Optimal Duration of Hormone Therapy

A good question...

Studies and statistics say...!?

As my radiologist said when she sits on the hospital tumor boards, the oncologists are all over the map when it comes to which agents, how long and their rationale.

Generally, I see 6-36 months in guidelines and clinical trails if definitive treatment is a choice.

With indefinite, well, the lengthy decision is taken out of the equation.

So, if deciding on systemic therapy, with what, how long. We know the differences generally between Lupron, Orgovyx, Casodex... We also know the differences between say Nubeqa and say Xtandi. We can list the know side effects, questions unknown is which ones will we experience and to what degree?

What are the pieces of the systemic therapy therapy decision making...?

Well, there is the science, GS, GG, Biopsy report, Pathology report from surgery, lab results, PSA, PSADT and PSAV, testing such as Decipher, Genomic, Dexa Scans...low, intermediate, high risk...heck, GS 8 vs 9-10, is there really a difference in making our systemic therapy decision...the medical community says yes and points to data from clinical trails - PFS, RPFS, OS...

Then there is science associated with co-morbidities - cardiovascular, diabetes, kidney function, weight, pulmonary...

What about drug interactions,,,? My oncologist was hesitant to prescribe Xtandi until was my cardiologist was on board due to interactions with Eliquis.

Lest we forget insurance, national health system rules...

Don't forget our medical teams, some who may not be as current as we are!

Trying to apply the science, the NCCN and AUA guidelines plus clinical trails to our specific clinical data. Keeping in mind that because they are the science, the rigor required, they may be dates, they ARE population based...

This is a hetero, not homogeneous disease, my PCa is not yours, the SEs I experience and the severity may not be yours, my T recovery when de-intensifying may not be yours, my insurance is not yours...

Maybe most important, the outcomes we want, quality of life while keeping in mind longevity.

Will the side effects over time degrade the quality and quantity of my life? My radiologist once said "Kevin, if you die of a heart attack, we have succeeded in you not dying of PCa...!"

All that's before we get to the discussion of duration of systemic therapy!

About that duration...

Both times I did systemic therapy, the duration was open to discussion between my medical team and I. In the case of my first time, 24 months Lupron in conjunction with six cycles Taxotere and 25 IMRT to the Whole Pelvic Lymph nodes was the agreed upon duration between Dr. Kwon and I. There were studies which pointed to 18 or 36 months. There were also studies which pointed to 18 months being as effective as 24 and 36. So, at 18 months, an early adopter of de-intensification if PSA drops to undetectable in the first 3-6 months and stays there, ok to come off treatment and actively monitor, we did.

The 2nd time is familiar to many of you. I wanted to do SBRT and six months systemic therapy, aka the SPORT trial. My radiologist agreed with that. My oncologist on the other hand advocated for the SBRT but 24 months systemic therapy, Orgovyx + Xtandi, yikes! We settled as you know on SBRT +_12 months Orgvyx, hold the Xtandi unless PSA did not drop to undetectable in the first three months and revisit a decision at 12 months to de-intensify or continue systemic therapy to 24 months. My radiologist supported coming off, my oncologist...we came off, my radiologist told my oncologist that I would actively monitor while off and would go back on treatment when the clinical data said it was time to do so. Here we are, 24 months later, the clinical data has not said so!

As to the question of "time to resistance..." Well, ditto.

My path has been to make hybrid decision, the guidelines are a starting point, we then look at clinical trails, review ALL the clinical trails and based on the question, is this likely to work for the next 3-5 years, decide. I am not sure of the value of a time horizon longer than that. As to the OS differences, well, just getting up in the morning means you are exposing yourself to situations that may end your time on this earth, that idiot who ran the stop sign,,,

I remember sitting with my mom when her oncologist told her at best chemotherapy could extend life six months but she may not like the quality of that life. She looked at me, me, my sisters and said, no thanx, tree weeks later, gone, albeit at home, hospice with all of us around.

Kevin

@robertov PC seems so personal: I had no palpable lump, PSA 6.x, Gleason 7 but PSMA PET showed lesions in prostate and adjacent lymph nodes. My treatment includes 44 IMRT treatments and 18 months on Orgovyx. @jeffmarc and I have had such extremely different outcomes from treatment: he continues to endure ADT like an athlete and I have been through all the known side effects. I was pre-diabetic (glucose 111) but lost 40 pounds during Covid, pre-diagnosis making all my indicators "normal". Unfortunately, since diagnosis, I've gained back 30 and am pre-diabetic again, and diabetes and stroke are my major fears. I think it's providential that I lost weight earlier. Had I gained 30 with no prior loss, I would definitely be diabetic. ADT has my Testosterone < 10, and life is so different. I had an hour of physical therapy yesterday followed by 2-3 hours of yard work, and I am still "crashed" today. The video doesn't apply to me, but other studies have shown that 18 months ADT is typically as effective as 24 or even 36, so we'll see! I am scheduled to complete ADT at the end of June and am anxious to see whether and how much testosterone returns afterward.

