Will T come back at end of 20 months of ADT..?

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jl_honda_vfr@mail.com - 07 Dec 2004 13:37 GMT

I am wondering if, and how, my testosterone will come back after 21
months of ADT
(ADT was Csdx+Lprn, then just Lprn)

Age 52
Baseline T was 240
.... ADT + RT ...
20 months later reads 11 (has been as low as 6, I think)

I sort of fear it not ramping back when I will finish at 21 months. I
plan on skipping the extra 3 months, actually (bad dog!), based on that
fear...

Opinions / personal experience??

Note that I am aware of the muscle and bone potential losses but am
taking care of them (excercise, Zometa).

jl_vfr

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I.P. Freely - 07 Dec 2004 16:33 GMT

I thought ADT was "permanent" (until the cancer becomes
resistant/refractory) or intermittent (8-9 months on/5-6 off/back on/ etc.
until it fails). Why would your ADT quit at some number like 21 months?

And how are you doing with the side effects? My doc recommends I go on ADT,
and I've spent weeks researching it, but the number, severity, and
commonality of physical and psychological side effects sounds much worse
than, oh, say . . . DEATH . . . literally! How's it been? My present
decision is that I'll jus take my chances and hope I beat my 6:1 odds of
dying from PCa within a decade.

I.P.

> I am wondering if, and how, my testosterone will come back after 21
> months of ADT
[quoted text clipped - 15 lines]
>
> jl_vfr

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Steve Kramer - 08 Dec 2004 01:10 GMT

IP,

I know you have researched, so forgive me if I'm treading on familiar
ground. It may be of some interest to others if not you.

There are two ways of looking at the permanency of ADT. One, is that you
take it to stave off reproduction of cancer cells until your cells start
subsisting on something else. Of course it's quite a bit more complicated
than than, but the poignant truth is that is is not permanent because if you
live long enough, it stops working. Your cells will adapt to eating
estrogen or some other protein. That is called 'going refractive.'

The other way of looking at it is really incramental watchful waiting, but
it's called intermittant androgen deprivation treatment (IADT) or
intermittant hormone treatment (IHT). The theory is that if you can give
someone ADT until his PSA settles down, he can go off of it until his PSA
begins to climb again. Then go back on it. Thereby, it is hoped, you can
stave off the time when the ADT becomes refractive, extending your life.

I've seen this theory stated as fact and rebuffed and everything in between.
But, it makes sense. My doc, however, has not seen any studies that he
trusts that show that IADT will extend life. But, it will give one more QOL
between AD treatments.

Signature

Prostate Cancer Survivor (so far), not a doctor
PSA 16 10/17/2000 @ 46
Biopsy 11/01/2000 G7 (3+4), T2c
RRP 12/15/2000 G7 (3+4), T3bN0M0
PSA .1 .1 .1 .27 .37 .75
EBRT 05-07/2002 @ 47
PSA .34 .22 .15 .21 .32
Lupron (1 mo) 07/21/2003 @ 48
PSA .07 .05 .06
Lupron (3 mo) 8/03 (48), 12/03, 4/04 (49), 09/04 (50)
non Illegitimi carborundum

> I thought ADT was "permanent" (until the cancer becomes
> resistant/refractory) or intermittent (8-9 months on/5-6 off/back on/ etc.
[quoted text clipped - 28 lines]
> >
> > jl_vfr

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Ed Friedman - 08 Dec 2004 17:02 GMT

> I've seen this theory stated as fact and rebuffed and everything in between.
> But, it makes sense. My doc, however, has not seen any studies that he
> trusts that show that IADT will extend life. But, it will give one more QOL
> between AD treatments.

Steve,

Have your doctor look at The Journal of Urology: Volume 161(4S)
Supplement April 1999 p 156, "INTERMITTENT ANDROGEN DEPRIVATION (IAD)
WITH FINASTERIDE (F) DURING INDUCTION AND MAINTENANCE PERMITS PROLONGED
TIME OFF IAD IN LOCALIZED PROSTATE CANCER (LPC)", The Oncologist, Vol.
6, No. 2, 177-182, April 2001, "Treatment of Localized Prostate Cancer
With Intermittent Triple Androgen Blockade: Preliminary Results in 110
Consecutive Patients", and most recently (and most convincingly)Program
and abstracts of the 95th Annual Meeting of the American Association for
Cancer Research; March 27-31, 2004; Orlando, Florida."The enhancement of
intermittent androgen ablation by finasteride administration in the
LNCaP mouse xenograft model.". The talk from the last reference can be
heard on the web by going to
http://www.aacr.org/PhotoAlbum/2004Webcast/Webcast_29march.asp and
clicking on the link labeled [Audio and Slides] beneath the name of Dr.
Scott Eggener. Basically, he showed that when done properly (as was
done in the previous studies I just mentioned), intermittent hormonal
blockade is ~4 times more effective than continual hormonal blockade.

