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Things That Puzzle Me About PCa # 14 in an unlimited series
I have written before about my puzzlement as to why prostate cancer is not treated as the chronic disease which it is in so many cases. Why there is such a difference in attitudes to heart conditions when the mortality rate for heart failure in men is about ten times that for prostate cancer? Note, before any takes me to task, I am not saying that all men diagnosed with prostate cancer have an indolent form of the disease. There are very dangerous types of prostate cancer that need early attention, but as so many studies are now confirming, the majority of cases are never likely to develop into life threatening situations.
Given that, why is there no focus on early, non-invasive management by way of intermittent ADT (Androgen Deprivation Therapy) for early stage tumours? Current theory is that ADT will starve very much larger populations of tumours that are well advanced – even metastasised disease can be managed well for many years with this therapy. So why not hit the small, contained populations before they get going? A regular poster on other sites often quotes Dr Strum, if a man is hesitant about having early therapy, as saying:
"There is NOWHERE in oncology where waiting for the tumor cell population to increase (and to mutate) is in the better interests of the patient."
If Dr Strum is correct, and as an oncologist he certainly knows a good deal more about the disease than I ever will, why do we not launch an early attack on early stage prostate cancer using ADT? This would surely deal with the tumour cells contained in the gland very effectively. And if the theory that prostate cancer is a systemic disease by the time it is diagnosable is correct, any cells that may have populated the rest of the body would also be dealt with. There might be a very small risk of mutation from androgen dependent cells to androgen independent cells, but this risk appears to be significantly reduced with intermittent therapy even in large tumour populations.
Of course there are side effects to ADT, as there are with all therapies. But in most early stage, low aggressive cases if an intermittent therapy is applied – and especially if it is what might be termed “ADT-lite” – just one form of ADT instead of the real heavyweight CAB or ADT3 - the permanent side effects will be few and far between.
It makes sense to me in my dithering way – does it make sense to anyone else. And if not, why not?
Re: Things That Puzzle Me About PCa # 14 in an unlimited series
Why not treat with early ADT seems to be the heart of your question here, Terry. I have several thoughts.
Many of us, and certainly myself, live quite physical lives, even at this age; active sports, conditioning and such. For me to be taking drugs that impede that life would be a huge setback. And all the many discussions I have read about ADT on this site confirm my disinclination to use it.
Furthermore, my understanding is that the ADT approach is repressing, hindering the cancer for the most part, not killing or removing it like surgery or radiation can do.
Thus the standard treatment paths: cure it if you can, otherwise deter and manage it as best you can. I am completely in accord with these.
I had surgery and then followup adjuvant radiation at three months because I became a t3a staged case. Thats a lot of treatment, but I feel just as strong and healthy now as before any treatment. No urinary problems. My sexual capability is down from before, but even after surgery sparing nerves on only one side, and ensuing radiation, there is life there. With less treatment, as in earlier diagnoses, I
expect that sexual function can be reclaimed ok in the majority of cases.
Related to your question is the model that we carry in our minds of prostate cancer as it progresses. I had a gleason 7 cancer, a PSA of 7, and pathological staging of t3a from my surgery. My internal model is that if I had been diagnosed a year earlier, my gleason might have been only 6, my PSA was lower, and my true staging would likely have been t2. And the cancer completely curable. If my diagnosis had occurred a year later then probably my cancer would have been more advanced and likely incurable. As it is, there is uncertainty about my situation, I may be cured or I might again see it arise in the future. If you have a different model of how prostate cancer progresses over time in an individual I would surely like to hear your thoughts. (I did discuss this view of mine with my urologist when first diagnosed. And he was in accordance. He recommended prompt action but enough research to be confident in my choices.)
Being completely candid, Terry, if I had been diagnosed as you were, even knowing how it would turn out over many years (knowing your history) I think I would have opted for curative treatment right away, probably surgery. Of course if you had taken that course we probably would not have this website, and we'd be the poorer for that.
Re: Things That Puzzle Me About PCa # 14 in an unlimited series
Hi Terry,
Interesting thoughts. I wonder if the answer still lies in the unknown. Or unproven to be more precise.
"There might be a very small risk of mutation from androgen dependent cells" to quote part of your post.
If I remember correctly, Dr. Strum has mentioned that for higher Gleason grades, using Casodex alone can/may/will encourage mutation of the androgen receptors. And usually we only have the hit & miss results from a biopsy to base a decision upon.So is a G6 definitely a G6 only ? Path. reports after surgery often suggest otherwise.
In the U.K., the medical world has shot itself in the foot before. Some years ago, nearly everyone who walked into a surgery was tested for cholesterol. If the result looked a bit high; they were put on a statin.( The ratio in cholesterol, which is the important figure was usually not tested ! )
Result has been various problems thought linked to long term statin use in younger people.
HRT was all the rage a decade or two ago. Again, health problems have been noted as a possible result.Prescribing HRT has quietly been reduced it seems.
Over-prescription of antibiotics is well known.
And so I wonder if this sort of thing may influence current thinking regarding such approaches of "managing" a problem.I guess only long term studies would help here.
Personaly I think the approach you suggest could be ideal for more elderly patients, for whom surgery , R/T etc . would be a large step to take. The difficulty I suspect would be in finding long term results. Many patients would die of something else.But I suggest that is the best result.
Perhaps when the stronger meds such as Abiraterone & MD3100 become available, a limited ( time ) application might be more successful with less risk of mutations ? For example, a six month course of more efficient blockade could yield better outcome, and yet would be more bearable than any continuous treatment.Just a thought.
Re: Things That Puzzle Me About PCa # 14 in an unlimited series
Well, Terry, more delicious food for thought.
As you are well aware, here in the good 'ol USA, we would have to work hard to see a medical oncologist who might suggest such a course of action/treatment. When I first was diagnosed, I read everywhere I looked that I should consult:
1. A urologist
2. A radiation oncologist
and
3. A medical oncologist...but probably this only after the disease had progressed so much that 1 & 2 could no longer play with it.
OK, I'm being a little facetious there, but really not that much. I doubt that many medical oncologists in the US even encounter many men with early PCa – the urologists/radiologists keep them in their corrals.
I am interested in what you think the implications for this are to Active Surveillance? If one subscribes to this opinion, is the early ADT attack necessary right away, or at what point does it become necessary? Roger from Indiana
Re: Things That Puzzle Me About PCa # 14 in an unlimited series
Terry,
I asked my onco about this very issue. He said that some do actually put this forward as a treatment strategy - but usually with older men. In my case, my relative youth would invite ADT resistance later on. He also mentioned that there's some evidence to suggest that long-term use of ADT (even on an intermittent basis) might encourage cells to become more aggressive (or perhaps he meant that it's the aggressive cells that survive.
Either way, the combination of age and aggressiveness, made me opt for radiation
Re: Things That Puzzle Me About PCa # 14 in an unlimited series
Terry,
Dr Bob Leibowitz in Los Angeles has been treating low risk patients with 13 months ADT3 for years and reports results equal to all other treatment options. He has published papers on his results that can be found on Compassionateoncology.com.
