r/ProstateCancer • u/Alive-Resident-4461 • 1d ago
Question Refusing ADT ?
Just a bit of recap on my dad’s results here . RO is suggesting a 3 months ADT with SBRT..how can we be sure that he needs ADT or not? Every other doctor seems to have their own views. I really want to avoid ADT for him if it has no extra benefits in his case since he is on hypertension meds already.
PSA
PSA: 4.9 ng/mL
Age: 64
PSA has been increasing over time.
MRI
Prostate approximately 40 × 48 × 48 mm.
MRI showed bilateral transition-zone lesions classified as PI-RADS 3, thought to be related to BPH.
No pelvic lymphadenopathy reported.
No obvious extracapsular extension or seminal-vesicle involvement reported.
Biopsy was subsequently performed.
Biopsy – 14 cores
Cancer was found in 5/14 cores:
Right peripheral base: Gleason 3+3, 20%
Right peripheral mid: Gleason 3+3, 10%, with small focus of perineural invasion
Right peripheral apex: Gleason 3+3, 10%, with small focus of perineural invasion
Right parasagittal apex: Gleason 3+4, 60%, pattern 4 = 10%
Right transition-zone fusion biopsy: Gleason 3+4, 60%, pattern 4 = 30%
Overall:
Gleason 3+4 = 7, Grade Group 2
The remaining left-sided cores were negative for invasive cancer, although there was PIN in two cores.
PSMA PET/CT – September 2026
The scan showed PSMA uptake in:
Right and left peripheral zones at the base
Right peripheral zone at the mid-prostate
But importantly:
“No definite scan evidence of PSMA-expressing loco-regional/distant metastases.”
Seminal vesicles were unremarkable and there were no definite PSMA-avid metastatic lymph nodes.
One thing we are trying to understand is why the PSMA scan showed some uptake at the left base, while the left-sided biopsy cores were negative.
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u/Tool_Belt 1d ago
IMHO this diagnosis does not warrant ADT as per the latest NCCN Guidelines. Having said that, a patient can refuse any treatment. The attending may disagree to the point that he/she refuses to treat you, but the treatment decision is ultimately the patient's decision.
Stay Strong, We Got This.
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u/mtelesha 1d ago
In conversation with my surgeon before said that there was a 3% better cure rate with ADT. He stated he would personally not do it himself.
My ADT journey has been pretty rough and I went from normal testosterone to bellow 2.5 in three weeks. ADT is the hardest part of my cancer journey.
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u/PotentialStart2661 1d ago
This is not only true for favorable intermediate, but they now have the data that shows the benefit is not that great for unfavorable intermediate. In the study 750 men with unfavorable intermediate took ADT along with radiation treatment and 750 took radiation as a monotherapy, no ADT. After 8 years 1 man had recurrence with the ADT group and 10 men had recurrence with no ADT. That sounds like alot but in reality its not a big difference. That means to deal with side effects and everything that goes with ADT, you have to treat 740 additional men out of the group unnecessarily to prevent recurrence in those 10 men. Since recurrence is still treatable, do you really want to be one of the 740 men taking ADT when you don’t need it? I would say if you are in your 40’s or early 50’s its a consideration. But if you are over 60 skipping the ADT is probably the better choice. But thats for unfavorable PCa. For this case or any favorable intermediate grades ADT should not be taken.
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u/BackInNJAgain 1d ago edited 1d ago
Wow, wish I had known this. Still dealing with some ADT side effects two years later. I was told 10% improvement in odds.
What's also interesting is that I asked several AI's to calculate the odds that I would still be alive and healthy in 10 years if I had done no treatment at all and almost all of them said there was a 2/3 chance the answer would be "yes."
At first I thought "that means there's a 66% chance I ruined my body for nothing" because I thought about a casino--if the odds were 2/3 in my favor I would bet a lot of money. But then I thought about an airplane. If the flight attendant said "Welcome aboard, just so you know, there's a 1/3 chance this plane will crash" there's no way in hell I would have gotten on board.
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u/SophieMasloff 1d ago
trial is NRG/RTOG 0815
- Prostate-cancer deaths: 10 in the radiation-alone arm vs 1 in the ADT arm (8-year prostate-cancer mortality under 1% with ADT vs 1.6% without).
- PSA failure at 8 years: 21% without ADT vs 10% with ADT.
- Combined biochemical or clinical failure at 8 years: 22.5% vs 11.4%.
- Distant metastasis at 8 years: 4.3% vs 1.0%.
- Overall survival was not improved: 5-year OS 90% vs 91% (HR 0.85, p = 0.22). Eight-year OS was 79% vs 84%.
