 |
 | Home | Contact Us | FAQ | Search & Site Map | Link to Us |
 | Sign In | Join | Other 45 Sites in Network |
Medical Forum / Diseases and Disorders / Prostate Cancer / August 2006When to start Hormone Therapy?
My question for all of you fine people here is at what psa point to start H.T.? Also can there be a bounce in psa after salvage IMRT to drive my 0.6 up from 0.1 after approx. 10 mos. ? RP 9-04 PSA 0.1 approx 9 mos. 0.6 I finished 8 wks.of salvage IMRT 72gy in 9-05 PSA 0.1, 0.1 & 7-20-06 back to 0.6 Bad news--will repeat psa again. T3a g-7 with microscopic extension at the bladder. PSA before RP 9.9 age 72+ Uro wants to start H.T. after repeat psa. I don't know but, I don't want too. He also wants a new C.Scan . I don't think that's right either. I will seek a Oncologest for H.T. THANKS, ART > My question for all of you fine people here is at what psa point to > start H.T.? Also can there be a bounce in psa after salvage IMRT to [quoted text clipped - 11 lines] > either. I will > seek a Oncologest for H.T. THANKS, ART I don't know the answer to your question. I agree that you should consult a specialist oncologist who is experienced with hormone therapy for PCa. Some questions I would ask him are: How long is it likely to take before I experience symptoms if I do nothing? How long if I take HT? Ditto for dying of PCa. If he can't answer that because there isn't enough information, then ask him how long might it take to gather enough info? For example, he might need to see the PSA trend over a year or so before he can see how quickly it's rising. Or he might need to take a PSA test every 3 months and see how long it takes for you to reach a particular threshold. Ask if there is some PSA level above which you should definitely begin HT. I would also ask about non-prescription supplements. Does he think that lycopene (in tomato juice), pomegranate juice, vitamins C, D or E, selenium, EGCG (from green tea), or any of the other supplements proposed for PCa patients are worth taking in hopes of slowing down progression? A recent study much discussed on this newsgroup claimed that men drinking 8 ounces of pomegranate juice significantly slowed the rate of rise of PSA. In general, I agree with your cautious approach. HT has significant side effects. You don't want it if you don't need it. Experts seem to disagree about the best time to take HT. Some say to take it immediately and some say to wait. I would ask the doctor about his view of the pros and cons of each approach. I'm sure you can live for years before you will experience any symptoms. I hope the years are many and that your health is good. Alan On July 22, Arthur Johnson inquired about PSA "bump" post RT. Strum & Pogliano define the PSA "bump" as follows: "Approximately 35% of patients experience a temporary rise in PSA after first having a decline in PSA after completion of brachytherapy. This...has been defined as an increase of 0.1 ng/mL or greater above the preceding PSA level followed by a subsequent decrease below that level. The average time to the PSA "bump" is 18-20 months." _A Primer on Prostate Cancer_ 2nd ed., page 103. Note that the reference is to brachytherapy, not to IMRT. And a genuine "bump" is due to prostatitis Arthur also inquired about the point at which to resume or start ADT. Alan Meyer responded, in pertinent part: > Experts seem to disagree about the best time to take HT. > Some say to take it immediately and some say to wait. > I would ask the doctor about his view of the pros and cons > of each approach. > My favorite med onc, Strum, says: "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. The use of early ADT3 as advocated by our group (Scholz, Lam & myself) & also by Leibowitz & Tucker & also per the experiences of Myers & Tisman, all attest to the rational, logical endocrinologic approach to PC management." (Emphasis in original) The exact PSA test result at which to start is a matter of debate. I have selected my cutpoint, but it is personal to me and likely would not be suitable to others. I'll only say that it isn't very high. Regards, Steve J > My favorite med onc, Strum, says: > > "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. One solid exception is a pt who is reasonably likely to die of something else before his PC symptoms get severe. It's a crapshoot, with odds loosely defined by each pt's circumstances and choices strongly impacted by his priorities. I.P. > In general, I agree with your cautious approach. HT has > significant side effects. You don't want it if you don't need > it. Everyone, before starting HT, should read the drug manufacturer's insert. Don't trust the doc to reveal everything, or to tell the truth.. Some of the side effects have nothing to do with the prostate and/or the family jewels. Those drugs can be nasty with other parts of the body. Some have produced arthritis in otherwise healthy males. Visit http://www.fda.gov and do a search for the name of the HT the doctor plans to give. Also visit http://www.rxlist.com and look up the name of the drugs. > ... > Everyone, before starting HT, should read the drug manufacturer's [quoted text clipped - 9 lines] > HT the doctor plans to give. Also visit http://www.rxlist.com > and look up the name of the drugs. This is absolutely right. I got arthritic like symptoms in both hands after taking Lupron. When I read the label it said "joint pain" was quite common. I called up the company and asked if it was possible to get rheumatoid arthritis because of Lupron. They gave me a one word answer, "Yes" - offering no further ideas for what to do about it. Today, two and a half years later, I control the symptoms with lots of exercise for my hands. But I still wake up in the middle of the night with pain in the fingers and have to squeeze a rubber ball for a few minutes to get rid of it. Alan > I got arthritic like symptoms in both > hands after taking Lupron. When I read the label it said [quoted text clipped - 7 lines] > the middle of the night with pain in the fingers and have to > squeeze a rubber ball for a few minutes to get rid of it. An OT tip for those of you on statins for your cholesterol: they give tens of thousands of people worse, sometimes far worse, joint and muscle pain than Alan describes, no to mention mental problems, some severe. I.P. > An