+3 and have been on ADT for almost 9 years. I’m also on Nubeqa. I am 77. Had a metastasis zapped on my spine two years ago. I know that if I stop Nubeqa My PSA will rise almost immediately. I tried Just reducing the pills I was taking when I was on Zytiga Two years ago and my PSA Rose immediately.

You can try Stopping the drugs, but make sure to get monthly PSA tests because if it starts going up, you need to get right back on it.

One thing you could do is have him stop Eligard But stay on Nubeqa. I know a lot of people that have done that. Many of them in their late 70s and 80s. Nubeqa will work even with testosterone coming back. I tried it for eight months last year and stayed undetectable, but my Testosterone was rising too quick so I had to go back on ADT.

Talk to him and his doctor about it. Most of the side effects are due to Eligard, Going to just Nubeqa Eliminates almost all of the side effects that are happening. Nubeqa Can reduce the effective testosterone so that if it rises, it will not cause the cancer to come back right away.

It's uncertain right now. The main studies I know of have shown no impact on overall survival for ADT holidays with aggressive non-metastatic prostate cancer, but a decrease in overall survival for ADT holidays with metastatic PCa (including oligometastatic). Additional research is underway, and new studies may contradict that.

Obviously, there are personal considerations that could tip the risk scales: for example, if the patient is already dealing with comorbidities like heart disease, diabetes, or osteoporosis, then ADT could make those worse, and it might be worth accepting a somewhat elevated risk of cancer progression over a serious risk of death or incapacitation from those. That's why there's no one size-fits-all answer: the OP's dad's medical team needs to look at all the health issues together.

@kujhawk1978 I appreciate the prompt response and not making a completely out of pocket comment that contributed nothing to the conversation as the first person decided to do.

For more specifics (didn't want to get too long winded in my initial post), my Dad was initially diagnosed as Gleason 8 (4+4) in December 2019. His RP was in March 2020 and the pathology report downgraded the Gleason score to (4+3) with a Tertiary pattern of 5.

His PSA was below 0.1 from May 2020 till April 2021 where it increased to 0.3, then 0.5 in July 2021, and finally 0.7 in September 2021. He underwent IMRT to the post surgical bed from January 2022 to February for 28 sessions. In July 2022 he had a double bypass procedure performed. Afterwards his PSA remained below 0.1 from this time till April 2024 where it was 0.2, then 0.5 in August 2024. A PSMA-PET done in early September 2024 confirmed the 2 metastatic lesions (C2 and L5 on his spine).

He received his first Eligard shot in September 2024 and underwent spot radiation for the 2 metastatic lesions between October-November 2024. A PSA test was done in October 2024 with a result of 0.23, then in November 2024 (also started Nubeqa at this time) where it was below 0.1 and has remained ever since (undetectable level threshold from the lab used is below 0.1/not an ultrasensitive reading).

He underwent genetic testing in March 2025 and had a result of No Clinically Significant Variants Detected (ATM, BARD1, BRCA1/2, CDH1, CHEK2, NF1, PALPB2, PTEN, RAD51C, RAD51D, STK11, and TP53 all tested). This same month, a CT scan for his heart was done that determined he had severe calcifications of the aortic valve that confirmed severe aortic stenosis.

A successful TAVR procedure was done in April 2025 and improved the chest pains/angina he was feeling when exerting himself for prolonged periods which would radiate down to his arm. However, he recently has been feeling aches/pains in his chest at times when exercising and exerting himself. This leads to my post concerning a possible holiday or if a cardio-oncologist will be able to steer us in the right direction. I wish I had a specific answer as to the recommended duration for the doublet therapy as his radiology oncologist stated he could delay being on it after having the SBRT performed but his medical oncologist wanted him on it for at least 18-24 months. This is the frustrating part to me as there is never a consensus for the duration or if he truly needs to be on indefinitely as I am starting to believe. I am trying to encourage him to get a second opinion from Cleveland Clinic as our team is currently a part of University Hospitals.

Unlikely you will get consensus on the intermittent vs continuous systemic therapy. If the former, same, no consensus on duration

My radiologist tells me when oncologists present their treatment plans to the "murder boards" they are all over the map on which agent, if recommending an ARI, which one, duration, criteria for coming off...

When I did triplet therapy, original systemic therapy was planned for 24 months. My medical team and I agreed to stop at 18 based on my treatment response.

Same for doublet therapy. I wanted to SBRT + 6 months Orgovyx. My radiologist agreed. My oncologist was ok with the SBRT but wanted 24 months of systemic therapy and include an ARI.

He was not wrong, guidelines such as NCCN said that. I was not wrong either, data from clinical trials such as SPORT pointed to six months ADT.

We settled, SBRT + 12 months Orgovyx, hold the ARI unless PSA did not drop to undetectable at three months, decide at 12 months to cone off treatment or continue.

I came off at 12 months...!

There are reasons for defined treatment periods:

Reduce possibility of castrate resistance
Financial toxicity
Intolerance of side effects
Risk of co-morbidities worsening, for example CV.

Of course, intermittent may also be a function of the duration of the break, rate of T recovery...

I find that you have to advocate for yourself.

Kevin

Diagnosed with G9 in 2021. Had RP and 6 months later diagnosed with oligo metastatic with single T8 met treated with SBRT. another 4 months had rapidly rising PSA with pelvic met. Treated at Johns Hopkins with triple therapy ( Lupron, Darolutamide and Taxotere) with rapidly undetectable PSA). Darolutamide discontinued after 4 chemo cycles (3 months) and Lupron stopped after one year. Had whole pelvic radiation about 3 months after chemo. Have been undetectable for 3 years off all treatment. My MO started me on TRT (I realize this is controversial) around a year ago and it has made a tremendous difference in my physical and mental well being. Still PSA undetectable. Treatment options are in flux.

@jeffmarc hi Jeff, thanks for the insight. One question it seems that you developed a metastasis in you spine while on ADT, is that correct?

@jeffmarc so are you on ADT + nubequa?

@trchar
Yes. I became castrate resistant 2 1/2 years after starting Lupron. I then went on Zytiga, but after 2 1/2 years, it only result in my being undetectable for one month. My PSA was low the whole time mostly around .2.

I developed a metastasis on my L4 during that time. It was zapped.

This article discusses it
https://pmc.ncbi.nlm.nih.gov/articles/PMC3908870/

@trchar yes, I am on both. With Nubeqa I’ve been undetectable for 23 months, Something that was pretty much a failure with Zytiga. I am on Orgovyx because it is cheaper than Lupron where I get treated.