Always on
Keep ADT running
Leuprolide, goserelin, degarelix, relugolix, or orchiectomy stays in place. Stopping ADT collapses the low pole and is not BAT.
Protocol
What a Hopkins-style cycle actually looks like.
This is the regimen used in TRANSFORMER, RESTORE, COMBAT, and the 2022 patient guide. It is a description of trials, not a prescription. Adaptive HSPC cycles are on the HSPC page.
Day 1
400 mg IM cypionate
Gluteal intramuscular testosterone cypionate, 400 mg. This dose sits inside the FDA-approved range for hypogonadism; the prostate-cancer use is off-label.
Days 2–28
Let it fall
No daily gel in the classic protocol. Levels peak, then decay toward a near-castrate trough. The next shot is on day 29. ARPIs are not co-administered unless a combination trial says so.
What gets watched
| What | Why | Usual cadence in trials |
|---|---|---|
| PSA | Can rise from androgen even without growth. Read as a pattern. | Every cycle, with scans. |
| CT + bone scan | Soft-tissue and bone truth. Early bone-scan flare happens. | Baseline, then about every 8–12 weeks. |
| Symptoms / pain | A 48-hour flare can be testosterone, not explosion. | Especially cycle 1. |
| Hematocrit, BP, edema | Androgen can thicken blood and retain fluid. | Labs around injections. |
| Quality of life | Fatigue, muscle, mood, sexual function often move first. | Ask. |
Expected effects
- Achiness, lower-leg swelling, breast tenderness or gynecomastia, hot flashes.
- Some men regain sexual function that ADT had taken — not those whose nerves were lost to surgery or radiation.
- More muscle, less abdominal fat, better fatigue scores in trial PROs after a few cycles.
- Pain flare 24–48 hours after injection in some men with bone disease; often fades.
Reasons trials stopped or excluded
- Symptomatic skeletal disease, cord threat, untreated obstruction.
- Uncontrolled cardiovascular disease. Isolated infarcts and strokes have occurred; causality is not clean. Hematocrit and blood pressure still get measured.
- High-grade hypertension. Fluid retention in heart failure.
- Radiographic or clinical progression — not PSA alone.
Drug cost is low next to branded ARPIs. Coverage for off-label prostate-cancer use is not guaranteed. Prefer a trial when one is open.