OT tip for those of you on statins for your cholesterol: they give > tens of thousands of people worse, sometimes far worse, joint and muscle > pain than Alan describes, no to mention mental problems, some severe. Crestor is one of the nastiest statins available. In addition to the joint/muscle problems I.P. describes, statins also react violently with anti-inflammatory and other meds. The sample packages a doctor may pass out do not mention any of these problems. > ... > Some questions I would ask him are: [quoted text clipped - 9 lines] > long it takes for you to reach a particular threshold. > ... Once you start taking HT, you won't be able to track the course of the disease until such time in the future when the PSA begins to rise again (if ever.) So, if the rate of rise of PSA is low enough that the PCa is not a threat to your remaining years, you won't know that if you're on HT. The HT will suppress the PSA. That's a possible reason for waiting long enough to find out just how active your cancer is. But I'm not doctor. This too is something to ask a medical oncologist about. Alan Hello Alan, Art is tracking PSA now after surgery and salvage RT and it is doubling in less than 6 months. If he undergoes ADT now and responds well he can go intermittent after a period of time. Sure there are Tx SEs, but one can't ignore the symptoms of PCa progression(which are very often ignored) that can ultimately be lethal. RalphV azustoo.org > Once you start taking HT, you won't be able to track the > course of the disease until such time in the future when the [quoted text clipped - 10 lines] > > Alan > Hello Alan, > Art is tracking PSA now after surgery and salvage RT and it is doubling > in less than 6 months. If he undergoes ADT now and responds well he can > go intermittent after a period of time. Sure there are Tx SEs, but one > can't ignore the symptoms of PCa progression(which are very often > ignored) that can ultimately be lethal. Good point. Some people who go on HT go on it for the rest of their lives. But you don't have to do it that way. As for the doubling time, I know that Art reported an increase from .1 to .6 in 10 months. But when the numbers are that low, are they reliable indicators of doubling time? Alan The problem with early recurrent PCa is that science is incapable through imaging techniques to detect micrometastatic deposits. In Art's case with no prostate gland after surgery, the detection of PSA is the best available early on. PSA is then an early warning system that something is happening while it is not visible by current imaging technology. Recognizing recurrence and deciding what road to take are two different and problematic situations for any one of us treated for PCa. If the 0.6 ng/ml is verified, in this case there is no doubt about recurrence after surgery and SRT. An increase from 0.1 to 0.6 is very small, but by using ultrasensitive PSA assays at least one study has demonstrated the significance of PSA changes in "the noise" of low PSA values. What to do and when to do in it such cases is a more difficult decision yet. As usual and with a high degree of uncertainty the final decision of what to do or not is left to the patient. Source: Shen S, Lepor H, Yaffee R, Taneja SS: Ultrasensitive serum prostate specific antigen nadir accurately predicts the risk of early relapse after radical prostatectomy. J Urol 173: 777-80, 2005. RalphV www.azustoo.org > > Hello Alan, > > Art is tracking PSA now after surgery and salvage RT and it is doubling [quoted text clipped - 11 lines] > > Alan > My question for all of you fine people here is at what psa point to > start H.T. . . . after salvage IMRT Of the four basic options -- right after RT or RP, when PSA rises, when mets are detected by tests, or when met symptoms appear -- the only ADT (HT) starting points oncologists agree on is when symptoms appear. Any earlier starting point is debated among the experts. I don't know when or whether I'll start it (I had RP 20 months ago), and have no specific, medical reason to pursue further treatment yet. I.P. > My question for all of you fine people here is at what psa point to > start H.T.? Also can there be a bounce in psa after salvage IMRT to [quoted text clipped - 11 lines] > either. I will > seek a Oncologest for H.T. THANKS, ART First thing I would do, Art, is buy a calendar with only 11 months in it. If I recall correctly, you were diagnosed in July '04, your PSA went up to 0.6 in July '05 and it's up again in July '06. But, enough of astrology.... Questions as you asked them: No, I don't think IMRT from September 2005 would cause a bump in July 2006. As a matter of fact, I don't recall anyone having a bump after IMRT. But, I could be wrong. Starting HT is a bigger decision than doctors like to make it out to be. I'm sure you have read, if you lurked over the last year, IP's constant dialogue ont he subject. Up to a point, he is dead on-balls accurate regarding the potential SEs and what they can do to a man in the short and long terms. But, the alternative might be that your PSA goes to 1.2 in three months, 2.4 in six, 4.8 in 9 and in your 75th year 9.6. Now on that, I am almost certainly wrong -- it could be better or worse. A jump from 0.1 to 0.6 might indicated a CAT Scan, or even a PET. Seeing an oncologist, at least as a second opinoin, is an excellent idea. But, take heart... You'll probably get the same replies.  SignaturePSA 16 10/17/2000 @ 46 Biopsy 11/01/2000 G7 (3+4), T2c RRP 12/15/2000 G7 (3+4), T3cN0M0 Neg margins PSA .1 .1 .1 .27 .37 .75 EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 Lupron 07/03 (1 mo) 8/03 (4 mo), 12/03, 4/04, 09/04, 01/05, 5/05, 10/05, 2/06, 6/06 PSA .07 .05 .06 .09 .08 .132 .145 Casodex added daily 07/06 Non Illegitimi Carborundum Hello Art, In a patient without a prostate (previous RRP) there can't be a classical bump in PSA as in those who have a prostate gland treated with radiotherapy. Based on the data provided: 1. You had a rapid recurrence after surgery(this increases the probability of systemic disease) 2. Your salvage ratiotherapy to the prostate bed yielded a PSA reduction that lasted a few months(not definined by the data). This PSA increase might be coming from residual disease in the prostate bed or from systemic disease. 