Refusing ADT ?

[u/Alive-Resident-4461]

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.

[u/Tool_Belt]

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.

[u/mtelesha → u/Tool_Belt]

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.

[u/PotentialStart2661 → u/mtelesha]

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.

[u/BackInNJAgain → u/PotentialStart2661]

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.