Hormone therapy - short or long term

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BB_Fan
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Date Joined Jan 2010
Total Posts : 1011
   Posted 12/20/2010 3:31 PM (GMT -6)   
Will1, in the recent posting of his story brought up an issue that I have been thinking about lately and I would be interested in the prospective of others. Will1 is a long term surviver who has been on HT for many years and has no intention of taking a holiday (intemittant HT). I also have corresponded with another individual with similar stats who is also a long-term surviver, has been on HT for a number of years, and doesn't intent to go off. In thinking about my own future treatment plan I had presume I would go the intermittant HT route if SRT did not work out for me. It seemed to be the best oprion for long term survival, but now I'm starting to question that conclusion. I know that there probably isn't a right answer here, but I wanted to know what other think/plan.
Dx PCa Dec 2008 at 56, PSA 3.4
Biopsy: T1c, Geason 7 (3+4) - 8 cores, 4 positive, 30% of all 4 cores.
Robotic Surgery March 2009 Hartford Hospital, Dr Wagner
Pathology Report: T2c, Geason 8, organ confined, negitive margins, lymph nodes negitive - tumor volume 9%, nerves spared, no negitive side effects of surgery.
PSA's < .01, .01, .07, .28, .50. HT 5/10. IMRT 9/10.
PSA's post HT .01, < .01

John T
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Date Joined Nov 2008
Total Posts : 4269
   Posted 12/20/2010 3:46 PM (GMT -6)   
I don't know if there is any survivial benefits to long term HT vs intermittent. After reading posts from many patients that are on intermittent it seems like they really appreciate the time off holidays that intermittent threapy provides them.
JT
65 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, no side affects and psa .1 at 1.5 years.

BB_Fan
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Date Joined Jan 2010
Total Posts : 1011
   Posted 12/20/2010 4:02 PM (GMT -6)   
I guess the question is - do you put yourself at risk giving the cancer the opprtunity to grow again. That seems to be the concern of Will and the other individual that I spoke to. I guess that it was my presumption that if the PCa started to grow again that I would just go back on HT and knock it out. That your long term survival would be better on IHT than continuous HT. I've got to tell you that the first medical oncologist I saw said that it didn't matter whether you started HT as soon as you had a recurrence, when you PSA reached some magic number (like 10), or went intermitted. You had cancer cells that would not be effected by the HT that would grow unabated, and that those were the ones that would ultimately get you. Needless to say that I didn't like the answer and don't see that doc any longer. Doesn't mean he was wrong.
Dx PCa Dec 2008 at 56, PSA 3.4
Biopsy: T1c, Geason 7 (3+4) - 8 cores, 4 positive, 30% of all 4 cores.
Robotic Surgery March 2009 Hartford Hospital, Dr Wagner
Pathology Report: T2c, Geason 8, organ confined, negitive margins, lymph nodes negitive - tumor volume 9%, nerves spared, no negitive side effects of surgery.
PSA's < .01, .01, .07, .28, .50. HT 5/10. IMRT 9/10.
PSA's post HT .01, < .01

duke68
Regular Member


Date Joined Mar 2007
Total Posts : 243
   Posted 12/20/2010 4:25 PM (GMT -6)   
the doctors at dana-farber are going to try cab for only 6 months if psa is undetectable.

they think the results will be the same as a longer time frame before going intermittent. With better ql and time to aipc.

I know dr Strum and others recommend a year.

This is for recurrence after curative failure.
The trial i am on has cab (lupron and bicalutamide) in both arms.
Both arms end after 6 months.
Gerry
age 68 diag. oct 2006 GS8 T2b psa 11.7
4 of 8 cores 20% 30% 60% 100%
rrp dec 2006 Gs9 4+5 m+ sv+ ec after 6 weeks psa 0.6 second opinion Dana-Farber pT3b 4+4 + T5 = GS9
Rt 35 sessions to lymph nodes and prostrate 4-2007
3/2007 cab 6 months lupron + casodex.
psa <0.1 from june 2007 to march 2010
psa 6/10 0.3 9/10 0.6 12/10 2.5 :(

Currently enrolled Dana- Farber P2 trial Avastin and cab

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 12/20/2010 5:00 PM (GMT -6)   
Good topic,
I do know a lot of men that were castrated when they had their prostate cancer surgeries. This is effectively long term hormonal therapy. They all seem to do well with it. Much needs to be considered about the QoL on long term ADT. My tenure was 3 years (28 months on cycle with a long slow regeneration of testosterone) and I am doing well both with the cancer and the reversal of the effects of ADT. The key to IHT is that QoL is the priority. For some men, long term therapies does not hinder their QoL.