3. Your present situation is probably very dependent on how fast the PSA doubling time(PSADT) is. A rapid PSADT (<6 months) should be your signal to start hormone suppression or other form of therapy that treats systemic disease as soon as possible. Although controversial, it seems that early versus delayed hormonal suppression has provided some survival benefits. Should your PSADT be reported in years, you could decide to just monitor your disease. Wish you the very best outcome. RalphV www.azustoo.org > My question for all of you fine people here is at what psa point to > start H.T.? Also can there be a bounce in psa after salvage IMRT to [quoted text clipped - 11 lines] > either. I will > seek a Oncologest for H.T. THANKS, ART Hi Ralph, We determined that due to microscopic ext. at the proximal margin the pc was local. To offer a cure IMRT was done. Right after psa was 0.1 3mos. later 0.1 & 6 mos. it was o.6 or approx.9mos. The rad. Dr. said it should go to 0.1 & stay there. The uro. said there is no cancer in the pros. bed, the cancer was killed. He did a DRE at every visit. So if it is systemic then I would end up with both local & distant disease. Thank you Ralph, Alan, IP and Steve. Art "So if it is systemic then I would end up with both local & distant disease." Art, in my personal opinion this state of affairs is far more prevalent than is recognized. Many men are heartbroken because they were diagnosed w/ a local recurrence (for instance, on DRE), had SRT, and recurred again. I agree w/ your uro that after RP and SRT, you're probably pretty well cleaned out down there. However, note that at .6 you are probably not going to have a palpable tumor even it if is local - we are still talking a very small mass of cells. Likewise, no usual scan like CT, MRI, or even ProstaScint is going to pick it up. Your residual local disease component was destroyed by the SRT w/ corresponding fall in PSA (but never to undetectable level) and a few months later the systemic component cranked up. [Dr. Judah Folkman's angiogenesis theory provides an interesting hypothesis for this phenomemon.] So you do have systemic disease and HT is the next weapon of choice. The main thing you have to consider is your general health and life expectancy. W/ the local component gone, you don't have to worry about urinary problems down the road so the bottom line is whether you will live long enough otherwise for the PCa to become a real problem in your life. Steve Kramer gave a PSA progression possibility but what he did not say is that you may very well be asymptomatic at those levels. If PCa is not affecting your life, who the hell cares what your PSA is? Bill Denton RP 2/12/02 PSA .93 Memphis > My question for all of you fine people here is at what psa point to > start H.T.? Also can there be a bounce in psa after salvage IMRT to [quoted text clipped - 11 lines] > either. I will > seek a Oncologest for H.T. THANKS, ART I am very far from an expert in such matters. But it seems to me you have to distinguish PSA bumps associated with radiation which occur when radiation is the primary method of treatment from when it is used as a secondary followup treatment. It is my guess that the situations are very different. Ask your doctor. As to your basic question, as others have indicated, there appears to be no real consensus among oncologists on the matter. > My question for all of you fine people here is at what psa point to > start H.T.? Also can there be a bounce in psa after salvage IMRT to [quoted text clipped - 11 lines] > either. I will > seek a Oncologest for H.T. THANKS, ART Art, Not sure if this has been said before - didn't have time to read all the posts. To me this would be a fairly easy decision. 1) you are 72+ with no symptoms. At your age there is a realitvely good chance that you'll die with PCa rather than from it. 2)You have exhausted all curative options. 3) H.T. is not a cure. It simply delays the advance until HT resistant PCa cells take over. They usually represent a more agressive strain, in the minority when you start HT (which is why it works and PSA plumits), and, with HT, they have no "competition". 5) H.T. may include some very unwelcome side effects. It's a crap shoot whether you will experience them. 6) Scrum is absolutely right when talking about curative measures. The question you have to answer is "will H.T. extend my life more now than if I wait until and if I develop symptoms. I'll bet no-one can or will offer you a hearty "yes" 7) IMHO you are a perfect candidate for "watchful waiting". Keep track of that PSA and if it really skyrockets or you develop symptoms, no matter how minor, rethink the decision. Meanwhile, outside regular PSA testing, forget the lousy PCa beast and enjoy your life. Pops, > Art, > 1) you are 72+ with no symptoms. At your age there is a realitvely good > chance that you'll die with PCa rather than from it. Well, maybe. He is not just any 72 year old, though. He is a 72 year old with RP, RT, and a PSADT <6 months. > 3) H.T. is not a cure. It simply delays the advance until HT resistant > PCa cells take over. They usually represent a more agressive strain, in > the minority when you start HT (which is why it works and PSA plumits), > and, with HT, they have no "competition". I am not sure about the "usually represents", "why it works"... that is opinion not shared by all. > 5) H.T. may include some very unwelcome side effects. It's a crap shoot > whether you will experience them. If he doesn't like the side effects, you can stop the ADT. No one is suggesting he get his balls cut off. Many men (maybe most?) have fine experiences with ADT. They find the side effects livable. My husband is one, and he is 49 years old. We are hoping that with good response, he can go off it in a year, but if it is two years, that's doable. If its never, well, better to live with ADT than die of PCa. Our opinion, certainly not necessarily anyone else's. My father in law died of untreated prostate cancer that went to his bones and brain. Now that was a nasty set of side effects from untreated prostate cancer. > 6) Scrum is absolutely right when talking about curative measures. The > question you have to answer is "will H.T. extend my life more now than > if I wait until and if I develop symptoms. I'll bet no-one can or will > offer you