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Medical Forum / Diseases and Disorders / Prostate Cancer / February 2008Johns Hopkins on ADT
Excerpts from their February “Health After 50” Medical Letter: Testosterone deprivation causes impotence, osteoporosis, and heart disease. Recent ADT cardiovascular studies have made doctors rethink who should pursue ADT. Without careful monitoring and preventive care, men > 65 on ADT for six months are at increased risk of heart attack. ADT bone loss will occur, especially during the first year. Get your BMD baseline measured before starting ADT, take 1-1.5 gms of calcium with Vit D daily, and perform strength training exercises to *reduce* bone loss. The extra threat of ADT probably overrides the increasingly strong and broad concerns about biphosponates such as Fosamax and its numerous problems such as brittle new bone layup. ADT initiates and/or enhances Type 2 diabetes or prediabetes within three months. This in turn increases risks of heart disease, vision loss, nerve damage, and maybe tumor growth. Obtain blood sugar and lipid profiles before beginning ADT and keep them up. Estrogen or progesterone work best to combat hot flashes, but should be reserved for severe cases of hot flashes. Libido and sexual function usually return within a year, especially in younger pts, after ceasing ADT. This can be mitigated by IADT, and is recommended for some pts with rapidly rising PSA but no mets. IADT may be as effective as continuous ADT, pending further research. Few men on such drugs as Lupron and Zoladex experience gynaecomastia, but men on antiandrogens such as Casodex frequently experience it significantly. ADT coincides with a peridontal disease risk increase from 4% to 80%. Get frequent, careful, focused dental care if on ADT. [Maybe that partially explains the increased CVD risk.] Anemia is common among men on ADT. One recent study shows that the ADT Syndrome, common w/ADT and including fatigue, depression, and trouble concentrating, may not result directly from ADT, but rather from T suppression, advanced age, advanced cancer, and/or psychological impacts]. Wives experience emotional impacts similar to and often stronger than their husbands on ADT … a good incentive to involve wives in our support programs. I.P. On January 30, Señor "Freely" wrote: > Excerpts from their February “Health After 50” Medical Letter: > > Testosterone deprivation causes impotence, osteoporosis, and heart > disease. Recent ADT cardiovascular studies have made doctors rethink who > should pursue ADT. Without careful monitoring and preventive care, men > > 65 on ADT for six months are at increased risk of heart attack. Other than a perhaps overly-broad argument that the declaration that ADT *causes* this or that SE without explaining that an individual's experience would not necessarily include each and every SE, and also failing to note that there are means available to mitigate such SEs that an individual might experience, and that if all else fails the patient can simply stop ADT, and, lastly, that the SEs of the alternatives might also be unacceptable -- I can't argue with JH. Here's an example of those anecdotes I criticize: I began my struggle almost five years ago with a dx of extensive Gleason 9 on the R plus a smaller Gleason 8 on the L, relatively low PSA of 5.7 ng/mL. The primary reason I"m still here to rant & rave & annoy Señor "Freely" is that I had adjuvant ADT for > a year. Yes, I experienced some SEs. But they were worth the results. Which include the fact that I am able occasionally to be of service to my brothers and sisters in adversity. Regards, Steve J "Often, the surest way to convey misinformation is to tell the strict truth." --Mark Twain > Excerpts from their February “Health After 50” Medical Letter: > > Testosterone deprivation causes impotence, osteoporosis, and heart > disease. Recent ADT cardiovascular studies have made doctors rethink who > should pursue ADT. Without careful monitoring and preventive care, men > > 65 on ADT for six months are at increased risk of heart attack. ... etc,,, > Wives experience emotional impacts similar to and often stronger than > their husbands on ADT … a good incentive to involve wives in our support > programs. > > I.P. I can't deny that some of us experience some of theses effects but nobody experiences them all (not that you asserted that they do). I am reminded of one of the funniest TV commercials I have seen. It is about investing in a pharmaceutical company, "Gene Enterprises" and it goes like this: "Gene Enterprises harnessed the power of the human gene, but there are a few side effects. Aside from "Not appropriate for women," which appears in text as the woman in the commercial dances around a field, there's "itchy rashes, full body hair loss, projectile vomiting, gigantic eyeball, the condition known as 'hot-dog fingers', children born with the head of a golden retriever, seeing the dead, bone liquefaction, possession by the Prince of Darkness, tail growth, elderly pregnancy," I don't mean to trivialize the discussion. ADT does indeed have some unpleasant