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Medical Forum / Diseases and Disorders / Prostate Cancer / November 2006Survival Advantage for Additional Hormone Therapy After Radiation for
Survival Advantage for Additional Hormone Therapy After Radiation for Men with Aggressive Locally Advanced Prostate Cancer November 8, 2006. The largest study examining the benefits of long-term use of hormone therapy after radiation treatment for prostate cancer shows men with aggressive locally advanced disease live longer if hormones are used for an additional 24 months. Research also showed other significant benefits for those with less aggressive cancers who receive hormones. The study results were presented at the Annual Meeting of the American Society for Therapeutic Radiology and Oncology in Philadelphia. The study, sponsored by the Radiation Therapy Oncology Group (RTOG 92-02), reports more than 10 years of data involving the use of androgen deprivation after radiation therapy in a phase III, multi-center study led by Gerald E. Hanks, M.D., who served as chairman of radiation oncology at Fox Chase Cancer Center from 1985 to 2001. (Hanks is a 2006 ASTRO Fellow). The study included 1,554 men with locally advanced prostate cancer. Everyone received approximately four months of hormone therapy (goserelin and flutamide) before and during their radiation treatments. After radiation treatment, the patients were randomized into two groups: to receive additional hormones (24 months of goserelin) or to receive no further hormone therapy. Patients received conventional external beam radiation. Median follow-up was more than 10 years for both groups. "At 10 years, the men receiving an additional 24 months of hormones showed significant benefit over those not taking additional hormone therapy," said Hanks. "The survival benefit was not present for the overall group, but became apparent when subgroups were analyzed," explained Hanks. The study showed a benefit in the following areas: disease-free survival (13.2 percent vs. 22.5 percent), disease-specific survival (83.9 percent vs. 88.7 percent), local progression (22.2 percent vs. 12.3 percent), distant metastasis (22.8 percent vs. 14.8 percent), and biochemical failure (68.0 percent vs. 51.9 percent). Hanks added, "All men with aggressive cancer (Gleason score of 8 to 10) who received hormone therapy showed a survival benefit of 31.9 versus 45.0 percent as well as other significant endpoints." Fox Chase Cancer Center was founded in 1904 in Philadelphia, Pa. as the nation's first cancer hospital. In 1974, Fox Chase became one of the first institutions designated as a National Cancer Institute Comprehensive Cancer Center. Fox Chase conducts basic, clinical, population and translational research; programs of prevention, detection and treatment of cancer; and community outreach. For more information about Fox Chase activities, visit the Center's web site at www.fccc.edu . American Society for Therapeutic Radiology and Oncology: astro.org For more information on radiation therapy for prostate cancer, visit http://www.rtanswers.org. knowledge is power - growing old is mandatory - growing wise is optional "Many more men die with prostate cancer than of it. Growing old is invariably fatal. Prostate cancer is only sometimes so." http://community.webtv.net/PALMER_ENT/doc > November 8, 2006.— The largest study examining the benefits of > long-term use of hormone therapy after radiation treatment for prostate > cancer shows men with aggressive locally advanced disease live longer if > hormones are used for an additional 24 months. > The study showed a benefit in the following areas: disease-free survival > (13.2 percent vs. 22.5 percent), disease-specific survival (83.9 percent [quoted text clipped - 5 lines] > who received hormone therapy showed a survival benefit of 31.9 versus > 45.0 percent as well as other significant endpoints." Am I reading these figures correctly? I understand 'em this way: 1. 13.2% vs 22.5% disease-free survival means RT w/o 2 years' extra ADT "cured" only about 1 of 8 (13.2%) as of 10 years, and the extra ADT helped only another 1 in 11 (22.5% minus 13.2%, or 9.3%) at the 10-year point. 2. 83.9% vs 88.7% disease-specific survival means about 1 of 9 (88.7%) died of PC by 10 years w/o extra ADT, and the extra two years of ADT "saved" only another 4.8%, or another 1 in 21, @ 10 years. 3. 22.2% vs 12.3% local progression means 1 in 10 was spared local recurrence @ 10 years by the extra ADT. 4. 22.8% vs 14.8% distant mets means the ADT spared about 1 in 12 from distant mets @ 10 years. 5. 68% % vs 51.9% biochemical failure means the extra ADT cut PSA recurrence in about 1 in 6 pts @ 10 years. 6. 