a hearty "yes" Anyone who ever offers a hearty yes when talking about prostate cancer treatment is probably a quack. > 7) IMHO you are a perfect candidate for "watchful waiting". Keep track I can't believe this. A PSA doubling time of <6 months and you think he is a perfect candidate for watchful waiting? What is your slant here? Do you believe that anyone age 72 should not get treatment for diseases? Or have you been in this situation yourself (age and all) and are speaking from your experience? It is STILL a personal weighing of options and choices. > of that PSA and if it really skyrockets or you develop symptoms, no > matter how minor, rethink the decision. Meanwhile, outside regular PSA > testing, forget the lousy PCa beast and enjoy your life. Pops, I don't care, personally, if Art gets ADT or not. However, his physician who went to school at least 12-14 years to become a specialist, and who has god-knows-how-many years of experience with this beast is making a recommendation based on his education and experience. There may be a reason for his recommendation. (Like, maybe, his data?) I'm getting tired of people who make ADT out to be a horror. Trust me, for some men, it is a cakewalk compared to RP and RT. My husband has had all three, and, for him, the ADT is the least of it. laurel > If he doesn't like the side effects, you can stop the ADT. At 72, that may not stop the SEs. I'd research those odds further at that age. > Many men (maybe most?) have fine experiences with ADT. Strum, many studies, many oncologists, many books, and the vast majority of ADT pts in this forum dispute that. > better to live with ADT than die of PCa. Nice slogan, but those aren't opposing choices, since ADT will not save our lives. In fact, the only way Art will benefit from ADT is if he gets mets with symptoms which are worse and/or longer-lasting than his ADT SEs. His ADT choice is not even close to a no-brainer. > [Art's] physician who went to school at least 12-14 years to become a > specialist, and who has god-knows-how-many years of experience with > this beast is making a recommendation based on his education and > experience. There may be a reason for his recommendation. (Like, > maybe, his data?) So why do so many oncologists lie (including major omissions) to their pts? e.g., 95% failed to address ADT-induced osteoporosis until recently. I think it's smart to question one's doctors and do the research Art is doing. Doctors and pts often have very different agendas. I.P. > Pops, > [quoted text clipped - 59 lines] > RT. My husband has had all three, and, for him, the ADT is the least > of it. Juniper, I am not against HT at all. It is still an alternative I may eventually have to consider. I'm only 2 years out after diagnosis at 59 and RRP at 60, and I haven't had to exercise the EBRT option yet. I am simply stating that HT is a life extender, NOT A CURE. Therefore it should be applied when that life extension is maximized with acceptable quality of life. That kind of thinking is not a strong point of MD's. They may be focused on minimizing the indicators (PSA), particulalrly when there are no symptoms. That is Strumms point of view; "the sooner the better". It's a good academic approach but may not be the most realistic. It's not always right and the data I have seen is inconclusive. In fact that data doesn't generally directly provide total survival time but tends to focus on remission time AFTER the start of HT. I note you're focused on doubling. I don't think I'm wrong when I read that he has had only one "out of limits" PSA reading. If it had gone to double digits I'd be more concerned. I would hope he would wait for a three-peat (at 1-3 month intervals) before proceeding unless the confirmed readings go totally squirrelly. There is a lot of research today dealing with "over-treatment" in particular with regard to older guys with this dad-gummed disease. Detection techniques are improving radically, but data regarding long term survival (not dying OF PCa) with versus without treatment in older folks is contaminated (old data) and inconclusive. Let's face it. We'd all like to live our lives out with all our "equipment" or at least with the best simulation of such. I personally often find myself depressed by my lack of physical sexual ability (desire is GREAT) which would seem to be permanent (WIllie is DEAD) and often wonder if I should have waited just a little longer and enjoyed a few more "wild oats". Academic - what's done is done. I know that I have found that a continuous focus on my disease can be depressing. The side effects (Wille) always bring those thoughts back. I'd rather they didn't. HT side effects may bring even more unwanted focus. I want to enjoy my remaining life, not spend it obsessing on the inevitable. That enjoyment may even be worth a few less years. I know I will do everything in my power to end a vegetative or painful survival. A lot of that thinking derives from faith and beliefs. With any cancer, treatment decisions are very personal. That is as it should be. I should have stated more clearly that my comments, then and now, reflect only how I would react to his conditions if they were mine. I wish him the best, as I am sure we all do..... > I want to enjoy my remaining life, not spend it obsessing on the > inevitable. That enjoyment may even be worth a few less years. I know I > will do everything in my power to end a vegetative or painful > survival. I hear that, especially when those "years" are more likely to be months . . . months ADT SEs rob MANY pts of anyway. I.P. Laurel, neither Pops nor I has suggested that Art never have HT - look at the topic of the thread - it is not "if" but "when." All Pops is saying, and I agree, is that at 72 it is very possible that his PCa will not advance during his lifetime to the point where the symptoms of the disease outweight the SEs of the Tx. The med-onc I saw at Vanderbilt said that he has a number of Pts w/ double-digit PSA and no symptoms. Since the verdict is still out on early vs. late, the current view is that you wait until clinical symptoms to start HT - so WW is not a crazy notion at all. And Pops said that Art should re-evaluate if PSA starts to take off. That's what I'm doing. Bill Denton RP 2/12/02 PSA .93 Memphis Current studies show that a