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Medical Forum / Diseases and Disorders / Prostate Cancer / March 2008When to start ADT after RP?
I had my RP 5 weeks ago but have advanced pca. My psa is already starting to rise (0.8 at 3 weeks, 1.37 at 5 weeks). I know I have to go on hormone therapy, most likely Lupron and Casodex, although the specifics have not been discussed. I understand there are two schools of thought on when to begin treatment, as eventually ADT stops working. One is to start as soon as possible, given my psa, and be aggressive with the treatment so as to give a knockout punch. The down side being the clock starts ticking right away. The other is to wait for signs of mets, and/or symptoms, and then start treatment, the thought being the time spent without treatment is that much extra time I will have before the ADT timetable runs its course. I have appts. with my uro and a med. onc but they are a month away, hence this post. I also suspect radiation will be advised, so I have the same question about that as well. For the record, this was not an easy topic to post, as I don't expect any encouraging answers, but I do have to make a decision, don't I........ > I had my RP 5 weeks ago but have advanced pca. My psa is already > starting to rise (0.8 at 3 weeks, 1.37 at 5 weeks). I know I have to [quoted text clipped - 16 lines] > any encouraging answers, but I do have to make a decision, don't > I........ Skeptic.... I am sorry to hear that. I don't know the specifics of your situation other than you characterize as advanced. Advanced to me means metastatic disease. Did you have lymphatic or seminal vessicle invasion, gleason etc? When I was in similiar situation post RP (with rising PSA) since I had clean margins (other than extracapsular extension (pathology speak for maybe) my md's and I hoped that things were localized and chose not to do ADT. but attack with radiation since radiation is curative (when it hits the target). Unfortunately radiation didn't kill beast like I'd hoped. Bottomline is I'd see both a med onc & rad onc. Say adios after you heal the the uro. He's done what he could. In retrospect I do the same thing all over. In my humble, non professional opinion I'd radiate immediately or radiate and medicate. The literature seems to suggest that earlier is better in both cases radiation or ADT (especially with fast PSADT). Good luck to you. > > I had my RP 5 weeks ago but have advanced pca. My psa is already > > starting to rise (0.8 at 3 weeks, 1.37 at 5 weeks). I know I have to [quoted text clipped - 39 lines] > > - Show quoted text - Should have clarified I'd only choose radiation if there was strong suspicion based on diagnostics that PCa was still localized. Alan is recollection is correct in that radiation is more successful the lower the PSA. See related article http://www.medicalnewstoday.com/articles/40185.php. Sorry to hear the news, skeptic. I have not (yet) had to make a decision on ADT. But with regard to salvage radiation, based on what I remember the doctors telling me when my PSA started to rise again; 1. salvage radiation is generally recommended only if the recurrence is local. 2. there is no reliable way to determine whether recurrence is local. 3. it is theorized that the higher the PSA immediately after surgery, the sooner it begins to rise again, and the faster it rises, the less likely the recurrence is local. 4. your path report should be looked at; if the surgical margins were clear, it is less likely that your rising PSA is due to local recurrence. 5. salvage radiation is rarely effective once post- surgery PSA exceeds 0.6, or at most 1.0 6. OTOH, salvage radiation is your one chance for a complete cure, given current treatment options. So it shouldn't be lightly dismissed. It's confusing with no easy, straightforward answers. I'd be talking with a rad onc and a med onc and see what they had to say, and then make your decision. I'm sure this is a tough time for you, but as many of the guys in this group will affirm, even in the worst case, you've got many good years ahead of you yet. Best wishes. Fred Skeptic.... I am sorry to hear that. I don't know the specifics of your situation other than you characterize as advanced. Advanced to me means metastatic disease. Did you have lymphatic or seminal vessicle invasion, gleason etc? ==> I agree with you, there should be something in between possibly curable cancer and mestatic cancer. However, Skeptic is correct that once it's out of the prostate it is considered "advanced". That said, he went into this with a PSA of 14 and a Gleason of 7, I think. His post-op biopsy should a Gleason of 8 and lymph node involvement.  