45% vs 31.9 survival benefit for G8-10 pts means 13%, or 1 in 8, were spared by the extra ADT. Man . . . these numbers mean our overall odds of benefiting from two years' extra ADT are something like 0.1 -- maybe 0.2 max if local and distant mets are always in different pts. I hope doctors quoting this study to sell their RP pts on preemptive adjuvant ADT will also quote these benefit figures, at least to the pts who were hit hard by their initial 4 months of ADT with the RT. Many pts who had experienced severe ADT SEs would have a hard time accepting 24-30 more months of certain SEs to gain mathematically slight odds of benefit. I.P. > ... > Man . . . these numbers mean our overall odds of benefiting from two years' extra ADT [quoted text clipped - 6 lines] > > I.P. I found the numbers pretty confusing. But leaving the confusion aside, I think there's one sense in which your interpretation of them may be missing something. One way to think about the numbers is not, how much does it affect my ability to live 10 years, but how many months does it add to my life. It _may_ be (I sure can't tell from the abstract) that some patients with aggressive cancer who would have lived 7 years live 8 years or 9 years with the additional ADT. If you look only at the 10 year survival rate, it looks like ADT didn't help them. But in fact it gave them one or two extra years of life. Is that worth it? As you say, that's an individual decision. Alan > One way to think about the numbers is not, how much does it > affect my ability to live 10 years, but how many months does it > add to my life. That was my greatest concern, too, two years ago and yesterday when I saw this. The adjuvant ADT dilemma depends more on what it adds and subtracts to our life's experience than on the likelihood of PSA returning within 10 years. > If you look > only at the 10 year survival rate, it looks like ADT didn't help > [those with advanced grades]. But in fact it gave them one or two extra years of life. I didn't see that in Curtis's post, where the extra ADT gave 1 in 8 pts some unspecified life extension across the 10-year barrier. The other 87% may have gained a year or a month or even have lost some time; did the source study expand on that? One virtually certain significant loss, measured in months, is to the extra sleep required by ADT pts. After all, the primary difference between daily sleep and the eternal dirt nap is that we awake from the former. I.P. > ... > > If you look [quoted text clipped - 9 lines] > all, the primary difference between daily sleep and the eternal dirt nap > is that we awake from the former. You're right I.P. It was not in the post. It is purely my speculation. However if the number of people living 10 years increases with ADT, and if other survival and disease free statistics improve, it seems likely that ADT provides some average extension of time. The "one or two years" in my post was just meant to be an example. It may be one or two months, or it may be two or three years. We don't know. Alan > it > seems likely that ADT provides some average extension of time. > The "one or two years" in my post was just meant to be an > example. It may be one or two months, or it may be two or > three years. We don't know. Maybe I'm kidding myself, but I think I'd find lifetime extension statistics more useful than live-or-die ten-year survival odds. I assume/hope the study will run to at least 15 years to provide that kind of data. I.P. >> it >> seems likely that ADT provides some average extension of time. [quoted text clipped - 6 lines] > assume/hope the study will run to at least 15 years to provide that kind > of data. And there will be big variables. You won't know which variable you would be in :-) Not worth worrying about - get on with enjoying today! Mary >> Maybe I'm kidding myself, but I think I'd find lifetime extension >> statistics more useful than live-or-die ten-year survival odds. I [quoted text clipped - 5 lines] > > Not worth worrying about - get on with enjoying today! Yeah, right. Just stick one's head in the sand, ignore the options that can or may add years or decades to one's life and/or ruin what's left of it, and just go shopping or skateboarding. THAT makes sense. I.P. >>> Maybe I'm kidding myself, but I think I'd find lifetime extension >>> statistics more useful than live-or-die ten-year survival odds. I [quoted text clipped - 9 lines] > can or may add years or decades to one's life and/or ruin what's left of > it, and just go shopping or skateboarding. THAT makes sense. I think so. I'm still alive and kicking after a brain tumour and breast cancer, Spouse is after a heart attack (22 years ago). He expects to be for, ooh, could be easily the best part of some time :-) Why worry? If you worry you die. If you don't worry you still die. Mary > I.P. > Why worry? "Worrying" and "researching one's options and choosing the best treatment" are hardly related. Using nomograms are part of the latter. > If you worry you die. > > If you don't worry you still die. Yep. But if you don't choose a valid treatment option, you may well die unnecessarily. I.P. >> Why worry? > [quoted text clipped - 7 lines] > Yep. But if you don't choose a valid treatment option, you may well die > unnecessarily. We've always trusted our surgeons to give us the best treatment for our particular circumsances. They know far more than we can ever know. They haven't failed us. > We've always trusted our surgeons