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino

livinadream
Veteran Member


Date Joined Apr 2008
Total Posts : 1382
   Posted 12/20/2010 8:34 PM (GMT -6)   
I, like Tony, went on a 2 years. I have been off for one year and my side effects are gone. Someday I will probably have to do it again but I tell you this, I am GLAD I took a break from it. I have no desire to be on hormones forever. That is just my opinion though

peace to you
Dale
My PSA at diagnosis was 16.3
age 47 (current)

http://www.caringbridge.org/visit/dalechildress

My gleason score from prostate was 4+5=9 and from the lymph nodes (3 positive) was 4+4=8
I had 44 IMRT's
I was on Lupron, Casodex, and Avodart for two years with my last shot March 2009. I am currently (7-22-2010) not on any medication.
My Oncology hospital is The Cancer Treatment Center of America in Zion IL
PSA July of 2007 was 16.4
PSA May of 2008 was.11
PSA July 24th, 2008 is 0.04
PSA Dec 16th, 2008 is .016
PSA Mar 30th, 2009 is .02
PSA July 28th 2009 is .01
PSA OCt 15th 2009 is .11
PSA Jan 15th 2010 is .13
PSA April 16th of 2010 is .16
PSA July 22nd of 2010 is .71
Testosterone keeps rising, the current number is 156, up from 57 in May

T level dropped to 37 Mar 30th, 2009
cancer in 4 of 6 cores
92%
80%
37%
28%

Jerry L.
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Date Joined Feb 2010
Total Posts : 3072
   Posted 12/20/2010 9:56 PM (GMT -6)   
Are there studies out there that show stats for continued HT vs. IHT?

After hearing Will's story, I am considering going down the HT road before my PSA starts rising. Don't want to, but being so young I sort of have to put the priority on quantity vs. quality.

Thoughts on this?
Nov. 2009 Dx at Age 44
Dec. 2009 DaVinci Robotic Surgery
Jan. 2010 T3b, Gleason 9
Feb. 2010 Adjuvant Radiation

PSA History:
-----------------
Nov. 2009 4.30
Feb. 2010 <.05
May 2010 <.05
Aug. 2010 <.05
Nov. 2010 <.05

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 12/20/2010 10:43 PM (GMT -6)   
Jerry,
Think hard about it. It was my least favorite of my therapies. There are many studies about the efficacy of intermittent versus long term ADT. In fact it is well accepted that intermittent has a very important role in improving QoL. The long term side effects of low testosterone are also well documented. I am not opposed to it but I certainly have a better understanding on the SE's since doing it. You and I are very close in our Dx and your G9 would have probably pushed into a decision to move forward (seeing as to how I did so with a G7).

Continue your excellent research. You are far from an uninformed patient now. If you move forward with ADT, keep looking at ways to avoid the SE's. This is particularly where i think an integrative oncology approach is beneficial. The use of ADT as conventional therapy and combining it with the complimentary options. This site has some great ideas...

www.integrativeoncology-essentials.com

Peace...

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3892
   Posted 12/20/2010 11:24 PM (GMT -6)   
Walsh, in his book, looks at it this way..If HT is effective and lowers PSA to undetectable or near undetectable, why not keep it there...He seems to think keeping the PC in full remission is more important than giving the patient a "vacation" and allowing the cancer to multiply, making it much more difficult to get it back under control, or even impossible to control..He also points out that after a period of time on Lupron, stopping the drug does not necessarily result in the hoped-for "vacation"..."T" recovery can be very slow if at all, and just about the time the "T" gets high enough so the patient feels better, the PSA level demands he go back on Lupron...I imagine the AGE of the patient plays an important part in determining the type of HT protocol that is used..Different men have very different priorities..

When HT is used as an adjunct to radiation, it is usually for a fixed period of time, one year, two years, three years....Then you are taken off ADT drugs and they see what happens...If the radiation worked and you are "cured", The PSA stays undetectable or near undetectable and the need for ADT ends....If your PSA starts rising right along with your testosterone, then radiation has failed and you go back on ADT for the duration...

My radiation oncologist INSISTED (over my objections) that I do two years of HT as he was SURE it would improve my survival chances which he feels are quite good..We shall see...
Age 68.
PSA at age 55: 3.5, DRE normal. Advice, "Keep an eye on it".
age 58: 4.5
" 61: 5.2
" 64: 7.5, DRE "Abnormal"
" 65: 8.5, " normal", biopsy, 12 core, negative...
" 66 9.0 "normal", 2ed biopsy, negative, BPH, Proscar
" 67 4.5 DRE "normal"
" 68 7.0 third biopsy positive, 4 out of 12, G-6,7, 9
RRP Sept 3 2010, pos margin, one pos vesicle nodes neg. Post Op PSA 0.9 SRT, HT, Dec

Carlos
Regular Member


Date Joined Nov 2009
Total Posts : 486
   Posted 12/21/2010 6:42 AM (GMT -6)   
BB,  Strum published an article with the results of his studies of IHT vs HT.  He clearly favors IHT.  The article is lengthy and was published in 2000 but I don't believe he has changed his views on anything.  This is a link: http://www.prostate-cancer.org/pcricms/node/199
 
Carlos

Dx 2/2008, age 71, PSA 9.1, G8,T1c. daVinci surgery 5/2008, G8(5+3), pT2c. LFPF, good QOL. PSA <0.1 for 2 yrs. PSA rose to .2 at 30 months, started SRT 12/15/2010.

