Guidance to help with ADT decision.

Some people tolerate ADT quite well, some less so. Orgoyx seems to be the one that causes fewest issues (pills rather than injections).

Regardless, ADT is just a "pause" button for the cancer. While he's taking it, it can delay the cancer from spreading somewhere like the spine, which could put your dad in a wheelchair or hospital bed quickly (that's what happened to me, though at age 56 at the time, I was young enough to fight my way back from paraplegia).

On the other side of the coin, while PSMA-PET is the most sensitive scan for prostate cancer, it's also the noisiest: it can find micro-tumours that MRI, CT, or bone scans miss, but it often also finds tumours that don't actually exist.

That's what makes it so hard when PSMA-PET is the *only* evidence of cancer spread outside the prostate: do you treat what might be nothing but an imaging glitch?

Best of luck helping him with some tough decisions.

ADT is temporary and can be stopped at any time if using Orgovyx. In order to have the best chance at putting prostate cancer behind him for the longest possible time, your father should try to stay on ADT as long as the doctor's recommend. It's not the overall survival time that is important to consider. Many men have very hard final years with cancer before they die and yet they live almost as long as other men without cancer. The more important thing is how long can your father go without having metastatic cancer and the hard final years that come with that. See my bio for more details.

As I mentioned in the other forum. Typos removed here.

IMRT for what he has is the good choice but SBRT would probably also be possible and would result in much less time spent doing radiation. Has that been discussed with the doctor, have you spoken to a radiation oncologist that does SBRT radiation? You can also treat lymph nodes at the same time.

Since he has heart issues, make sure they do not prescribe Zytiga. It causes a lot of heart problems. If they want to put him on an ARPI drug NUBEQA is the best. Has almost no side effects for anyone and doesn’t pass the blood brain barrier so it doesn’t cause brain fog.

Were any of these things found in the biopsy intraductal, cribriform, Seminal vesicle invasion, EPE or ECE. (Extraprostatic extensions extra capsular extensions). They can make the cancer much more aggressive, even with 4+3.

My brother at 77 had a 4+3, five sessions of SBRT at UCSF. He didn’t get a decipher score, but he did have cribriform. He’s 80 now and doing fine..

Here are current NCCN Guidelines in 2025. They now suggest 0 (zero) months of ADT for low intermediate (GG2); 4-6 months for high intermediate (GG3), and 18-36 months for high risk (GG4 and 5). Actually, the footnote suggests ADT + abiraterone for T3b with lymph node involvement.

The meta-analysis suggests:

* 0 months for 1 intermediate factor (PSA 10-20, GG2 or 3, T2b-c)

* 6 months for 2 or more intermediate factors (PSA 10-20, GG2 or 3, T2b-c)

* 12 months for NCCN high risk (PSA >20, GG4 or 5, T3 or 4)

* undefined for NCCN very high risk (2 or more PSA >40, GG4 or 5, T3 or 4)

I am 77 and I’ve been on ADT for eight years. I really have no side effects from it that are a problem in my daily life. I do run on my track 1 mile twice a day and go to the gym three days a week because ADT does damage your muscles a lot. I’ve also been on bone strengtheners for eight years because ADT can weaken your bones and give you osteoporosis. Six months would not be a problem with most issues I did get real bad hot flashes for the first few years, but have many solutions for that if he has a problem you could ask.

So, @siems1111 , as you can see from the replies, it's trickier than just a quality- vs quantity-of-life issue.

ADT giveth and ADT taketh away. If your father goes on it, he may experience hot flushes, bone density loss, gynocomastia (breast tissue development), weight gain, and periods of low energy, in addition to rarer but serious side effects.

If he doesn't go on it (and the cancer really has spread outside the prostate, as the PSMI-PET suggests), he could experience bone fractures — including the spine — paralysis, failure of vital organs, and/or years of pain.

In the end, it's not really about a 16% reduction in mortality; it's about how much he wants to take on now to postpone far worse stuff (but stuff that might never happen).

FWIW, I'm 61 now, and like @jeffmarc , I'm living a pretty normal, happy life as I approach 4½ years on ADT and Apalutamide — they've gotten easier over time as my body has adjusted. But not everyone is lucky that way. As Jeff also mentioned, exercise — just moderate stuff like going for long walks and light resistance training — makes a huge difference in mitigating the biggest ADT side effects.

Hi, sorry to hear about that. If he can tolerate ADT then that to me would be my decision as I have already made it. ADT isn't too bad, at least for me.
As for the radiation, I had SBRT which was 5 sessions for the prostate and 3 sessions for the pelvis. I really hated those sessions and if I had to do it for a long period like the 9 weeks you said they suggested, then I would have enjoyed it even less. From what I've read and heard they both give about the same results. Take the easy road if you can.
Sometimes facilities only have one type of radiation machine available and can't offer the more advanced machine. Do what's best for your dad, even if it's inconvenient for you and your dad.
Has he gotten a second opinion from a center of excellence like MD Anderson, Memorial Sloan Kettering, Mayo or other clinics of the same standings? When I got second and third opinions, I told my doctors and they were happy I did so, so his doctors shouldn't be offended if he went that route. He's only got one life so do whatever he/you can do to make it better.
Best of luck and the people on this chat room are a wealth of information.
Cheers Dave