fast doubling PSA (as Art has at <6 months) increases his risk of disease progression and death. The point is Art's PSA is taking off NOW. In the first place WW is a recognized option for diagnosed, untreated men. To use that term in his case is to confuse the issue for newly diagnosed men. In Art's case, follow up, monitoring disease, treatment result observation are the proper terms. Think of those men that are learning about the disease and how you and Pops confuse the issue for them when applying the term to treated patients. Sources: 1: Sengupta S, Myers RP, Slezak JM, Bergstralh EJ, Zincke H, Blute ML. Preoperative prostate specific antigen doubling time and velocity are strong and independent predictors of outcomes following radical prostatectomy. J Urol. 2005 Dec;174(6):2191-6. PMID: 16280762 [PubMed - in process] 2: Ward JF, Zincke H, Bergstralh EJ, Slezak JM, Blute ML. Prostate specific antigen doubling time subsequent to radical prostatectomy as a prognosticator of outcome following salvage radiotherapy. J Urol. 2004 Dec;172(6 Pt 1):2244-8. PMID: 15538240 [PubMed - indexed for MEDLINE] RalphV www.azustoo.org > Laurel, neither Pops nor I has suggested that Art never have HT - look > at the topic of the thread - it is not "if" but "when." All Pops is [quoted text clipped - 11 lines] > PSA .93 > Memphis Ralph, I was more defending the concept of WW or whatever you want to call it [how about salvage watchful waiting?] than taking a position on what Art should do. If his .6 PSA is confirmed by a repeat, he may very well conclude that it is taking off and start HT. However, note that Walsh et al. would probably not. You state that post-SRT PSADT is a predictor of disease progression and DEATH and cite 2 studies. The first deals w/ PRE-RP PSADT not post-SRT. The second, at least in the abstract I read, does not stratify mortality. It does say that mets are more likely sooner w/ a PSADT <12 mos. but not whether the guys who died were the ones w/ the quicker PSADT. That seems logical but cannot be assumed. Indeed, as to recurrence after SRT, more of the ones w/ quicker PSADT recurred w/i 5 years but at 10 years there was no statistical difference: "Biochemical disease-free rates at 5 years for PSADT less than 12 or 12 months or greater was 48% and 66%; respectively (p = 0.080). By 10 years there was no significant difference in biochemical disease-free rate (34% vs 35%)." I think the moral of the story is that if you have advanced PCa it will kill you if you live long enough no matter what you do. What you do might change the timing a bit - but that's about it. :-( Bill Denton RP 2/12/02 PSA .93 Memphis Bill, Your defense of the concept of WW was what prompted me to clarify the situation. It is not what I want to call it. WW is defined in the medical literature as an option for untreated, diagnosed PCa patients. You might think that this fine line is not worth to talk about. I respectfully disagree because it is important to understand the possible consequences to a newly diagnosed man who is looking for his options. In my original post to Art I was trying to clarify his situation and said: "Your present situation is probably very dependent on how fast the PSA doubling time(PSADT) is. A rapid PSADT (<6 months) should be your signal to start hormone suppression or other form of therapy that treats systemic disease as soon as possible. Although controversial, it seems that early versus delayed hormonal suppression has provided some survival benefits. Should your PSADT be reported in years, you could decide to just monitor your disease." My intent was not to urge him to undergo HT immediately. The intent was for him to understand the possible risk associated with his recurrence situation if the PSADT was < 6 months. The references provided apply because once a patient has the prostate gland removed there should never be PSA detected or as is in his case after a salvage treatment applied later. RalphV www.azustoo.org > Ralph, I was more defending the concept of WW or whatever you want to > call it [how about salvage watchful waiting?] than taking a position on [quoted text clipped - 22 lines] > PSA .93 > Memphis Ralph, we are not in disagreement. I am in the same boat as Art except I did not have SRT because I heeded the warning signs and not traditional wisdom. For early systemic disease PSA is about all we have but we always need to focus on the disease and not PSA. My point is that many, if not most, 72 y.o. men will die of something else before their PCa causes them significant problems irrespective of what their PSA is. The problem I had w/ your post was that you stated that the studies cited predicted DEATH based on post-SRT PSADT when they do not. Seems like mortality is something most studies stay away from and I am aware of relatively few that try to predict it. I just don't want to have people getting freaked out about dying when they shouldn't. Bill Denton RP 2/12/02 PSA .93 Memphis Bill, I do not think we are in agreement. I am not evaluating personal preferences. Each patient must do what they consider best for themselves. That said, individuals with elevated PSA measurements after radical surgery have disease recurrence. If PSADT is reported in years, that patient has the option to just observe his disease without any further treatment. If PSADT is very short as is the possibility with the case under discussion, studies demonstrate that the risk of progression and death increase for such patient. That is a piece of statistical data. The fact that most 72 yo men die with PCa rather than of PCa is irrelevant. Again, you imply that the study cited does not apply to the current case. It does for the simple reason that surgical patients should not demonstrate positive PSA levels as they do not have tissues that secrete such amounts of PSA. If a level of PSA of 0.6 ng/ml is verified, that has to correlate to prostate cancer tumor volume. If Art's PSADT continues at the same rate it is important for the him to understand the risk. What he does with the information is his choice. RalphV www.azustoo.org > Ralph, we are not in disagreement. I am in the same boat as Art except > I did not have SRT because I heeded the warning signs and not [quoted text clipped - 14 lines] > PSA .93 > Memphis Ralph, I am a lawyer and I