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4269
   Posted 12/21/2010 1:13 PM (GMT -6)   
Carlos,
Excellent article that should be read by anyone considering HT. Strum is the foremost expert on HT having worked with  Dr Labrie when it was first developed to treat PC. In all due respects to Dr Walsh, who is a great surgeon, his knowledge of HT is fairly limited. As Strum and other medical oncologists who use HT say, you have to use tests other than psa to determine how the HT is working on your particular version of the cancer. You can't just choose intermittent vs long term, as the way your PC will react to the treatment will govern the type of treatment.
"A Primer on Prostate Cancer" by Dr Strum and "Beating Prostate Cancer, Hormone Therapy and Diet" by Dr Myers are must reads for anyone on HT or considering HT.
JohnT

Jerry L.
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Date Joined Feb 2010
Total Posts : 3072
   Posted 12/21/2010 1:42 PM (GMT -6)   
I was hoping for a good novel for the holiday season, but I think I'll read these books.  Thanks for sharing.

JNF
Veteran Member


Date Joined Dec 2010
Total Posts : 3887
   Posted 12/21/2010 4:21 PM (GMT -6)   
Dr. Snuffy Meyers is another oncologist that favors IHT. He also favors a three-way approach with Lupron, Cassodex, and Proscar. He often keeps the person on Proscar during the Lupron/Cassodex vacation. Not only has he been a pioneer in PC research and treatment he is a 13 year survivor of advanced disease. As John T says above, his book is a must read.

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 12/21/2010 5:34 PM (GMT -6)   
Probably interesting to note:

Stephen Strum (retired), Bob Leibowitz, Mark Scholz, Howard Scher, Pete Scardino, Nick vogelzang, Snuffy Myers, Richard Lam, Bill Catalona, Randy Fagin, Peter Carroll, and I am very certain many more...

All are great prostate cancer oncologists, all will attempt to start with intermittent hormonal therapy before committing to permanent or extended HT.

That says a lot...

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3892
   Posted 12/21/2010 6:04 PM (GMT -6)   
Dr. Walsh's book, pages 480, 483..You might not like the message but please don't shoot the messenger...

BB_Fan
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Date Joined Jan 2010
Total Posts : 1011
   Posted 12/21/2010 6:41 PM (GMT -6)   
Thanks for the responses. Carlos, thanks for posting the Strum's article. When I first wa diagnosed I read Walsh's book cover to cover. then spoke to a medical oncolgist who was not a specialist in PCa and was not aware of some of the current studies. My understamding was that HT would only be effective for a very short time. Perhaps 2=3 years at best. My uro confirmed that thinking when I was heading into SRT telling me that HT would only be effective for 3 years if SRT failed. I have read Myer's book and I will get Strum's.
Dx PCa Dec 2008 at 56, PSA 3.4
Biopsy: T1c, Geason 7 (3+4) - 8 cores, 4 positive, 30% of all 4 cores.
Robotic Surgery March 2009 Hartford Hospital, Dr Wagner
Pathology Report: T2c, Geason 8, organ confined, negitive margins, lymph nodes negitive - tumor volume 9%, nerves spared, no negitive side effects of surgery.
PSA's < .01, .01, .07, .28, .50. HT 5/10. IMRT 9/10.
PSA's post HT .01, < .01

Jerry L.
Veteran Member


Date Joined Feb 2010
Total Posts : 3072
   Posted 12/21/2010 7:08 PM (GMT -6)   
Fairwind,

Don't have the Walsh book..what do those pages say?

Thanks,
Jerry L.

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 12/21/2010 9:58 PM (GMT -6)   
Jerry,
I have the Walsh book sitting right here. Walsh refers to the efficacy of IHT or even early HT as theoretical. There are no randomized trials that confirm that it works any better than providing HT when it is absolutely necessary (failed local therapies and a rising PSA).