to give us the best treatment for our > particular circumsances. They know far more than we can ever know. They > haven't failed us. Congratulations. You've been very, very, very, VERY fortunate, living far closer to the fringes of the Bell curve than many of the pts here with horror stories about the BS their physicians sold them and the vital info they omitted and than studies have shown. I.P. >>> If you worry you die. >>> If you don't worry you still die. >> Yep. But if you don't choose a valid treatment option, >> you may well die unnecessarily. What is "unnecessarily? We're all going to die someday. What is our date on the perpetual calendar? > We've always trusted our surgeons to give us the best > treatment for our particular circumsances. I did, until I had the reaction from Lupron. Then I realized I wasn't getting the best advice for the circumstances. > They know far more than we can ever know. Why don't they share that knowledge with patients? > They haven't failed us. #1 uro and his office staff had the worse manners I've ever run into. And his exam rooms leave much to be desired. #2 uro screwed around and screwed around with me. #3 (after #2 retired) refused to listen to patients. Twice he referred me to a treatment center after I had twice told him I couldn'd trust the place. The * only ** treatment they know is radiation. Any coincidence that they're related to the cancer center that is trying to pay off its purchase price for all its equipment? The oncologist (I had never heard the term until August) I'm now seeing listens, doesn't attempt to shove, explains what a patient needs to know/hear, is very encouraging, hands out literature that is neither pro nor con toward any treatment. >> it >> seems likely that ADT provides some average extension of time. [quoted text clipped - 6 lines] > assume/hope the study will run to at least 15 years to provide that kind > of data. I'm hoping I can read the 15-year results of those studies occurring now.  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 PSA <0.04 Non Illegitimi Carborundum > Survival Advantage for Additional Hormone Therapy After Radiation for > Men with Aggressive Locally Advanced Prostate Cancer The title of another paper delivered at the same conference says it all Six Months of Androgen Deprivation Therapy Added to Surgery or Radiation as Effective as Two Years for Prostate Cancer Patients's Survival Which paper is correct, could they both be correct? Were the underlying populations, or some other key factor, different enough to produce one result in experiment A and another result in experiment B? Hopefully the authors will sort through such questions over time. But for the time being it seems like there's little real information for the PCa patient to walk away with...ron > > Survival Advantage for Additional Hormone Therapy After Radiation for > > Men with Aggressive Locally Advanced Prostate Cancer [quoted text clipped - 11 lines] > for the time being it seems like there's little real information for > the PCa patient to walk away with...ron My reading of the study report is that there were only two groups in the study, 4 months of ADT vs. 4 months + 2 years. No patients were randomized to 4 months + 6 months in that particular study. So both papers could be correct. But the paper you cite, assuming that it has a sufficiently valid sample size and study design, gives us additional information. If I thought that study were valid I would just take the 6 months of ADT (or maybe it's 4+6 months?), not the 2 years. Alan Also reported on the same day, at the same conference is the following. It's not a contradiction, but just the opposite for different circumstances. > Survival Advantage for Additional Hormone Therapy After Radiation for > Men with Aggressive Locally Advanced Prostate Cancer ........................................................ Excess Mortality Seen Among Prostate Cancer Patients on Long Term Androgen Deprivation Therapy: Presented at ASTRO By Ed Susman PHILADELPHIA, PA -- November 9, 2006 -- In a surprise finding, a retrospective study suggests long-term use of anti-male hormone drugs increase the risk of mortality among patients who were at high risk for recurrence of prostate cancer, doctors said here at the American Society of Therapeutic Radiology and Oncology (ASTRO) 48th annual meeting. "More than 6 months' treatment with these androgen deprivation drugs appears to double the risk of mortality in these patients," said Cliff Robinson, MD, resident in oncology, The Cleveland Clinic, Cleveland, Ohio. Dr. Robinson and colleagues reviewed the charts of 579 men treated for prostate cancer at the Cleveland Clinic between the years 1998 and 2003. "Specifically, we were looking for ways to improve outcomes of high risk patients," said study co-author Chandama Reddy, MS, biostatistician, The Cleveland Clinic. "We weren't looking to find something wrong with anti-hormone treatment, but these numbers just jumped out." Dr. Robinson said that the 5-year survival after definitive treatment for prostate cancer among the 153 