I echo what @bonanzaman suggests. I went through the same decisions recently. I'm 80 and the MRI and bioipsy shoed one lesion of 4/5 in the prostate and two small lesions in adjacent lymph nodes. Other than that, I had a clean PSMA-PET scan and a clear bone scan. I went to a local RO who suggested 28 sessions with a year of undefined ADT. I asked about SBRT and he said it wasn't sufficiently studied. For a 2nd opinion, I went to a center of excellence and after reviewing the same information, the RO said a session of SBRT and Orgovyx for several months, starting a month before the radiation, would likely knock out the pc. I'm 2 months post SBRT and except for occasional hot flushes, I feel fine. Immediately after the SBRT I had about 10 days of GI/GU issues but the they have completely dissipated. A second opinion at the major teaching hospital was absolutely the right decision for me, even though it required travel away from home for about 10 days.

Hey I'm coming from a wife's perspective, my husband got diagnosed a year ago, when his PSA was almost 300! his only symptoms were peeing frequently and a bit of ED (but we had a lot of stress going on) He's 56 now and I'm 48. CT scan showed outside the prostate (so advanced PC) Gleason scores were mostly 8 and 9s and PSMA pet scan showed it all over his body! we were devastated to say the least! For being rather young getting this and stage 4!! Oncologist said ADT- triple therapy, which the urologist had warned us before the biopsy, that it meant chemical castration! My husband refused!! that's his manhood!! I pleaded and begged and said I don't care about the sex life! that I'd rather have a husband alive and no sex life than a dead husband and still no sex life!!
He finally did it, it was supposed to be one dosage of Firmagon to reduce the PSA and then quarterly Lupron shots, because Lupron CAN raise it in the beginning before it goes down but because it was so advanced, the doctor recommended Firmagon first! Lupron has more side effects though and it was enough to deal with hot flashes, my husband didn't want the man boobs, so he decided to stick with Firmagon and eventually the doctor let him and stopped pushing Lupron. He was also supposed to take Zytiga pills and prednisone but his blood work was bad because he had been sneaking certain supplements without telling the doctor- I'm sure the doctor figured it out though and figured out that my husband is a tough nut to crack! Eventually the blood work and liver function was normal again and he started Zytiga and Prednisone and I think he also takes calcium daily. Over the summer he did 6 rounds of docetaxel chemo and tolerated it very well other than getting tired.
The main side effect of everything is the hot flashes which wakes him up several times a night, but he used to wake up to pee before all this started, and he cries easier, so we can have hot flashes and cry together!
PSA is 0.24 now and the latest scan showed GREAT improvement, just a few spots left, but nothing like the first scan where he lit up like a Christmas tree! it was everywhere!!
Hardly any sex life, he can take a HAPPY pill that somewhat works but it's mechanical and he has no feelings or lust behind it and the pill gives him a terrible headache!
Overall he's had to come to terms with the situation that it's not all about HIM, he has to do it for the family, for me! for our children!! (4 children ages 10-23 and 3 live at home) I NEED HIM! I need him emotionally too!
I forgot to say that he's always been a gym guy, he lifts weights 5 days a week, eats pretty perfectly, now that his hair has grown back (more gray) he looks and acts and seems FINE! So it's all worth it! (statistics show 30% make it 5 years in that situation, so we'll see!!)

Not to discourage you from ADT in any way but it's not like other medications in that "six months" doesn't mean six months--it means at least a year because testosterone doesn't return immediately after stopping. I finished six months of Orgovyx in October 2024 and my testosterone FINALLY crossed into low normal (320) in December 2025, about half of what it was pre-treatment. FWIW, my doctor told me my case is an outlier and that most men under 65 recover from Orgovyx in 6-8 months.

However, I did go into the 200 range after about six months which was enough to alleviate some of the worst symptoms, and all my symptoms have since resolved except that it did give me osteoporosis and I'm now trying to decide whether the side effects of a bone infusion drug are worth it for 10% less fracture chance.

@beaquilter wrote "(statistics show 30% make it 5 years in that situation, so we'll see!!)"

Those are old stats, too, mostly collected before doublet therapy became common. IIRC, the multifaceted STAMPEDE trial showed that when you add Zytiga to ADT while the metastatic cancer is still castrate-sensitive, 5-year survival jumps up to 60% (different studies have shown the same effect with other ARSIs, like Apalutamide).

And even that doesn't take into account the fact that your husband had triplet therapy (chemo as well as ADT and ARSI), which is cutting-edge emerging care for polymetastatic castrate-sensitive prostate cancer like your husband's.

Finally, your husband was young (mid 50s) at first diagnosis. Many of those patients were in their 70s or 80s, and died of something else during the initial 5-year period.

No guarantees, but there's lots of reason to hope.

@beaquilter
I’m not sure your husband is still having the problem with the hot flashes at night but my Embrlabs wave device Stopped those for me. I used to wake up with the sheet soaked under me, The device definitely stopped that.

Just something to consider if you still have that problem.

If he is still on Zytiga then this drug seems to work well to eliminate hot flashes

Oxybutynin

Patients could be on abiraterone acetate (Zytiga) but not other newer androgen receptor pathway inhibitors -- enzalutamide (Xtandi), apalutamide (Erleada), and darolutamide (Nubeqa) -- that are CYP3A4 metabolized and may affect oxybutynin serum