Connect
Information on limiting ADT
Anyone wishing to get a better handle on whether and when (if ever) he should use ADT, I suggest considering enrolling this clinical trial.NCT05588128
It's supervised by Dr. Ravi Madan, NIH Senior Clinician and Director of NIH's prostate cancer research
I'll let him speak for himself through his recent interview.
https://www.urotoday.com/categories-media/2757-urology-tube-video-channels/asco-2025-vl/4947-psma-pet-in-biochemical-recurrence-when-to-treat-vs-when-to-wait-ravi-madan.html
But in a nutshell the clinical trial chiefly examines this issue: PSMA PET scans allow early detection of prostate cancer and BCR. But simply because we can see it, does that mean we should always go after it hammer and tong? The study by following the natural history or development of the cancer without ADT endeavors to determine which cancers require early intervention and which don't. Blood tests including PSA, circulating tumor cells, ctRNa etc are collected every three months and PSMA-PETs are done every 6 months to keep track of developments. So they watch you like a hawk and they know when to blow the whistle to get you out of the pool. In my case, they recently put me on enzalutamide for three months while keeping in this trial also putting me in another. The trial allows for metastases directed therapy and even 6 months of ADT. In all cases your regular physician remains the lead dog on the sled and is copied with all NIH test results. Further the NIH is a marvel in efficiency with tests and imaging being done in the morning and meetings with Dr Madan in his staff that afternoon to discuss the results. Imagings can take a day or two, but the results are quickly put on your NIH portal web cite. They also cover transportation costs. I'm in the Washington, DC area so it's a quick ride on the Metro.
My experience with now 2 months of enzalutamide is some dizziness and "fog brain". Just starting to get a bit of the expected nipple sensitivity. Thus far it's barely noticeable, certainly nothing requiring surgical treatment.
The mild nipple reaction may be because do intense workouts both cardio and muscular. I believe that regimen has lessened all the potential impacts of my dance with this devil, including rapid recovery from my prostatectomy.
When BCR hit I also was very fortunate to have Dr Sean Collins as my radiotherapy oncologist at Georgetown University Medstar who believes there maybe too much lifetime prescription of ADT.
See
https://share.google/v5bxNUMWuzXjawO0W
It's also a great lecture on treating oligometastatic nodal pc where he states it shouldn't have arbitrary number of lymph node cutoffs, and discusses serial use of SBRT. He publishes extensively and is well worth following.
He's now at the University of Southern Florida and Tampa Hospital.
So kind of a windy discussion.
But I hope it has some useful nuggets for many.
Like
Helpful
HugInterested in more discussions like this? Go to the Prostate Cancer Support Group.
Connect
Failed to note my 2 months on enzalutamide dropped my PSA from 3.7 to .1.
I understand that's very good but not unusual.
icorp, excellent links. Thanks!
Tell your doctor Enzalutamide Has too many side effects and you want to switch over to Darolutamide, Which works just as well, but doesn’t have the brain fog or the fatigue issues.
You need to be emphatic with your doctor that you want this changed. Do not let the doctor talk you out of it.
-
Like -
Helpful -
Hug
3 ReactionsThanks for the tip!
I complete this trial at the end of this August.
I can review the bidding then w Dr Madan of NIH and my team at Georgetown Medstar.
Thanks again!!
That was a good discussion. PSA doubling time seems to be the most important factor when deciding if treatment is appropriate with ADT or doublet therapy.
Interestingly, SBRT to positive lesions doesn’t show any survival benefit; Dr Kwon says that salvage radiation shows no benefit, and SBRT is all you need….so maybe they’re both right or both wrong and BCR will one day be measured by a PSA doubling time of 6 months?? And the actual number value will be irrelevant?? 😳
Just to add to the confusion, @jeffmarc has posted often about the odds of success/survival DROPPING with salvage treatment initiated after PSA values rise higher than 0.2; the higher the number, the lower the success rate…
So all this conflicting data makes my head spin, but I hope they are all pieces of a puzzle that someone a lot smarter than me can put together.
I have been on and posted on this forum for some time, so, my history may not be unfamiliar,
I may be an outlier, my clinical history is attached.
I certainly have the garden variety of clinical data that would suggest a lifetime of continuous treatment..
GS 8
GG 4
PSADT and PSAV - rapid
18 months to BCR.
Yet, of these 11+ years, only three have been on treatment.
RRP March 2014
SBRT March 2016
Triplet Therapy January 2017
Doublet Therapy April 2023
The genetic test I have had done does not show any mutations, so perhaps that is a factor in my clinical journey given the risk factors.
I am not yet in the school of thought that says advanced PCa can be cured. I do believe that avances in treatment may allow us to manage and live with it.