and potentially harmful side effects but it can kick the crap out of PCa at least for a time. My PSA went from 1.6 to undetectable on Lupron and I'm prepared to suck it up and pay the price in side effects. > ADT does indeed have some > unpleasant and potentially harmful side effects but it can kick the crap out > of PCa at least for a time. My PSA went from 1.6 to undetectable on Lupron > and I'm prepared to suck it up and pay the price in side effects. Well, at least ADT kicks the crap out of *PSA*. What it does to our *cancer* is highly individual. I.P. > Excerpts from their February "Health After 50" Medical Letter: > [quoted text clipped - 43 lines] > > I.P. Can't wait to start but beats the alternative. > Can't wait to start but beats the alternative. Dominic, Since all of the animal studies ever published (all one of them) demonstrate that intermittent ADT followed by high levels of T plus low levels of DHT is about 5 times more effective than continual ADT (and may be even more effective than that in men, according to Dr. Leibowitz's web site, but his work has yet to be published), it is hard to justify the statement that "it beats the alternative". Ed Friedman On Jan 30, 9:20 pm, e...@math.uchicago.edu wrote: > ... > Since all of the animal studies ever published (all one of them) [quoted text clipped - 5 lines] > > Ed Friedman Ed, Do you have any idea why Dr. Leibowitz has not published his findings? Thanks. Alan > Ed, > [quoted text clipped - 4 lines] > > Alan Alan, I don't know for sure, but one of the problems is that Dr. Leibowitz will never do a double-blind study, i.e., deny any of his patients what he considers the optimum treatment. Another problem is that he hasn't been doing it enough years to determine the long-term effect. Also, using T under any circumstances for treating PC is considered taboo, and many doctors refuse to believe Dr. Leibowitz's results. This makes it less likely that he can get his work published in a peer reviewed journal. Let me pass on to you an observation about Dr. Leibowitz's findings from a PC "expert" which Ralph V was kind enough to pass on to me. "My personal bias is that massive testosterone doses not have much to do with the well-known fact that men with prostate cancer can have long remissions after induction testosterone blockade with or without chemotherapy. Based on our study published in the Journal of Urology, higher testosterone tends to cause shorter, not longer remissions. Remember, Bob treats hundreds of patients. The fact that a mere 8 of them have had exceptionally long remissions only tells us that prostate cancer is a heterogenous condition and that a variety of outcomes can be expected." Obviously, I disagree with this "expert", and if you examine the PSA doubling times of all of the patients' case histories I'm pretty sure that barring a sharp rise in PSAD, there is no chance that any of his patients that he listed as being treated with high T/low DHT are in danger of dying before the age of 100. Ed Hi Ed, Dr. Derek Raghavan of Taussig Cancer Institute at the Cleveland Clinic is suggesting a treatment regime for my brother that has similar numbers as Dominic, of taking a bicalutamide initially and nothing more if his immune system can keep his psa under 30 n/ml. Should his psa exceed 30 n/ml then he would add LHRH agonist. He states that this regime is not common for most urologist and oncologist. Have you heard of anyone else trying this protocol and know if they had any success? Ron S. -- Message posted using http://www.talkaboutsupport.com/group/alt.support.cancer.prostate/ More information at http://www.talkaboutsupport.com/faq.html > Hi Ed, > [quoted text clipped - 9 lines] > > Ron S. Ron, A recent article in Nature Clinical Practice Urology 3:408-409, 2006 concluded "Adjuvant bicalutamide provided no benefit to patients with localized prostate cancer, but improved PFS in patients with locally advanced disease, and appeared to increase overall survival in select patients.". Reading the article, the only patients that had improved survival with bicalutamide were those receiving radiotherapy for locally advanced disease. As I've said before, the animal studies show that by far the best treatment for PCa is intermittent ADT followed by high T/low DHT. Doctors stick with continual ADT because that is what others do and what guarantees no malpractice suits. If nobody had ever done continual ADT in humans and doctors had to decide from scratch using the scientific information available today which treatment was better - continual ADT or intermittent ADT followed by high T/low DHT, it is hard to believe that any hospital ethics committee would permit humans to undergo continual ADT, since the only animal study done to date demonstrates that continual ADT is ~5 times worse than the high T/low DHT protocol. Ed Friedman Who is the PC expert you have quoted? >> Ed, >> [quoted text clipped - 35 lines] > > Ed > Who is the PC expert you have quoted? Bert, I have no idea. Ralph was the one who contacted the experts and he passed the comments along to me with no mention of the names of the doctors