@jime51 I just saw your post in which you said you were pre-diabetic from ADT. Me too. After 12 months of ADT I had a glucose level of 115. Two changes in the diet, prescribed by a dietitian, did not change that significantly. Finally after 8 months since the 115 reading I asked my oncologist for Metformin. He brought up a report of an a trial in an arm of the Stamped trials that used Metformin and we read the summary together. He then prescribed the drug at 850mg twice a day. Four month of the drug had only modest effects, glucose 100 to 105, but there was same effect on cholesterol and triglycerides which decreased about 5 to 10 points.

Now after 8 months on the drug I had recent glucose reading of 95 to 100. I consider that a success.

You might ask you doctor for the metformin prescription. If needed find the many studies of metformin with prostate cancer patients on ADT, and take one of two of then with you to the doctor.

@overage
Are you also getting A1c results? That tells you what your blood sugar is over the last 90 days and it’s a lot more usable number than fasting blood sugar. Which only gets one point in time.

The doctors at the Medical Center I go to don’t really use fasting blood sugar any more, they go by A1c. It gives them more realistic, look at long-term results.

Seven or eight years ago, they told me I was prediabetic and sent me to a class with a dietitian. In my case all I had to do was stop eating ice cream with chocolate sauce every night. Brought my blood sugar, right down to normal. Now I eat a small piece of cake or a couple of cookies in the evening. My A1c has been 5.4 the last couple of times, It’s always close to that. Of course the huge salad I eat for lunch every other day probably helps.

@jime51 I just saw your post in which you said you were pre-diabetic from ADT. Me too. After 12 months of ADT I had a glucose level of 115. Two changes in the diet, prescribed by a dietitian, did not change that significantly. Finally after 8 months since the 115 reading I asked my oncologist for Metformin. He brought up a report of an a trial in an arm of the Stamped trials that used Metformin and we read the summary together. He then prescribed the drug at 850mg twice a day. Four month of the drug had only modest effects, glucose 100 to 105, but there was same effect on cholesterol and triglycerides which decreased about 5 to 10 points.

Now after 8 months on the drug I had recent glucose reading of 95 to 100. I consider that a success.

You might ask you doctor for the metformin prescription. If needed find the many studies of metformin with prostate cancer patients on ADT, and take one of two of then with you to the doctor.

@jeffmarc The other thing that is going on now is research into GLP1 s and cancer including prostate cancer are heating up. GLPs may interfere with cancer growth. In that context it may make sense to switch off metformin to GLP1??????

@jime51 I just saw your post in which you said you were pre-diabetic from ADT. Me too. After 12 months of ADT I had a glucose level of 115. Two changes in the diet, prescribed by a dietitian, did not change that significantly. Finally after 8 months since the 115 reading I asked my oncologist for Metformin. He brought up a report of an a trial in an arm of the Stamped trials that used Metformin and we read the summary together. He then prescribed the drug at 850mg twice a day. Four month of the drug had only modest effects, glucose 100 to 105, but there was same effect on cholesterol and triglycerides which decreased about 5 to 10 points.

Now after 8 months on the drug I had recent glucose reading of 95 to 100. I consider that a success.

You might ask you doctor for the metformin prescription. If needed find the many studies of metformin with prostate cancer patients on ADT, and take one of two of then with you to the doctor.

@overage You do not want to recommend Metformin 850mg to your friends unless seeking constipation relief. Metformin IR has a 50%+ side effect of diarrhea (you must be in the lucky 50%). Metformin ER at 500mg has less than 10% diarrhea and is a first line drug for type 2 diabetes. It can also be taken anytime. Multiple 500mg pills are cheaper than other doses ER doses. The 500mg dose comes in both IR and ER forms; 850mg is only IR. As Marc mentioned, if the fasting glucose reading is high that should be followed with an A1c test that shows glucose levels over the past 60-90 days.

@jim18 You will note that I wrote: “You might ask you doctor for the metformin prescription.” The doctor can inform him of any side effects and how to titrate into this drug.

I had one bowel movement with diarrhea after my first tablet of metformin 850mg. I then read the instructions on titrating of this drug. Then for 3 days I took one half a tablet (425mg) once a day with breakfast, then for the rest of the 30 day supply one tablet a day. In titrating up to two tablets I took one tablet at breakfast and one half tablet at dinner for 6 days. After that it was two tablets a day.

Extended release was not mentioned. The trial used 850mg tablets and that is what the oncologist followed. I am now paying about $55 for a 90 day supply with my senior discount. Changing to the ER tablets would increase my 90 day cost to about $135 to $160 for 1500mg or 2000mg per day.

I am preparing a response to Marc on why the A1C test may not be accurate for me. If interested look up something on the validity of the A1C with anemia.