high-risk individuals who had not received any post-procedure treatment was 92%. Among the 351 patients who received anti-hormone treatment for 1 to 6 months, the survival rate was also 92%. But among the 74 patients who took the anti-hormone treatment for longer than 6 months, the survival was 76% (P = .0007). "That's a significant difference," Dr. Robinson said. In addition, Jay Ciezki, MD, staff physician, The Cleveland Clinic, and another co-author of the study, said that with or without hormone therapy there did not appear to be any impact on prostate cancer recurrence. The group's poster was presented November 8th. Patients in the study had all undergone surgery to remove the prostate or radiation therapy to kill the cancer, either with external beam radiation sources or brachytherapy, the insertion of radioactive pellets into the prostate gland. Before any treatment was performed, the men who were considered to be at high risk for prostate cancer recurrence had to have the following: a prostate specific antigen (PSA) level higher than 20 ng/mL; a cancer that was judged by pathologists to be highly aggressive; or cancer that had already extended through the wall of the prostate. They could also be judged at high risk if they had both a PSA score of 10 ng/mL and a moderately aggressive cancer. The Cleveland Clinic researchers are now looking to determine the cause of death of the study patients to determine if the use or lack of use of the monthly injections of androgen deprivation drugs prevents prostate cancer deaths, Dr. Robinson said. [Presentation title: Greater Than 6 Months of Androgen Deprivation Therapy Does Not Improve Overall Survival for High-risk Prostate Cancer Patients Treated with Radiotherapy or Prostatectomy. Abstract ID: 2302] > Also reported on the same day, at the same conference is the following. > It's not a contradiction, but just the opposite for different [quoted text clipped - 12 lines] > increase the risk of mortality among patients who were at high risk for > recurrence of prostate cancer It's stuff like that that makes my uro onc now advise me to just fugheddaboutit until we see some serious PSA or even a met before acting again, by which time we may just give me an anti-PC shot and bedone widdit. It was also stuff like that that convinced me to reject their post-op ADT recommendation two years ago. I.P. > Before any treatment was performed, the men who were considered to be > at high risk for prostate cancer recurrence had to have the following: [quoted text clipped - 3 lines] > be judged at high risk if they had both a PSA score of 10 ng/mL and a > moderately aggressive cancer. -gulp- I had a PSA 10.6 (11.3 during the Lupron flare, which I don't count) and a Gleason 4+3 is considered aggressive, maybe. And I had 2 four-month shots of that dangerous Lupron. Now what? -kh >> Before any treatment was performed, the men who were considered to be >> at high risk for prostate cancer recurrence had to have the following: [quoted text clipped - 8 lines] > > And I had 2 four-month shots of that dangerous Lupron. I suspect -- and know in my own case -- that more important than statistics blaming ADT for a slightly delayed or advanced demise is the impact ADT would have on my QOL in the meantime. If your QOL on ADT suits you, THEN the question arises of which statistics you believe and wish to act on. I.P. > I suspect -- and know in my own case -- that more important than > statistics blaming ADT for a slightly delayed or advanced demise is the > impact ADT would have on my QOL in the meantime. If your QOL on ADT > suits you, THEN the question arises of which statistics you believe and > wish to act on. I'm not sure what the stats say or what the underlying mechanisms are. Everyone seems to say that hormone-chemo doesn't "cure" PCa. It can slow it down for a while. Only for a while, then it doesn't work so well, eventually it stops working. My read of this thread is that a blast of Lupron up front lengthens life in some cases. It also lengthens life if you get a blast at the end, in some cases. Given that, does it matter when you get it? Is some Lupron at the begining and at the end better than just at the end? I certainly did not like my Lupron experience. I had the hot flashes and general weakness but that wasn't my main complaint. I had the lack of libido and the cox-a-floppin'. That was tolerable but I prefer groping women and giving them a few minutes and a few firm inches, adequate only these days, even with Vitamin-V. I had a real problem with the confusion, the sugar fog, the other Lupron biochemical side effects. -kh kh wrote: > I certainly did not like my Lupron experience. I absolutely hated my experience with Lupron. > I had the hot flashes and general weakness but that > wasn't my main complaint. Ditto at this end. > I had the lack of libido and the cox-a-floppin'. That was > tolerable but I prefer groping women and giving them a > few minutes and a few firm inches, adequate only these > days, even with Vitamin-V. I didn't lose libido, but I had the cox-a-floppin'. It's