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 PSAD 0.19 years EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 PSAD .056 years Lupron 07/03 (1 mo) 8/03 and every 4 months there after PSA .07 .05 .06 .09 .08 .132 .145 PSAD 1.4 years Casodex added daily 07/06 PSA <0.04, <0.05, <0.04, <0.04, <0.1 2/12/08 Non Illegitimi Carborundum > Skeptic.... I am sorry to hear that. I don't know the specifics of > your situation other than you characterize as advanced. Advanced to me [quoted text clipped - 20 lines] > PSA <0.04, <0.05, <0.04, <0.04, <0.1 2/12/08 > Non Illegitimi Carborundum Given the lymphatic involvement then good bet it's not localized. :( Some literature differentiates between "high" risk and advanced. Probably splitting hairs. Maybe I prefer to look at it that way because personally I don't want to think of having advanced cancer but I guess I do otherwise I wouldn't be doing what I'm doing. Stay well. > I had my RP 5 weeks ago but have advanced pca. My psa is already > starting to rise (0.8 at 3 weeks, 1.37 at 5 weeks). I know I have to > go on hormone therapy, most likely Lupron and Casodex, although the > specifics have not been discussed. Looks as if the PCa was systemic and a local tx such as surgery, while it can debulk the tumor, could not be curative. > I understand there are two schools of thought on when to begin > treatment, as eventually ADT stops working. [quoted text clipped - 5 lines] > that much extra time I will have before the ADT timetable runs its > course. I simply cannot understand doing nothing about the PCa while it spreads and causes symptoms. That makes it much more difficult to treat with much hope of success. And IMO "success" means delaying, delaying, delaying until something else knocks one off his twig. > I have appts. with my uro and a med. onc but they are a month away, > hence this post. I recommend that the med onc be the only tx consultant. What is a uro, who is only a surgeon, going to do? If I understand the situation correctly, there is no longer any need for a surgeon. > I also suspect radiation will be advised, so I have the same question > about that as well. What, exactly, would the RT radiate? The so-called "bed?" The pelvic lymph nodes? Other? If this is systemic PCa, I wonder whether such RT will be helpful in any meaningful manner. I further recommend that "skeptic" discuss early chemo with the med onc. If the latter is not well-educated in tx of PCa, consult one who is. Some are listed on the website of the Prostate Cancer Research Institute (PCRI) via this portal: http://prostate-cancer.org/resource/find-a-physician.html Yeah, yeah, I hear the gasps of horror from some: "Eek! Chemotherapy! End of the world!" Well, relax and read http://www.prostate-cancer.org/education/andind/Guess_ChemotherapyForPC.html Also see Eigl BJ et al, "Timing is everything: preclinical evidence supporting simultaneous rather than sequential chemohormonal therapy for prostate cancer." Clin Cancer Res. 2005 Jul 1;11(13):4905-11. "CONCLUSIONS: In laboratory models of prostate cancer, simultaneous androgen deprivation plus paclitaxel is more effective than sequential treatments. These findings provide preclinical proof-of-principle for ongoing clinical trials addressing the role and timing of systemic therapies in prostate cancer." PubMed ID: 16000589 PubMed, a service of the US National Library of Medicine and the National Institutes of Health, is at www.pubmed.gov Early chemo is the subject of 17 clinical trials right now. See http://tinyurl.com/39w2k5 for the website. > For the record, this was not an easy topic to post, as I don't expect > any encouraging answers, but I do have to make a decision, don't > I........ Sorry to disappoint, but there is much that can be done. See the PCRI site at http://prostate-cancer.org/index.html Also: post a Prostate Cancer Digest on the Physician to Patient site at http://www.prostatepointers.org/mlist/mlist.html At least one dedicated and expert PCa specialist will likely respond within a day or so. It could, as I know very well, be a lifesaver. Good luck, though mostly we make our own luck. Steve J Skeptic, I'm sorry to hear about the failure of your treatment and your rapidly rising PSA. I'm not a doctor and have no special expertise beyond what any of us have but, for whatever they're worth, here are my thoughts on your condition. To begin with, I don't know if radiation is warranted. It is my recollection that the success of radiation is much higher for men with PSA less than 1.0 (and the lower the better) than for men with higher PSAs. I suspect that your disease has already spread beyond the reach of prostate radiation. Whether that is true or not is a question for you to ask your doctors. They may have some tests they can perform that will help figure it out. But I fear that the odds are against you. Next, I think that if I were you, I would begin ADT early rather than late. Although I can't give you citations without