Ed Friedman

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Steve Kramer - 08 Dec 2004 18:22 GMT

Thanks, Ed. I will do that.

Signature

> > I've seen this theory stated as fact and rebuffed and everything in between.
> > But, it makes sense. My doc, however, has not seen any studies that he
[quoted text clipped - 22 lines]
>
> Ed Friedman

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I.P. Freely - 08 Dec 2004 18:23 GMT

The text of "Triple Androgen Blockade" is at
http://theoncologist.alphamedpress.org/cgi/content/full/6/2/177?maxtoshow=&HITS=
10&hits=10&RESULTFORMAT=&searchid=1102528532456_891&stored_search=&FIRSTINDEX=0&
minscore=5000&journalcode=theoncologist .

If that long link won't work in newsgroup world, just ask Google for "Triple
Androgen Blockade" and follow your nose.

Neither that nor the slides accompanying Dr. Eggener's talk -- nor any of
the other scores of papers I've skimmed -- support any fourfold advantage to
IAD that I could find. (It wasn't obvious how to play Eggener's talk, and
I'm still in the fire hose mode, reading mostly the abstracts of the
hundreds of relevant papers out there and stydying few whole papers.) The
best IAD advantage I've seen so far is Eggener's slide showing an increase
from 30 to 55 months' survival, and notice that 1) Eggener studied survival
only (i.e., heartbeat), with no regard to QOL and 2) the "Triple Androgen
Blockade" study examined IAD as the primary (i.e., only) treatment. Most of
the studies I've found the past few weeks of searching indicate at best an
IAD advantage (over continuous) of 10-20%, with side effects dwindling but
lasting through much of even the off-treatment cycle.

So much to read, so little time to read it (if a decision needs to be made
soon).

I.P.

Reply to this Message

Ed Friedman - 08 Dec 2004 19:08 GMT

> Neither that nor the slides accompanying Dr. Eggener's talk -- nor any of
> the other scores of papers I've skimmed -- support any fourfold advantage to
> IAD that I could find. (It wasn't obvious how to play Eggener's talk, and

The ~4 fold advantage I was talking about is seen by taking his figures
for mean increase in tumor mass. The increase was 138% with continual
blockade vs. 36% for intermittent blockade with testosterone(T) and
finasteride(F) added, which means the increase in mean tumor mass was
3.83 times more in continual blockade. It is likely that the percentage
would have been even lower for the T+F group if greater amounts of T had
been added (see the powerpoint file at
http://www.prostateweb.com/ppt/Fullerton_March_23_2004.ppt slide #23,
which shows a patient who had RP, followed by intermittent blockade,
followed by T+F, which clearly demonstrate that higher levels of T
result in lower PSA, or amount of prostate cancer since this patient had
RP).

1) While it is true that quality of life was not addressed, does anyone
seriously believe that continual blockade will give a better quality of
life than intermittent blockade followed by added T+F?

2) The study does only look at intermittent blockade and only as primary
treatment. I included it to demonstrate that intermittent blockade in
which F is added during the blockade and afterwards is much more
effective than continual blockade, or intermittent blockade without F.
To give you an idea of just how effective it is, for the patients in
that study when compared to a study of patients with similar starting
conditions treated with RP (published in Sept., 2001 in the NEJM), the
Student t test indicates that the probability is over 96% that the
chance of dying from prostate cancer in 6.2 years was less with
intermittent triple blockade than with RP (and will probably increase in
probability as the years go by since a number of RP patients had
metastasized and were fighting for their lives, whereas none of the
patients on intermittent triple blockade had).

The bottom line is, if you have hormonal blockade, the results are
better if F is added. If you have intermittent hormonal blockade, the
results are better if F is added both during and after the blockade.

Ed Friedman

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I.P. Freely - 08 Dec 2004 20:08 GMT

That added detail helps. I'll dig into it (even after all the stuff I've
read, it STILL glazes my eyes over at first skim. Maybe I won't even notice
the cognitive SEs of HT.)

I.P.