The advances in imaging bring on a quandary, just because we can, should we? I have seen folks on this forum and others post about ever so slight changes and consequent worries about changes in USPSA.
I liken the USPSA to when we drive from Kansas City out to Colorado for vacations. In eastern Colorado you can see for miles and miles the headlight of a distant train. You know it's coming but the time, distance and speed for your paths to intersect, even driving 84 mph (9 MPH over the 75 mph speed limit, enough where the CHP leaves you alone), will take some time to reach you.
The question is, when do I need to act based on what I see and what do I need to do!?
I've laid out the decision criteria my medical team and I have to guide us:
Three or more PSA tests spaced three months apart showing an increase.
AND...
PSA between .5.-1.0
Why?
Given the variability is USPSA tests, even when doing your part to control the variables, same lab, same time of the day, same pre-draw routine, there can be variations. My clinical history shows that.
If imaging is a critical factor in the treatment decision, then we want a reasonable chance of it locating the activity. We define reasonable at around 67%, thus the .5-1.0 range. We do not feel that entails any risk of waiting for my PSA to rise to those levels.
Then there is the treatment decision. I fired one urologist who said based on my PSA data alone, no imaging, didn't think it was necessary, he would put me on ADT monotherapy for lifetime...I have advocated for treatment for defined periods, combining systemic with MDT and then using my response as data to come off treatment at the end of that defined period. What is that evidence of response, PSA drops to undetectable in the first three to six months and stays there.
When my medical team and I agree to come off treatment, I don't walk away. We actively monitor, labs and consults every three months.
There is no doubt about the "Prostate Specific Anxiety" test and the call to action it drives. However, it is but one part of a very complex puzzle in making a treatment decision.
Kevin
-
Like -
Helpful -
Hug
2 ReactionsI've learned a lot in reading all the posts.
Dr. Madan is still looking for volunteers.
What I greatly like about him and the trial is they watch you like hawks and know when to blow the whistle to get you out of the pool.
So again I urge consideration of this clinical trial and others he heads
The clinical trial NCT05588128, led by Dr. Ravi Madan, is a study of men with biochemically recurrent prostate cancer (BCR). The study uses PSMA PET imaging to monitor the disease's natural history in these patients without immediate aggressive treatment.
About the trial (NCT05588128)
• Purpose: The "natural history study" is designed to observe how BCR evolves over five years using the advanced imaging agent 18F-DCFPyL with PET/CT scans.
• Hypothesis: The study addresses the question of whether immediate treatment is necessary for PSMA-detected cancer lesions or if careful monitoring is a safe alternative.
• Patient population: Participants are men whose prostate cancer has returned after initial treatment (either surgery or radiation) and is now detectable by a rising PSA level, but not visible on conventional CT or bone scans.
• Monitoring schedule:
• All participants: Followed for up to five years, with blood tests for PSA every three months.
• PSMA-negative patients: Receive 18F-DCFPyL PET/CT scans annually.
• PSMA-positive patients: Receive 18F-DCFPyL PET/CT scans every six months.
Dr. Ravi Madan's perspective
Dr. Madan, a Senior Clinician at the National Cancer Institute, explains that the improved sensitivity of modern PSMA PET scans has created a "compulsion to do something" among doctors and patients when small lesions are found. However, his research suggests that these findings may not always represent an aggressive or immediate threat.
Key points from Dr. Madan include:
• Balancing detection with necessity: In an interview from June 2025, Dr. Madan noted that PSMA imaging is widely used, but there is "very little data telling us how to use it" effectively for biochemically recurrent disease. He stresses the importance of not rushing to treat every newly visible lesion.
• Observing the disease's natural course: Dr. Madan argues that PSMA-positive biochemically recurrent prostate cancer is often an indolent, or slow-growing, process. He says that monitoring patients helps to define the natural history of the disease rather than rushing to treat newly visible but potentially slow-growing lesions.
• Preliminary findings: In a presentation at ASCO 2025, Dr. Madan discussed early results showing that PSMA-positive BCR is indolent and that patients have a limited risk of clinical progression within six months. He emphasized that PSMA imaging alone can create anxiety for patients but does not necessarily translate to a need for immediate intervention.
• Preserving quality of life: His broader research focuses on delaying the need for androgen suppression therapy, which has significant side effects, in favor of less toxic strategies that maintain a patient's quality of life.
Overall, the trial and Dr. Madan's commentary highlight a paradigm shift in how clinicians approach biochemically recurrent prostate cancer, moving from an aggressive treatment reflex to a more measured, evidence-based strategy of active monitoring.
This is for informational purposes only. For medical advice or diagnosis, consult a professional. AI responses may include mistakes. Learn more
-
Like -
Helpful -
Hug
2 Reactions