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August 10, 2017. Little old Toadsworth is getting older. If you haven’t taken a spin in your Mario Kart recently, you may not know he was treated for prostate cancer 5 years ago. And now he is shocked to learn that his PSA is creeping up. Poor Toadsworth is nervous about his PSA but also about the side effects from restarting the androgen deprivation therapy (ADT) he received for 6 months with his radiation. What should he do? We recently discussed the LATITUDE and STAMPEDE trials out last month that show ADT + abiraterone improves survival in advanced, recurrent, and metastatic prostate cancer. But starting ADT in biochemically recurrent but completely asymptomatic men like Toadsworth remains controversial. Good thing the TOAD trial was published last year showing greater survival with immediate vs delayed ADT (thoughcritics are quick to highlight it was underpowered...and undervalued side effects). To further nudge Toadsworth toward ADT sooner than later, quality of life results from the TOAD trial are now published in Lancet Oncology and (surprisingly?) show no significant detriment to quality of life with immediate ADT. Unsurprisingly, sexual function and hot flushes were worse. But perhaps what we’ve really undervalued is the anxiety of living with an untreated recurrent cancer. What does this mean for Toadsworth? His physician should probably assess his anxiety level with a watch and wait approach and then decide which option will get him back in the Parade Kart quickest.