To some degree he is correct ~ the study data is scarce. The very same can be said about ADT3, too. But I don't necessarily agree that it isn't worth a shot. There is no study to the contrary either. The attempt is to prolong a remission while reducing the morbidity of HT. It certainly sounds good. And if it isn't proven to work in a negative way then I'll take the longer term of remission that initial HT does offer in high risk cases. Meaning, quality of life is always better when not worrying as much about whether the disease is coming back. For me it comes down to this ~ I didn't watch and wait, I attempted to do something that isn't proven to fail.

Tony

Fairwind
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Date Joined Jul 2010
Total Posts : 3892
   Posted 12/21/2010 11:20 PM (GMT -6)   

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 12/21/2010 11:42 PM (GMT -6)   
Read that book a full year before my initial dx, after my first biopsy came back negative despite a quickly rising PSA. Still consider it a good primer on all things PC. Doesn't have all the answers, but covers most things in great detail. Hoping a revised version will come out again in the near future. Was always money well spent.
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 11/10 Not taking it
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/23/10

JNF
Veteran Member


Date Joined Dec 2010
Total Posts : 3887
   Posted 12/22/2010 3:07 AM (GMT -6)   
There are two other recurring themes that come from the oncologists listed earlier.

Generally speaking they all start HT early rather than waiting for a PSA rise. They also advocate ridding the gland and immediate area of cancer even though there is a high probability or even proof of the cancer being out of the capsule. This is akin to the "de-bulking" surgical protocal followed in most tumor based cancers. The point being to get rid of or destroy the initial primary source of the cance to lighten the load on the body and to reduce the main source off cancer production.

As noted there is a general lack of studys at this time, but the specific evidence these oncologists report from their practices is convincing to me. See also the writings and work of Dr. Oliver Sartor now at Tulane University.

leeanglo
Regular Member


Date Joined Dec 2010
Total Posts : 191
   Posted 12/22/2010 5:00 AM (GMT -6)   
HI,jnf ....and other members.IM presently on zoladex ht shots and have been for a couple of months or so.I was of the thinking that even though i have bone and lymph node envolvement surely it would make sense to remove the source of the cancer at the prostate gland.My urologist here in the uk as recommended no radical surgery as he feels there is no benefit in putting me through surgery now that my desease as spred to bones and higher lymph nodes.I would like to understand if bone mets spread further desease or do any further mets come from the original source being the prostate gland ?The u doc talks alot about quality of life and i have no desire to be cut open unless it will make adifference to my long term survival.
age 44.
T3a N2 mI gleason 4+3=7 psa on dx 144
12 biopsie cores all positive.

BB_Fan
Veteran Member


Date Joined Jan 2010
Total Posts : 1011
   Posted 12/22/2010 7:43 AM (GMT -6)   
I have read that larger tumors contain more hormone resistent cells. These cells will not be killed by HT and will keep on multiplying, spreading desease. I believe that this is the reason for debunking. I am relatively early in my research of PCa, perhaps will respond.
Dx PCa Dec 2008 at 56, PSA 3.4
Biopsy: T1c, Geason 7 (3+4) - 8 cores, 4 positive, 30% of all 4 cores.
Robotic Surgery March 2009 Hartford Hospital, Dr Wagner
Pathology Report: T2c, Geason 8, organ confined, negitive margins, lymph nodes negitive - tumor volume 9%, nerves spared, no negitive side effects of surgery.
PSA's < .01, .01, .07, .28, .50. HT 5/10. IMRT 9/10.
PSA's post HT .01, < .01

tarhoosier
Regular Member


Date Joined Mar 2010
Total Posts : 495
   Posted 12/22/2010 9:02 AM (GMT -6)   
This discussion requires a definition of terms. Fernand Labrie in Qu├ębec City pioneered the long term use of androgen deprivation therapy. Strum studied with Labrie. For men who were treated first in their late 60's to early 70's the idea of a cure may not be relevant. Labrie believed in continuous ADT and his studies and reports showed significant success at avoiding death from PCa, if that is your definition of cure. Other oncologists wish to treat all the elements of the body and so allow periods of rest from the drugs in order to restore bone health, weight, metabolic syndrome, incipient diabetes, and other issues which regularly arise. Judd Moul, Mayo, and others have published data showing a median response to ADT of 10+ years for men who are recurrent. For those with widespread disease this would be much less. E. David Crawford did a landmark study in the 80's identifying that the amount of disease present at initiation predicted the term of response. In any case, the old saw of 2-3 years is absurd and whoever continues to throw that around needs to use his (her) continuing medical education training in 2011 on current PCa studies to be up to date on such basic information.

tarhoosier
Regular Member


Date Joined Mar 2010
Total Posts : 495
   Posted 12/22/2010 9:12 AM (GMT -6)   
Tony:
I am unsure of the intent of the first sentence of you 7:58 reply. Do you consider the Messing trial to relate to the timing of ADT?
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