> > Neither that nor the slides accompanying Dr. Eggener's talk -- nor any of
> > the other scores of papers I've skimmed -- support any fourfold advantage to
[quoted text clipped - 36 lines]
>
> Ed Friedman

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Stephen Jordan - 07 Dec 2004 17:20 GMT

> I am wondering if, and how, my testosterone will come back after 21
> months of ADT
[quoted text clipped - 8 lines]
> plan on skipping the extra 3 months, actually (bad dog!), based on that
> fear...

At pp 153-154 of Strum's excellent book* he writes that, provided that
the patient is not taking an anti-androgen (e. g. Casodex) or other
medication that blocks the interaction of testosterone and/or
dihydrotestostrone (DHT) with the androgen receptor, normal testosterone
levels should eventually be restored when the ADT is stopped.

However, as usual, everyone is different and some men who are highly
sensitive to ADT might never regain natural testostrone production.

Strum emphasizes, "Men who have received continuous ADT for longer than
two years are those most prone to delayed recovery or possible
non-recovery of normal testosterone production."

I have been on ADT (Zoladex first, now Lupron) since ~September. SE's
minor, mainly hot flashes which are to my delight much less with Lupron
than with Zoladex. I was impotent before beginning ADT (secondary to
failed cryotherapy, which is another story) so cannot comment on that
aspect of ADT SE's. There is some fatigue, but I'm unsure whether it's
from the ADT or the IMRT that was concluded in mid-October. Whichever, I
expect it to resolve itself.

Because the treated tumor is/was a Gleason 8, I expect to continue the
ADT for a total of a year, at which time will review the situation and
decide how to proceed.

Regarding IP's response to jl's post, what to do is in his sole
discretion, but his chosen course (roll the dice) would not be mine. It
seems overly pessimistic. I very much doubt that a 3-4 month trial of
ADT would have serious or long-lasting adverse consequences even if IP's
fears come true. Nonetheless: his choice; I wish him well.

* _A Primer on Prostate Cancer_, subtitled "The Empowered Patient's Guide."

Regards,

Steve J
__

"Never give in--never, never, never, never, in nothing great or small,
large or petty, never give in except to convictions of honour and good
sense. Never yield to force; never yield to the apparently overwhelming
might of the enemy.''
--Sir Winston L. S. Churchill

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I.P. Freely - 07 Dec 2004 23:30 GMT

I hear you, and am trying to minimize the gamble and the effect of pessimism
by increasing my knowledge. I expect to post the 1-page summary of my
research file (and the decision it leans me towards) later this week in
preparation to submitting it to my doctors just before Christmas; it will
indicate why I'm leaning towards putting HT off until PSA failure or even
symptoms (Hint: a guy named Walsh agrees, the SE picture painted by a guy
named Strum reinforces Walsh, and a 3-4 months trial reveals only a (small?)
part of the picture.)

I.P.

"Stephen Jordan" <mycroftscj@earthlink.net> wrote >

> Regarding IP's response to jl's post, what to do is in [I.P.'s] sole
> discretion, but his chosen course (roll the dice) would not be mine. It
> seems overly pessimistic. I very much doubt that a 3-4 month trial of
> ADT would have serious or long-lasting adverse consequences even if IP's
> fears come true. Nonetheless: his choice; I wish him well.

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Alan Meyer - 07 Dec 2004 19:06 GMT

At age 57, I got a 7.5mg injection followed one month later by 22.5mg.
In theory this should have lasted a total of 4 months. In my case
testosterone was still low (around 20 IIRC) at 5 months, came up to 120
or so at 6 months, and was over 500 at 7 months. I don't know what my
baseline was.

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DP - 07 Dec 2004 23:30 GMT

> I am wondering if, and how, my testosterone will come back after 21
> months of ADT
[quoted text clipped - 15 lines]
>
> jl_vfr

Your scenerio is very much like mine. I did 21 months total of hormone
thereapy, three months prior to RRP and 18 months post surgery. When I
stopped, I was 51 years old. I had the same question you have, and asked my
doctor. His comment was that the testosterone would return "when it
returns". Anywhere from four to six weeks, maybe longer, maybe never. But
as far as averages go, most men are back to normal, or near normal levels
after about six weeks past the Lupron having been depleted from their body.
You have to restart your testicals producing testosterone, and each person
will vary as to how soon that happens. I was a little concerned about the
aspect of it never starting, but that is unusual, especially in a man in his
early 50's.

Dale P

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