returning to somewhat normal following 4 years of that single shot. > I had a real problem with the confusion, the sugar fog, > the other Lupron biochemical side effects. I had a breathing problem. Couldn't walk 100 feet without having to stop. My legs felt weak (and I already had a problem from ankylosing spondylitis - which itself is a SE of Lupron but the damned uro didn't mention that beforehand). I could not finish a single dance for a couple of months, until my breathing returned to somewhat normal. I propose that every patient receive the insert that comes with a drug and have a chance to read every SE possible with that drug before allowing a doctor to administer it. On Veterans Day, NICK wrote, in pertinent part: > I propose that every patient receive the insert that comes > with a drug and have a chance to read every SE possible > with that drug before allowing a doctor to administer it. > An excellent source of detailed information on medications is http://www.rxlist.com/ Recently I encountered on-line a woman whose husband has been txd by a very well-known Eastern US med onc. He had prescribed a certain med that, in combination with another, drastically reduced blood pressure. There is a warning about this in the literature and the combination is contra-indicated, but the medic was evidently not aware of it. Sure enough, the patient had experienced very low BP levels. It could have killed him. It is hardly necessary to point out that, once the facts were known, the woman and her husband were very unhappy with the famous medic. The take-home lesson for us all is this: Do your own research; become familiar with the meds and txs and the reasons for their use. Ask questions; if necessary be a nuisance. In other words, become an empowered patient. It is more than important, it is vital. Medics are not gods. Regards, Steve J "Empowerment: taking responsibility for and authority over one's own outcomes based on education and knowledge of the consequences and contingencies involved in one's own decisions. This focus provides the uplifting energy that can sustain in the face of crisis." --Donna Pogliano, co-author of _A Primer on Prostate Cancer_, subtitled "The Empowered Patient's Guide." > > I propose that every patient receive the insert that comes > with a drug and have a chance to read every SE possible > with that drug before allowing a doctor to administer it. I haven't looked, but I wonder whether statin inserts mention the mental problems surfacing with them. The drug companies admitted them internally last century, but they're only recently and sparsely reaching the U.S. press. I.P. > I had a breathing problem. Couldn't walk 100 feet without > having to stop. My legs felt weak (and I already had a > problem from ankylosing spondylitis - which itself is a SE > of Lupron but the damned uro didn't mention that beforehand). > I could not finish a single dance for a couple of months, until > my breathing returned to somewhat normal. It's 2 years since the last Lupron shot. One weird "effect" was an intermittent, sharp pain in a couple toes on my left foot. I recall stamping my feet under the desk, trying to stop the pain, this was during Lupron. 2 years later, there's still something wrong with those toes. Maybe Lupron aggrevates arthrytis or wears out the small joints. I get winded. 3 years ago, I enjoyed taking long walks in my neighborhood. It's a hilly residential area, older homes. I used to hit the pavement 2 or 3 times a week for an hour at a time. Slower than a jog but more than strollling. It's much harder now and I don't go as often, maybe 3 times a month. This is not a good lifestyle change for someone who works at a desk. After working all day, I'm exhausted. I still don't have the energy that I used to have. A drug that gives you "the Lupron Belly", tricks you into eliminating the regular exercise of walking the neighborhood, gives you joint pain, that in itself could shorten your life. Then there's the other exercise that Lupron eliminates, the one where the instructions read, in part: Step 1. Take one big busted blond or slim-waisted brunette. Step 2. Remove all clothing... ... Step 9. Using your tongue and lips.... ... Step 36. Attach the bungi cords .... ... -kh > It's 2 years since the last Lupron shot. One weird "effect" was an > intermittent, sharp pain in a couple toes on my left foot. I'll be. I've had those. Never attributed them to Lupron, though I did not suffer from them before. I wonder.... > I get winded. 3 years ago, I enjoyed taking long walks in my > neighborhood. It's a hilly residential area, older homes. I used to > hit the pavement 2 or 3 times a week for an hour at a time. Slower > than a jog but more than strollling. Been on Lupron for three years and now on Casodex. Still walk a lot. During the summer, sometimes seven days straight. 3 to 5 miles usually, never less that 2½. The only time I don't feel good is when I don't walk. 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 PSA <0.04 Non Illegitimi Carborundum |
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