searching Pubmed, I know there have been a number of studies claiming a survival advantage for early ADT over late ADT. As far as I know, there is no evidence whatsoever that getting ADT earlier might result in your dying earlier. The only argument I've seen against early ADT is that the patient might live just as long with late ADT and will have an extra number of months or more without the side effects of ADT. I don't think there is a ticking clock with ADT. I don't think it's the case that you get X months of remission with ADT and that, by not using them until you really need them, you can extend your life. I don't think that any of the late ADT advocates say that. Dr. Walsh, an advocate of late ADT, claims that the hormone refractory tumor cells grow at the same rate whether you're on hormone therapy or not. Therefore, he says, the cancer will kill you when those cells cause enough damage. The hormone sensitive cells can therefore be suppressed whenever you wish, with no effect on longevity. Advocates of early ADT however speculate that there may be hormone sensitive cells that become less sensitive over time. It's better to suppress them now, while they can be suppressed, than to wait until they have multiplied and more of them may become insensitive. As far as I know, no one has a theoretical answer to this question, but the empirical studies appear to show a survival advantage for early ADT. So I personally would go that route. I can tell you that I was on hormone therapy for a while as an adjuvant to my radiation. I know what it's like, and I didn't like it. But I can also tell you that it's certainly bearable. Your sex drive will take a big hit, and you'll experience other side effects, but your capacity to enjoy life need not go down at all. You will still enjoy most of the things you always enjoyed. You will be able to counter many of the side effects by using exercise and maybe some medical help. Life will go on and will still be very, very much worth living. You've still got some good years ahead and it's possible that some of the new therapies will give you some more good years when the ADT stops working. So my advice is, go for the ADT. No doubt you've had many sleepless nights. No doubt you'll have some more. But don't despair. You're still alive and you've got some more living to do before it's all over. All of us are getting older. All of us are facing the big questions, if not from prostate cancer, than just from advancing age and the knowledge that something will get us. But we can still be strong men. Best of luck. Alan > I had my RP 5 weeks ago but have advanced pca. My psa is already > starting to rise (0.8 at 3 weeks, 1.37 at 5 weeks). I know I have to [quoted text clipped - 16 lines] > any encouraging answers, but I do have to make a decision, don't > I........ 1. My first step would be to run any and all rational tests available to determine whether the recurrence is local (thus susceptible to SRT) or distant (thus targetable at this stage only by ADT). It's possible this could avert a wasted SRT program. 2. Then you might run any tests that may indicate my cancer's degree of androgen dependence, in the hopes that may help predict ADT's expected benefits in your own case. 3. If those left ADT a real contender, you might study ADT in much more depth, including: A. The statistics on its benefits and SEs. B. Any personal medical problems (e.g., arthritis, diabetes, depression, cardiovascular disease) highly likely to be exacerbated by ADT. C. ADT 1 vs 2 vs 3 benefits vs SEs. Last I heard, ADT3 adds only SEs, not benefit. This may help you evaluate the tradeoffs between *your* ADT's benefits and *your* expected SEs. 4. Have some oncs you trust predict the path of your disease with and without ADT, and compare those to your personal priorities. I'd fire any onc who said only, "Just take the ADT. It's your only option." 5. Keep researching the literature on pros and cons of ADT now vs upon clinical evidence vs upon symptoms. I saw no definitive assessment of that dilemma when I researched it three years ago, but I'm sure the literature has flip-flopped more than once since then. 6. The race is then on between a rational, informed decision and one driven by fear of rising PSA. Both are valid, as both have the potential for measurable benefit and/or harm. Ideally, research and analysis leads to a sound choice before we feel compelled to act or get off the pot. I.P. > 1. My first step would be to run any and all rational tests available to > determine whether the recurrence is local (thus susceptible to SRT) or > distant (thus targetable at this stage only by ADT). It's possible this > could avert a wasted SRT program. He has. The post-op biopsy found cancer in the lymphatic system. If he did a prostascint scan and found a hotspot on his prostate