ANDROGEN DEPRIVATION.THERAPHY FOR SHORT OR LONG TERM?

@zonanaa
Other comments may say that, but test results I have seen from clinical trials have shown that for people with aggressive prostate cancer they need to stay on it for 24 months or longer..

I attend nine advanced prostate cancer online meetings a month. I run into many people whose doctors have recommended 24 months or even a lifetime ADT (like I have been on for Eight years) When they have Aggressive cases.

It’s definitely a lot nicer to not have an aggressive case.

@jeffmarc
Yes, so far that was the belief. Before even non aggressive cancers were having at least 6 mos of ADT with RT for salvage radiation.

This new study that Dr. Kishan explained (in provided link above) showed that no ADT was necessary for any salvage that started before PSA 0.5 .

We had consultations recently with him and even for my husband that is high risk and nodes involved his opinion was that more than 6 mos of ADT is not necessary. Intensification with added Nubeqa yes, but more than 6 mos would not possibly have additional benefit. Now it is up to us to decide, of course.

There is definitely VERY STRONG trend with shortening ADT in all cases. My personal opinion is that new lines of drugs like Nubeqa have very strong effect on cancer progression during treatment and if added to regular ADT they change the game plan. BUT, that is my "amateur" opinion. However - there is a tectonic shift in protocols for ADT usage.

The UroToday article begins with Agarwal describing his understanding of what Kishan et.al. studied as the evidence for "the utility of androgen deprivation therapy in patients who have biochemical recurrence after prior definitive therapy." Kishan doesn't disagree.

Kishan et.al., in the Lancet article under discussion, appear to be saying something different. Under a headline "Interpretation" they write:

"Our findings, we believe, provide the strongest level of evidence to date suggesting there might be no meaningful overall survival benefit to adding hormone therapy, either short-term or long-term hormone therapy, to PORT [ i.e. Post Operative Radiation Therapy } for PSA 0·5 ng/mL or less, with no apparent difference in efficacy for short-term versus long-term hormone therapy."

So, in the published study it seems the patients studied were those who had post operative radiation therapy for any reason, whether that was the discovery of positive margins immediately after surgery or if a steady PSA increase at some point afterwards caused a diagnosis of biochemical recurrence.

If I thought these findings applied to my case, I'd ask my RO about this study. If things did not seem clear I might then seek a second opinion from Kishan or his group.

A diagnosis of biochemical recurrence means there is proof of actively growing cancer. Positive margins are a risk factor for eventual biochemical recurrence.

Hello
Thank you for your response and comments I appreciate these and take in
nubeqa in consideration

If you had immediately radiation after RP then I think that's called Adjuvent, not Salvage treatment (salvage is later when confirmed returned).

Not sure semanitcs makes a diff. My my RO kept correcting me. I had adjuvent. And they said 6 months ADT during IMRT was sufficient.

Said the goal is to see if radiation worked - and "save your ADT bullets" for later if you need them. I understand metaphor but not sure if it applies.

I keep questioning it. Researched extensively. Got more confused.

@adoptedtomato

Adjuvant RT - it is administered after RP with NO evidence of cancer. PSA is undetectable but RT is done as prevention of BCR

Salvage RT - is any RT in any period AFTER BCR happens OR if PSA is not undetectable immediately after RP.

So difference is not between actual "timing" but between evidence of disease present or not before RT starts.

@climateguy
ASCO seems to say the same thing when they talk about what treatment to do after BCR following a Prostatectomy. They recommend only using ADT when the PSA hits above .5 with Higher risk patients.

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/

@adoptedtomato
Actually, here’s more information on this exact subject from 2024

This information is from Dr. Eleni Efstathiou, One of the top GU oncologists in the country. She recently moved from Houston to Portland.

Adjuvant radiation
Dr. Efstathiou concluded as follows
* Early salvage radiotherapy is favored over adjuvant radiotherapy in most patients
* Consider adjuvant radiotherapy in otherwise fit, motivated, very high-risk patients with ≥2 of the following risk factors:
* pT3b-4
* Gleason score 8-10
* pN+ Lymph node Metz
* Decipher score >0.6
* In high-risk patients, use lower thresholds to initiate ‘ultra-early salvage or adjuvant-plus’ radiotherapy
* If giving adjuvant radiotherapy, it implies high-risk disease. Thus, Dr. Efstathiou would recommend treating the prostate bed and pelvic lymph nodes, in addition to short-term versus long-term ADT, depending on risk factors
* May consider genomic classifiers or artificial intelligence tools to help with informed decision-making
* The goal is to avoid (or delay) radiotherapy in those who we can, without missing a window to cure patients who are guaranteed to recur

Here is a link to the article supplied by @surftohealth88 originally
https://www.urotoday.com/conference-highlights/apccc-2024/151546-apccc-2024-debate-how-to-best-manage-a-fit-patient-with-high-risk-localised-and-locally-advanced-prostate-cancer-how-to-select-patients-for-adjuvant-therapy-after-radical-prostatectomy-and-how-to-treat-them.html

@jeffmarc
Thakd Jeff for comments and paper link

@jeffmarc
Jeff, is their any information on percentage of prostate cancer metastasis found at BCR with PSA .2?