Uros Prescribing ADT

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Steve Jordan - 25 Dec 2006 21:11 GMT

As some might recall, I rant from time to time about uros (surgeons)
prescribing ADT and other medical interventions for PCa, something which
many of them might not be qualified to do (but which can be very
profitable).

Interesting article on the topic, published in the June 2006 National
Cancer Institute Bulletin.

http://www.cancer.gov/cancertopics/treatment/prostate/hormone-therapy-use

or

http://tinyurl.com/yeu44f

Fourth paragraph: "This scenario is cause for concern because patients
might be getting therapy that may not be in their best interest."

Regards,

Steve J

"Flagrantly, we docs ignore the declaration of biology. We do this out
of ignorance, greed or both. The prime directive of the physician, the
real physician, is patient outcome, & not physician income (or ego)."
-- Stephen B. Strum, MD

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Bill - 26 Dec 2006 14:35 GMT

When I first recurred I started looking into the next steps and who
should be guiding them. I was told by several neutral M.D.s that it has
been traditional and customary for uros to treat through the ADT stage.
However, my take on this is that w/ most uros you will also get
traditional and customary ADT - Lupron every 3 mos. - and will not be
closely monitored. I.e. I cut it out, now I'm going to chemically
castrate you, and when that stops working you are on your own. It seems
logical to me that med-oncs should be the ones supervising this Tx.
However, so far the med-oncs I've seen have also been rather
old-school. I think sophisticated ADT3 and 4 like Strum advocates is
still a work in progress w/ few practitioners.

Bill Denton
RP 2/12/02
PSA 1.10
Memphis

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I.P. Freely - 26 Dec 2006 15:30 GMT

> When I first recurred I started looking into the next steps and who
> should be guiding them. I was told by several neutral M.D.s that it has
[quoted text clipped - 7 lines]
> old-school. I think sophisticated ADT3 and 4 like Strum advocates is
> still a work in progress w/ few practitioners.

I agree with the first idea, but has some study now shown benefit from
ADT3? They hadn't last time I checked a year or so ago.

I.P.

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Steve Jordan - 26 Dec 2006 21:37 GMT

On December 26, Bill replied to me, in pertinent part:

> I think sophisticated ADT3 and 4 like Strum advocates is
> still a work in progress w/ few practitioners.

Dunno about the "few practitioners" evaluation. But I have experience
with only one med onc, and she was certainly not adverse to initiating
ADT2 or ADT3 in January 2005. It was my decision to begin the procedure
with only an LHRH agonist (Trelstar). I thought that, if it did not have
the desired effect, then I could move to a more comprehensive regimen. I
should make it clear that I was on adjuvant ADT from the time of IMRT in
late 2004.

It worked out quite well (so far), with undetectable PSAs for > a year.
I began IADT as of March 2006.

The idea of "combined hormonal blockade (CHB)" or "combined androgen
blockade CAB)" using an LHRH agonist plus an androgen antagonist such as
Casodex (ADT2) plus perhaps the 5-alpha reductase inhibitors Proscar or
Avodart (ADT3) is indeed "hotly debated" as Strum and Pogliano put it on
page 136 of _A Primer on Prostate Cancer_ 2nd ed. However, to this
layman it makes sense to suppress the production of testosterone (T) and
its metabolite dihydrotestosterone (DHT) because they, especially the
latter, encourage the development of PCa cells.

A quick search of PubMed found this: "Can combined androgen blockade
provide long-term control or possible cure of localized prostate
cancer?" by Labrie et al.

Their answer, in a word, is "yes."

See, Urology. 2002 Jul;60(1):115-9.

The PubMed ID number is 12100935

Regards,

Steve J

"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. Surprisingly, only a few others in academic medicine have ever
gone that route. Dr. Oefelin in Cleveland is one of these. In my experience
it is the early use of therapy before the tumor burden increases
substantially that allows for long term responses. I realize I am battling
the academic world which only sees results in peer-reviewed literature as
having the sole take on the truth. This is just not the case...."
--Stephen B. Strum, MD

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