who responded. Ed Friedman >> Ed, >> [quoted text clipped - 10 lines] > will never do a double-blind study, i.e., deny any of his patients > what he considers the optimum treatment. Wouldn't he accomplish greater good if he bit the bullet, conducted a study anyway, and convinced the oncology world of the validity of his technique? I.P. > Wouldn't he accomplish greater good if he bit the bullet, conducted a > study anyway, and convinced the oncology world of the validity of his > technique? > > I.P. I.P. I agree with you, but such things are beyond my ability to control. Also, I seriously doubt that any study he did would convince the oncology world of anything. Medicine is notoriously slow to change. The most recent example of it taking 15 years for doctors to acknowledge that ulcers were caused by bacteria, even though the data was irrefutable as of day 1 illustrates that point. When you consider that doctors are brainwashed in medical school to demonize T with regards to PCa, it would probably take quite a few decades to change their minds. Another thing that would be great is if animal researchers followed up on the study showing that intermittent ADT followed by high T/low DHT was ~5 times better than continual ADT. Considering the study was done at Northwestern University (not a rinky dink school by any means), there is no excuse for the blindness being shown by the rest of the researchers throughout the world. It is almost as if they really don't care how many people die unnecessarily from prostate cancer. In the mean time, many of them waste their time searching for a drug to get FDA approval by prolonging the lives of doomed men by a few months. If I were a cynic, I'd say that personal profit trumps scientific advances in today's world. Ed Friedman > If I were a cynic, I'd say that personal profit trumps > scientific advances in today's world. Cynic ... or realist? I don't generally pay much attention to unproven remedies, but I will keep asking my oncs about, and following, Bob's and your work because a) My PC will probably return. b) SRT is well under 15% likely to help me. c) I'd need proof of several ADT facts relevant to my own case to subject myself to ADT. d) The other new imminent fixes such as immunology are at least 3-5 years away. I.P. On Jan 30, 9:20 pm, e...@math.uchicago.edu wrote: > > Can't wait to start but beats the alternative. > [quoted text clipped - 8 lines] > > Ed Friedman Thanks Ed . When I got my second opinion at Hopkins they weren't big on intermittant nor were they big advocates of a complete blockade however I am likely to go into a clinical study that I'll get a blockade and possibly chemo. Unless I decide not to do the study. Stay tuned. On Jan 30, 9:20 pm, e...@math.uchicago.edu wrote: > > Can't wait to start but beats the alternative. > [quoted text clipped - 8 lines] > > Ed Friedman Let me clarify what I meant (sorry for not doing sooner). Regardless of potential SE's whether antiandrogen approach or complete blockade or intermittant etc there will be SE's unless I get lucky. At the age of 51, not pursuing therapy with a doubling time of about 3mo's is not acceptable alternative for me. I'll suck it up with the risk of potential SE's to hopefully arrest my PSA and lower my risk of metastatic disease. I'll find out in two weeks whether I enter a chemo and blockade arm of trial or just the blockade. Wish me luck as I battle on. > I'll suck it up with the risk of potential SE's ADT needn't be a "risk", in the sense of an unknown. You can always back out if the SEs you experience are intolerable and untreatable. That option not only reduces your risk (of unknowns) but also gives you some control over them, even if you choose not to stop the ADT. You're young enough that your T should recover if you stop the ADT for whatever reason. > to hopefully arrest my PSA and lower my risk of metastatic disease. ADT doesn't lower the risk of mets. It just delays it for an unknown period by suppressing the androgen-dependent portion of your cancer -- and your PSA -- while the androgen-independent portion marches on under the cover of suppressed PSA. > Wish me luck as I battle on. Your key word is "battle". It's all we can do, and each pt defines his own battle priorities and plan. Yours sound fine to me. I.P. > Can't wait to start but beats the alternative. The alternative is no ADT. Which beats which depends on its intended effect on our cancer, its unintended effects on our bodies and minds, and our criteria. I.P. > > Can't wait to start but beats the alternative. > [quoted text clipped - 3 lines] > > I.P. If I understand Dominic's meaning, then there are other alternatives such as estrogen...ron Alan wrote and asked: > Do you have any idea why Dr. Leibowitz has not published > his findings? Do any publications agree with his methods? Were there a hundred or more patients in his study? Was it a double-blind study? Did 50% or more of those enrolled in the study show the expected/desired result(s)? In other words, was the study a failure or a success? ___ Blue Wave/QWK v2.12 |
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