know how to use and check citations to authority. Suffice it to say that neither of those studies stand for the proposition for which you cite them. It goes w/o saying that Art realizes that his rising PSA means that he still has PCa, as do I, and that if he lives long enough it will kill him - that is why he asked us when to start HT. All I said is that it is possible that, despite his fast PSADT, and despite the PSA level he may have at any given time, he could possibly go for years w/o clinical symptoms. We've had men here w/ PSA in double digits w/o symptoms, and my Vanderbilt med-onc has similar Pts. Indeed, despite the fact that my last PSA rose from .6 to .93 in 3 mos., he told me he would not start HT until it doubled a couple of times in 3 mos. in whole nos. Your implication is that Art is at risk of death if he does not start HT now. Now don't you think that is a bit extreme? "In the first place WW is a recognized option for diagnosed, untreated men. To use that term in his case is to confuse the issue for newly diagnosed men." That is the most prevalent use but not exclusive. Just today I was in my uro's office having blood drawn for my next PSA and picked up a book 100 Questions and Answers about Prostate Cancer by Ellsworth, Heaney, and Gill (2003). In the chapter on recurrence after RP they have a section on WW. So, I'm not the only one who uses that term at stages other than after initial Dx. WW means foregoing Tx for a time while monitoring disease progression - and that could apply at any stage. Bill Denton RP 2/12/02 PSA .93 Memphis Bill, If Art realizes that he still has PCa, why is he asking if his PSA elevation is related to a RT "bump"? It might be clear to you w/o saying, but that doesn't sound that he has it clear in his mind. Don't you think? You said: " Your implication is that Art is at risk of death if he does not start HT now. Now don't you think that is a bit extreme?" I did say that a short time PSADT has a higher risk of progression and death. That is quite different of what you imply above.Those are statistics based on studies done. I never told him to start HT now. What I did was to provide information to him and to clarify that his PSA elevation was recurrence and not a bump. Don't you think that you are misinterpreting my intent? Enough said... RalphV www.azustoo.org > Ralph, I am a lawyer and I know how to use and check citations to > authority. Suffice it to say that neither of those studies stand for [quoted text clipped - 29 lines] > PSA .93 > Memphis Hi Ralph, I am very aware that I have had a second reoccurence of PC. You are very kind to want to be certain I know my PC is serious. My reason for the bounce question was after IMRT my psa went down again & was less than 0.1 & stayed there until my 9th. mos. psa 0.6 To me that sounds like the pc was zapped. My NEW PSA this week is 0.5 down 1/10 Either a lab error now, before or both. My URO is very short when questioned on certain matters. This is hard on me. But I will work with ONO.. & RAD. DR. to find the best treatment. I also will use my own judgement. I have printed each & every E-mail so I can highlight everything to keep it all in order. I am so very appreciative of the advice I have received from everyone. This will help me get through the most difficult time in my life. Please read my post on July 27th. Thanks, Art > Hi Ralph, > I am very aware that I have had a second [quoted text clipped - 6 lines] > with ONO.. & RAD. DR. to find the best treatment. I also will use my own > judgement. Sounds like you're tracking very close to mine, thought my EBRT wasn't as successful as your IMRT. Regardless, you're close enough to realize that your prognosis (now) should be close to mine (circa July 2003) and probably better. Your decision is visit more specialized docs is a good one. SignaturePSA 16 10/17/2000 @ 46 Biopsy 11/01/2000 G7 (3+4), T2c RRP 12/15/2000 G7 (3+4), T3cN0M0 Neg margins PSA .1 .1 .1 .27 .37 .75 EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 Lupron 07/03 (1 mo) 8/03 (4 mo), 12/03, 4/04, 09/04, 01/05, 5/05, 10/05, 2/06, 6/06 PSA .07 .05 .06 .09 .08 .132 .145 Casodex added daily 07/06 Non Illegitimi Carborundum > Hi Ralph, > I am very aware that I have had a second [quoted text clipped - 13 lines] > Please read my post on July 27th. > Thanks, Art The reduction from .6 to .5 is great news. There may have been an error in one of the readings, or it may have been a very tiny variation that was almost, but not quite, undetectable, for example from .55 reported as .6, to .549 reported as .5. We don't know for sure that there is any significant difference in the readings. It's also possible that your PSA varied by a tenth of a point. There are natural factors that cause PSA variation in prostate tissue. With the 157 gram prostate you reported in your July 27 post, it's conceivable to me that there is some prostate tissue that the surgeon didn't reach and it's following the usual variations in PSA output that prostate tissue does. Whatever the case, we do know that the PSA did not increase, and that is terrific news. Unless the experts, i.e., the specialist doctors you are seeing strongly advise otherwise, I'd be inclined to hold off on HT. And I have one other important piece of advice. Don't forget to live your life! Smell the coffee. Look at the landscape. See some movies. Enjoy your friends and family. Do some volunteer work. We all know that we're getting on in years. If the PCa doesn't get us, something else will. So let's not spend all our time obsessing about it. Let's get on with the real business of living. I sometime think that Curtis, Dave, and the others who post jokes on this newsgroup shouldn't mark them Off Topic. Maybe we need jokes as a direct part of our response to cancer. Alan > Hi Ralph, > I am very aware that I have had a second [quoted text clipped - 13 lines] > Please read my post on July 27th. > Thanks, Art ART, There's alot of emotion here so lets be specific. HT is simply medical castration. It knocks your testosterone production down to nothing. A certain percentage (hopefully 100%) of your PCa cells require testosterone to "prosper". They are starved and die. It is known, however, that there are certain types of PCa cells that don't need testosterone to "flourish". How many have you