ADT: What You Really Need to Know

The only people who really like androgen deprivation therapy (also called ADT, or hormonal therapy) are the drug companies that make billions of dollars a year selling the drugs.   Doctors don’t like it, and men don’t like being on these drugs.

So why do it?

There are very few specific situations when ADT therapy is the right thing to do.  These are the most common:

* Intermediate-risk men who are given six months of ADT plus external-beam radiation;

* High-risk men who are getting radiation therapy.  This is a finite course of ADT, and this combination – two or three years of ADT plus external-beam radiation – has been proven to cure cancer in many men.

* Men with metastatic prostate cancer.  ADT can make a big difference in these men, in relieving their symptoms and dramatically improving their quality of life.  It can also extend life – some men have been on ADT for 20 years and are still going strong.

Who should not get ADT?  Anybody else with prostate cancer. If you just have a rising PSA after radiation therapy or radical prostatectomy, that is not a good enough reason for a doctor to put you on ADT.  If your doctor wants to put you on ADT to “shrink your prostate” before brachytherapy, that’s not a good enough reason.

ADT has never been shown to extend life if it’s given too soon.

Why not just give it?  At least it’s doing something, rather than sitting around waiting for the cancer to spread.  Well, that sounds good.  Please refer to the previous paragraph, and read the last sentence again.  Now, if you have a rising PSA, there are other things you can do that may help a lot.  These include:

• Salvage surgery or radiation, if your doctor thinks the cancer is still confined to the “prostate bed,” the area around the prostate. (Note: In this case, if you get salvage radiation, your radiation oncologist may want to put you on a limited course of ADT, which is one of the two specific acceptable situations for ADT; see above.)
• Immunotherapy; a vaccine such as Provenge, designed to boost your body’s ability to fight off the cancer.
• Early chemotherapy.
• A clinical trial testing a promising new drug.

Don’t get us wrong; we’re not hating on ADT.  If you need it, you need it.  But it’s not just like taking a vitamin supplement or getting a flu shot.  There are serious side effects with long-term ADT – things that testosterone normally helps protect you from – including thinning of bones, loss of muscle mass, weight gain, loss of libido, hot flashes, mood changes, depression and, our main subject here, the risk of cognitive impairment.

Before we get into that, let’s take a brief detour into the metabolic syndrome.

“Metabolic syndrome” includes an unholy cluster of bad things that can lead to a heart attack or stroke.  Elevated blood pressure; unhealthy levels of blood sugar, cholesterol, and triglycerides; and abdominal fat – a big jelly donut of visceral fat, also known as “heart attack fat,” right around your belly, a cardiac spare tire.  A big gut equals a bigger risk for diabetes, heart attack and stroke.

All of this is magnified with ADT.

Maybe you already have some of these risk factors; maybe you’ve already had a heart attack, or you’ve got diabetes.  If you need ADT, you need it.

But hear these words:  You will need to fight what it’s doing to do to the rest of your body, even as it saves you from your prostate cancer.

You will need to get mad at it.  Work hard to take back your life – work doubly hard, because not only will it try to turn you into a tub of butter, but you might get mildly depressed.  Your brain will tell you that you’re too tired to exercise.  It’s deceiving you.  You must not listen to it.  Exercise anyway.

Here’s what you’re up against:  Normally, if a man wants to lose a pound, he needs to burn 3,500 calories.  A man on ADT who wants to lose that same pound needs to burn 4,500 calories.  He’s slogging upstream with ankle weights.  His metabolism is slower, his sugar metabolism is messed up, his blood pressure may be higher, and for many reasons, he probably feels like crap.  Maybe he stops taking care of himself.   This is the worst thing he can do.

You need to be aware of this, because it might not be on your doctor’s radar.

Just as important, you need to enlist your family and friends, NOT ONLY to help push you to exercise and eat right – cut way down on the carbs and sugar, especially – but to tell you if you seem depressed, because depression might have snuck up on you, and you might not have noticed it.

All of these things can be fought.  However, if you just go back to the urologist or oncologist for a 5-minute appointment and another Lupron shot, you are probably not getting the monitoring you need.  Depression may not show up in a brief doctor’s visit.  Even if the scale shows that you’ve put on weight, your doctor might say, “Well, that’s common with ADT.”

Years ago, when doctors first started using ADT, men didn’t live that long.  Now, men are living for years or even decades on ADT, and if that stops working, there are other drugs that can help, and exciting new types of drugs showing amazing results for some men in clinical trials.  This is very good news; however, the downside is that doctors might just think, “hey, it’s great, he’s still alive and his PSA is not moving up.”

But we know that weight gain is not only a common side effect of ADT; it’s bad.  It’s also something you can help prevent.  You need to exercise, with cardio (walking, swimming, riding a bike, aerobics, jogging, etc.,) plus weights for strength.  These can be light weights; you don’t need to turn into Arnold Schwarzenegger and bench-press a Volkswagon Beetle or anything like that.  You just need to keep your muscles working.  Exercise will help with depression, with the cardiac risks, and with the risk to your brain.  As University of Colorado radiation oncologist E. David Crawford, M.D., recently put it, “What’s heart healthy is usually prostate-cancer healthy… I’ve got a number of (patients on ADT) who are in great shape and they’re tolerating [treatment] quite well. These are the people who are out there, who continue to lift weights, they continue to exercise, they watch their diet.”

The metabolic syndrome that ADT causes may be a major reason – nobody knows for certain yet – why some men who are on ADT have cognitive impairment.