Weighing the cancer risk reduction & quality-of-life cost of ADT?

The side effects of ADT can be anywhere between mild and severe. I was on ADT for 6 months while having salvage radiation. The side effects went away and my testosterone returned to 400 within 3 months. More recently, I was on ADT for 3 years due to a single metastasis on my sacrum. I stopped ADT 13 months ago due to the side effects. I have had no signs of PC for 4 years, but still have side effects, although my blood pressure, blood sugar and red blood count have normalized. My testosterone is slowly returning, currently at 100. Hot flashes, insomnia,
and emotional lability are still a daily occurrence.

@jeffmarc

Hi Jeff. Please check out Dr. Kishan's presentation on RT and ADT in the attached Youtube video link: https://www.youtube.com/watch

Towards the end , on a page titled ADT Meta-Analysis, he shows ADT improves both overall ten year survival and metastisis-free survival rates by 9% and 8 % respectivley, and then adds for intermediate risk patients we have to treat 18 patients to benefit 1, and for high risk patients, we have to treat 8.4 to benefit 1.

I could be wrong, but I understand this to mean roughly 1 in 8 high risk patients like me gain cancer control or life-prolonging benefit from ADT. That is because I am assuming Dr. Kishan is here giving us the Number Needed to Tread (NNT) number for ADT. And the way I understand it, NNT gives the average number of patients who must receive treatment for one patient to experience the expected beneift of the treatment.

I have already set up a consultation appointement with him for December 9th , and this is one of the many questions I will ask him since - as he clearly sated in the video- he strongly believes in adding ADT to RT, and since he also beleives an NNT number of 8 or 10 is very good in the medical field (which is very counter-intuitive to folks like me).

I believe that standard of care today is to wait until PSA starts to rise. Several trials have compare adjuvant vs. early salvage RT and found no difference between the two in terms of cancer control for localized PCa (and SVI is still considered localized). The longer you can wait for salvage RT, the lower the side effects.

I would try to make an appointment with a RO at a center of excellence for a second opinion, independently of what your urologist says.

I agree and I never stated that Dr. Kishan is opposed to ADT. On the contraty I stated in my earlier response, that Dr Kishan is a very strong advocate of ADT. My question and concern is about his other statement that 1 out 8.4 high risk patients who are treated with ADT get the cancer cure and life prolongation beneift of ADT. He also said an NNT number in this range (1 ouf of 10) is a good number in medicine. That is what is puzzling me since to me, this means - on the average - 7 out of 8 high risk patients like me who get ADT get NO real benefit from ADT while they are 100% guaranteed to get side effects which could be mild or serious. That is what I am wrestling with since quality of life is very important to me. I will see what he says about my question and concern.

@topf
Waiting too long could be a real problem. Here’s what the America Society of clinical oncologist say about it.

From Ascopubs about what PSA to do salvage radiation.

≤0.2 ng/mL:
Starting at this level maximizes disease control and long-term survival. Patients treated at PSA < 0.2 ng/mL achieve higher rates of undetectable post-SRT PSA (56-70%) and improved 5-year progression-free survival (62.7-75%).
Delaying SRT beyond PSA ≥0.25 ng/mL increases mortality risk by ~50%.

0.2–0.5 ng/mL:
Still effective, particularly for patients with low-risk features (e.g., Gleason ≤7, slow PSA doubling time). The Journal of Clinical Oncology recommends SRT before PSA exceeds 0.25 ng/mL to preserve curative potential.

0.5–1.0 ng/mL:
Salvage radiation remains beneficial but may require combining with androgen deprivation therapy (ADT) for higher-risk cases.

This article discusses the above;
https://ascopost.com/news/march-2023/psa-level-at-time-of-salvage-radiation-therapy-after-radical-prostatectomy-and-risk-of-all-cause-mortality/

@topf
Waiting too long could be a real problem. Here’s what the America Society of clinical oncologist say about it.

From Ascopubs about what PSA to do salvage radiation.

≤0.2 ng/mL:
Starting at this level maximizes disease control and long-term survival. Patients treated at PSA < 0.2 ng/mL achieve higher rates of undetectable post-SRT PSA (56-70%) and improved 5-year progression-free survival (62.7-75%).
Delaying SRT beyond PSA ≥0.25 ng/mL increases mortality risk by ~50%.

0.2–0.5 ng/mL:
Still effective, particularly for patients with low-risk features (e.g., Gleason ≤7, slow PSA doubling time). The Journal of Clinical Oncology recommends SRT before PSA exceeds 0.25 ng/mL to preserve curative potential.

0.5–1.0 ng/mL:
Salvage radiation remains beneficial but may require combining with androgen deprivation therapy (ADT) for higher-risk cases.

This article discusses the above;
https://ascopost.com/news/march-2023/psa-level-at-time-of-salvage-radiation-therapy-after-radical-prostatectomy-and-risk-of-all-cause-mortality/

@jeffmarc

Yes, Jeff, but @topf was talking about adjuvant vs salvage.

@soli
I just want to add that all those statistics are just that - numbers and averages , and how will each patient react or what the result will be is very individual. There are absolutely no guaranties. I even stumbled on a study that mentioned as a "side note" that average lifespan after RP for patents who "did nothing" is 13 years ! It really makes you think ... Also, most studies concentrate on "time to BCR" while OS (OVERALL survival) is at the end almost the same - one just gets treatments sooner or later it seems but results are very, very close in "years" lived in total. Graph for example can show 25% better result but translated in real numbers it is 25% of 8 % which is actually 2 % !!! So yes, 25% of patients had somewhat longer life span but only 8% died in total in the whole cohort in that span , so, it made a difference for just 2% of patients and not much in total number of years. I am talking here in general terms, this study was not about ADT - I am just saying that one needs to read results and studies in detail and try to see the whole picture and what certain "%" means "in real life."

I did not have time to watch this video but isn't this video about initial therapy ? Not about adjuvant ? I am sure that there must be a difference of how is treatment performed and what is included in it and what type of radiation. I do not think that SBRT is first choice for adjuvant ? I might be wrong, but as far as I read and what our RO suggested is IMRT plus 6 mos of ADT.

My personal view about ADT is that it is overall less harmful that radiation, and especially if it is just for 4-6 mos. One can always stop using it if side effects are just intolerable and some people have really minimal side effects with it.