got? Your guess is as good as mine. You'd prefer to as close to zero as possible as PCa is generally slow growing, and the older you get the slower it grows (that's true of most, if not all, PCa cell types). That numbers game is hard to play, but that's what you've got to deal with. NOW. Remember what I said about HT being medical castration? Think of it that way because you'll be loosing your primary male hormone. Perhaps you can't "perform" any more after RP. With HT you likely simply won't care. Your last test came back lslightly lower. You have not establised a solid trend with respect to PSA acceleration. My recommendation - wait another three months. Get another test. If it's stable, defer to 6 months. If it's risen (and hasn't gone completely wacko) wait another three months and get three in a row to establish a trend. If the trend (high doubling is confirmed) reconsider HT. Other wise keep testing and watching until it has. As far as your fear of death: Somebody here said you'll die from PCa if you live long enough. That's absolutely true, but it's a bit out of context. People don't just die of "old age". Everybody dies of something. Something goes wrong and can't be treated. One of the big problems with medical statistics is that those "old age" deaths are included in the diseases that caused them. IMHO that unfairly biases the data. Wer'e gonna die. Period. By the way, virtually all men who die of "old age" and are autopsied, have PCa at some level. It may not have killed 'em, but it was there. Again, my recommendation. Don't fixate on dying. Fixate on living with a high level quality of life. When your living goes below an acceptible quality then you have new decisions to make. Unitl then, ENJOY!! I haven't seen that subject dscussed on this forum. That is the subject of stubbornly maintaining life even when its quality is miserable or non-existent. I know it's part of the physician's creed. I personally think it's bull. Of course faith plays a big part. As for me, I just can't shake the notion that this thing called "me" is more than a (now rapidly deterirotating - haha) body. I'm ready to move forward and be eager to see what's in store when the time comes... Pops, Been on HT for 29 months. Testosterone is less than 1. I still think about sex and I can still perform. It's all in one's head I'm telling you. :) >> Hi Ralph, >> I am very aware that I have had a second [quoted text clipped - 68 lines] > rapidly deterirotating - haha) body. I'm ready to move forward and be > eager to see what's in store when the time comes... > Pops, > [quoted text clipped - 75 lines] > > rapidly deterirotating - haha) body. I'm ready to move forward and be > > eager to see what's in store when the time comes... MAS, Hooray for your head (no pun intended)! A lot depends on when one becomes a unick (SP?). > HT is simply medical castration. Or as my uro called it, "chemical castration." I took one treatment, had horrible reactions, and never returned. I went to the FDA's site http://www.fda.gov and a drug site http://rxlist.com and discovered some of the other side effects that the doctor had never mentioned. Ralph, I think your premise - that a fast post-SRT PSADT indicates an increased risk of death - is probably correct in the long run, but, despite your stating it is a statistic, you have yet to cite a single study that comes to that conclusion. I just don't think any of us should state something as fact when it is really our personal theory. The fact that Art's PSA actually dropped a bit proves the soundness of Pop's and my suggestions that he should wait and watch it for awhile until there is a definite trend. BTW Art, I would insist on ultrasensive PSA testing - you are dealing w/ numbers so small that rounding to the nearest tenth introduces a huge error. E.g. your .6 could have been a .55 and your .5 could have been a .54 - virtually no change. Or the .6 could have been a .64 and the .5 .45 - a 14% drop. If your doctor balks, tell him to just humor you. Bill Denton RP 2/12/02 PSA .93 Memphis Bill, It is not my personal theory. I am glad that Art retest denotes stability, but unfortunately it doesn't mean much since analytical test variability is within the limits of the results. One fact is that his PSA at 0.5 or 0.6 is a sign of recurrence after his treatments. No one can predict what course Art's disease will follow. He has a high probability of harboring systemic disease as indicated by the presence of a PSA after surgery and salvage radiotherapy. His response to ADT, if he ever decide to initiate that treatment, will depend on the nature of his residual disease and how androgen dependent it is. The important thing is that he be aware of his options and makes decisions based on his priorities. That was the intent when posting to Art. The fact that many studies support the notion that a rapidly increasing PSA can be the result of metastatic progresion after primary treatment and that rapidly progressing metastatic disease is the form of PCa that kill most men these days is significant for men facing this situation. It is definitily not my theory or an invention of mine. Here are some references that link shorter PSADT with a higher risk of death: D'Amico AV, Cote K, Loffredo M, Renshaw AA, Schultz D. Determinants of prostate cancer-specific survival after radiation therapy for patients with clinically localized prostate cancer. J Clin Oncol. 