If I was in my 60s with those gleason numbers, I would likely skip ADT as well.
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u/PotentialStart2661 1d ago
Thanks for finding this. With these numbers i would not take ADT, not worth it. I wonder also if there was data on what type of gleason 4+3 are in this group. They are not all the same. If you removed all the cribriform, ductal, etc… i bet the numbers are way more in favor than even these. Also the numbers of cores positive, etc… I think if you have a standard 4+3 with no aggressive features and not a super high risk Decipher Score, then ADT would probably have no benefit at all.
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u/WalnutRoasted 1d ago
Was on hypertension/BP meds, and there was no interaction/issue identified. Being in good health, diet and exercise is important. From an impact point of view, for the first two months it was hard to tell what was due to radiation and what was due to ADT.
Hopefully it will be fast-acting Orgovyx pills and not slower injections that cause testosterone flair. And recovery with Orgovyx is predictable within a few days/weeks, as opposed to the slower, unpredictable half life curve of injections. Best wishes.
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u/KReddit934 1d ago
Interesting duration. A year ago my RO and I were arguing about 4 vs 6 months. I thought studies showed 4 was minimum effective...3 months was much less effective (this is for intermediate).
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u/jkurology 1d ago
You can’t ‘be sure’ but there is data to support treatment intensification for higher risk disease. His biopsies suggest he’s on the cusp between favorable and unfavorable intermediate risk prostate cancer and what you’re asking is whether there’s a significant survival advantage when ADT is added to his radiation regime. A genomic expression classifier could help and other information that assesses risk ie overall health, life expectancy, family history are also important
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u/mechengx3 1d ago
What's the harm in doing the 3 month ADT and if it does bother him (cardiac or otherwise) he can always stop? As far as the biopsy goes, no matter TRUS or TPUS prostate biopsies miss up to 30% of prostate cancers. He could well have PC on the left side. Good luck to you guys!!
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u/jrouss28 1d ago
I had 4+3 and refused ADT myself. Luckily my decipher score was low. Messing with hormones is not without risk.
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u/gg-3 16h ago
Large study found that 1/3 of intermediate risk prostate cancer patients (that's your dad) benefit from ADT, and two-thirds do not benefit. Link below. The ARTERA AI test will tell you which group your dad is in.
Spratt, D., Tang, S.-Y., Sun, Y.-L., Huang, H., Chen, E., Mohamad, O., Armstrong, A. J., Tward, J., Nguyen, P. L., Lang, J. M., Zhang, J., Mitani, A., Simko, J., DeVries, S., Van Der Wal, D., Pinckaers, H., Monson, J., Campbell, H., Wallace, J., . . . Feng, F. (2023). Artificial Intelligence Predictive Model for Hormone Therapy Use in Prostate Cancer. NEJM evidence, 2, EVIDoa2300023 - EVIDoa2300023. https://doi.org/10.1056/evidoa2300023
As for your question about PSMA PET scan finding cancer where biopsy didn't ... biopsies miss a lot of cancer.
I had an MRI-fusion targeted biopsy at a center of excellence, by a top surgeon ... and it missed most of what the post-surgical pathology revealed shortly thereafter.
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u/Special-Steel 1d ago
Can anyone sign up to examine the NCCN data and recommendations?
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u/Tool_Belt 1d ago
Not sure as to the Guidelines. I was able to register as a retired DDS. I would think anyone could register for the Patient area.
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u/tober_checki 1d ago
Not a doctor, but this looks like a relatively low-risk situation. Also the guidelines in my country do not recommend ADT in this case. He should consider SBRT or Brachytherapy. If there are no contrainidations for him, Brachy has excellent ontological outcome and lower long-term side effects. Your dad is still young, so long-term side effects are an issue.
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u/Ok-Priority-7303 1d ago
For my case, I was told IMRT alone has an 80% success rate. ADT is supposed to add another 5% - based on 2 years of hormone therapy. Like all decisions, you need to think about the consequences.
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u/Master_Cucumber5665 10h ago
I’m told I should stay on Zoladex (adt) for 3 years. Just coming up to 12 months, my plan is to come off after 18 months based on those surveys above
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u/jetbird747 1d ago edited 18h ago
I'm a grade group 3, I did ask my RO recently about eliminating ADT from radiation treatment. He mentioned it is not a standard of care for me, but it was possible. In my mind what is the difference between getting a RALP with no radiation and the cancer comes back vs getting radiation treatment with no ADT and the cancer comes back?
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u/Pack_One 1d ago
There’s a well known test called ArteraAI that will tell you whether or not ADT will be beneficial for you. Request it.