2002 Dec 1;20(23):4567-73. PMID: 12454114 [PubMed - indexed for MEDLINE] Slovin SF, Wilton AS, Heller G, Scher HI. Time to detectable metastatic disease in patients with rising prostate-specific antigen values following surgery or radiation therapy. Clin Cancer Res. 2005 Dec 15;11(24 Pt 1):8669-73. PMID: 16361552 [PubMed - indexed for MEDLINE] RalphV www.azustoo.org > Ralph, I think your premise - that a fast post-SRT PSADT indicates an > increased risk of death - is probably correct in the long run, but, [quoted text clipped - 17 lines] > PSA .93 > Memphis Like I said, Ralph, I think your premise is correct. But these latest studies are not what we [lawyers] call "directly on point." The first deals w/ recurrence after RT as primary Tx -not post-SRT. Of possible interest to Art, and support for Pops and me, is the finding that: "Despite the median age of 73 years at diagnosis, 45% of patients with high-risk disease were estimated to die from prostate cancer within 10 years after RT...." The other side of that coin is that 55% of them were still alive at a median age of 83! So, on average, if you don't think you will live another 10 years anyway, why screw up your remaining life treating PCa? Likewise, the second study also deals w/ recurrence after primary Tx. I have no reason to doubt that the several factors, of which PSADT was only one, that correlated to disease progression after primary Tx also correlate to disease progression after salvage Tx - but these studies don't say it. Let's talk about PSADT. First of all, if you are using PSA to determine disease progression, then PSA doubling is a self-fulfilling prophesy. The second study cited found a correlation between PSADT and post-primary Tx time to metastasis, but just about everything else correlated too! The earth-shaking [not] conclusion - the sicker you are, the sicker you are liable to become sooner. Wow, imagine that. I cannot argue w/ the premise that a man whose PSA is increasing at a relatively fast rate is liable to reach the point where he is symptomatic and where PCa affects his daily activities. What I can and do argue is that that point in many cases will not come before the man dies of something else. There was a study discussed here recently where it was clear that the biggest threat to many men w/ advanced PCa was other diseases. A fast post-SRT PSADT is not a good thing and deserves close monitoring. It does not mean that you need to jump immediately into ADT. Unless you adhere to the minority view that early is better than late, there is nothing ro be gained by jumping into it other than treating your PSA. I simply say that for a 72-year old man, who may have other serious health issues, it is not unreasonable to hold off on ADT for a little while and see what happens. I'm 55 and that's what I've done. Bill Denton RP 2/12/02 PSA ? Memphis Bill, There is nothing "directly on point" with prostate cancer so take your profession out of the equation. What you do with your disease is your business, but don't tell the folks out there that it is my theory and it has no support because you decide to classify a study as "not directly on point". The point is that Art failed prostatectomy and salvage radiotherapy so that he must consider that these studies and many others out there apply to his situation. More so when the failure is double. There is no sense to keep beating this matter since you consider the conclusions of the second reference rediculous by saying: "The earth-shaking [not] conclusion - the sicker you are, the sicker you are liable to become sooner. Wow, imagine that." Guess what, a rapid primary treatment failure and a rapid salvage treatment failure ARE earth-shaking events to the person that has experienced them irrelevant of what your opinion is! Let's move on... RalphV www.azustoo.org > Like I said, Ralph, I think your premise is correct. But these latest > studies are not what we [lawyers] call "directly on point." The [quoted text clipped - 37 lines] > PSA ? > Memphis Ralph, I agree we've adequately hashed this one out and should move on. Well, almost. FWIW a study "directly on point" would simply determine the correlation between post-SRT PSADT on clinical [taking out the self-fulfilling aspect] disease progression and mortality. Bill Denton RP 2/12/02 PSA ? Memphis Glad that we agree...as to the hashing that is. Your definition falls short by the lack of a requirement for a controlled randomized clinical trial to really be "directly on point". RalphV www.azustoo.org RP 6/29/92 Orchiectomy 9/9/92 PSA <0.03 ng/ml Geez, man, where did I say ANYTHING about methodology? I didn't say the lab techs would wear white coats either. The first step is to determine the objective - and that's all I defined. Anyway, this kind of study could probably be done retrospectively using randomized already-existing data. Bill Denton RP 2/12/02 PSA ? Memphis Thanks to everyone for responding. Your combined time & effort has been most helpful in my decision making process. Each opinion, questions to ask & your discussion between yourselves have made it possible. I do understand what everyone has stated & that helps. Made appt. with Rad. Dr. & Oncologist. Will see Uro. next wk. My NEW PSA was down to o.5 from o.6 Can't tell if a lab error was made now or before .Maybe this will be one for the W.W. group, I hope so. My health is good & I understand the debate on quick rising psa. My pre RP was 9.9 but was in the low 9.1 way back in 95. Had a few jumps but always came back down. Very large prostate 157 grms. lymph nodes negative. My worse fear is dying of PC. & it has me very scared. Also HT. is a big worry. Caught in the middle. Thanks very much art. > My worse fear is dying of PC. & it has me very scared. Also HT. is a > big worry. Hey, look at it this way: if you go on HT, you get BOTH, unless HT buys you time to die of something more pleasant first . . . which is always an option ANYway. Worrying helps far less than HT does, and may even have worse SEs. Gotta stop that stuff and devote that time and energy to things more productive or fun. I.P. RE: Point 2 To write that Art has "exhausted all curative options" is an issue that simply can not be made. Now if you wrote that according to the FDA and ACA, cure is no longer an option, then I would not be opining. OK, the primary treament failed, but does not mean that Art can not still shoot for curative treatment. There are options out there. Art would be wise to consult with a Medical Oncologist that specializes in Prostrates. Gourd Dancer >> My question for all of you fine people here is at what psa point to >> start H.T.? Also can there be a bounce in psa after salvage IMRT to [quoted text clipped - 40 lines] > matter how minor, rethink the decision. Meanwhile, outside regular PSA > testing, forget the lousy PCa beast and enjoy your life. |
Reply to this Message |
 Sign In
 Join
 My Latest Posts My Monitored Threads My Blog My Photo Gallery My Profile My Homepage Start New Thread Enable EMail Alerts Rate this Thread
|
©2008 Advenet LLC Privacy Policy - Terms of Use
This website includes both content owned or controlled by Advenet as well as content owned or controlled by third parties.