bed, he would know his surgeon screwed up, but that cancer had already gotten out of the barn. > 2. Then you might run any tests that may indicate my cancer's degree of > androgen dependence, in the hopes that may help predict ADT's expected > benefits in your own case. I could be wrong, but I think the test for that is Lupron followed by two quarterly PSA assays. > 3. If those left ADT a real contender, you might study ADT in much more > depth, including: [quoted text clipped - 5 lines] > This may help you evaluate the tradeoffs between *your* ADT's benefits and > *your* expected SEs. I concur, so long as Skeptic takes it one step further to research how he might minimize the SEs. Stopping short and scaring yourself straight with the idea of not taking ADT because of possible, even likely, SEs is just suicide. ADT is one of those treatments about which one can change his mind later. > 4. Have some oncs you trust predict the path of your disease with and > without ADT, and compare those to your personal priorities. I'd fire any > onc who said only, "Just take the ADT. It's your only option." What if that is his only option? > 5. Keep researching the literature on pros and cons of ADT now vs upon > clinical evidence vs upon symptoms. I saw no definitive assessment of that > dilemma when I researched it three years ago, but I'm sure the literature > has flip-flopped more than once since then. As I recall, three years ago, your decision was IF you were put into the position of choosing and IF it curtailed your highly adventuristic playing the you MIGHT choose six months of high quality of life over two years of ADT-affected life. Later, you agreed you would probably take the ADT if that were the only option. > 6. The race is then on between a rational, informed decision and one > driven by fear of rising PSA. Both are valid, as both have the potential > for measurable benefit and/or harm. Ideally, research and analysis leads > to a sound choice before we feel compelled to act or get off the pot. That I agree with. > that cancer had already gotten out of the barn. In his case I see no strong incentive to bother with, let alone risk, SRT. >> 2. Then you might run any tests that may indicate my cancer's degree of >> androgen dependence, in the hopes that may help predict ADT's expected >> benefits in your own case. > > I could be wrong, but I think the test for that is Lupron followed by two > quarterly PSA assays. Walsh puts that "test" this way in both his old and new books: "If you have nothing but rising post-RP or post-RT PSA and lymph node involvement, and you feel fine, [I and other doctors, despite opposition] believe there is no evidence that starting ADT now, as opposed to later, will prolong life. [Does] early ADT delay the cancer's progression? Sort of; it delays our *knowledge* of progression, without stopping the clock." This test would provide *some* idea (with both false positive and false negative SE indications), though, of his ADT SEs. > I.P. wrote >> This may help you evaluate the tradeoffs between *your* ADT's benefits and [quoted text clipped - 4 lines] > the idea of not taking ADT because of possible, even likely, SEs is just > suicide. Not literally, of course, but it could certainly be misleading. That's why I said "help" evaluate; many preexistent conditions are almost guaranteed to increase with ADT. >> I'd fire any >> onc who said only, "Just take the ADT. It's your only option." > > What if that is his only option? Even if that were true, and it never is because no oe can make us take it, I'd want my doctor to convince me before taking a step that huge on anything more than a trial basis. At least one renown oncologist with mets quit ADT because it was worse FOR HIM than the all-too-obvious alternative. > As I recall, three years ago, your decision was IF you were put into the > position of choosing and IF it curtailed your highly adventuristic playing > the you MIGHT choose six months of high quality of life over two years of > ADT-affected life. AFAIK, the choice would be several months of extra heartbeat vs several years of impaired QOL. And there's much more than my active lifestyle at stake, including my dear wife's health. ADT is likely to strap a normal personality into an emotional roller coaster; it's *extremely* likely to convert an already strong-willed man into an ogre. I'm not willing to subject my wife to that for years just so I can draw a few more breaths; I'd rather she wanted me to live a little longer than die sooner. > Later, you agreed you would probably take the ADT if > that were the only option. Again, it's never the only option. I'd take ADT if it improved my QOL, and would not, with my present knowledge, take it Just In Case (i.e., with no evidence I have cancer) my G8 may return. In between those extremes anything is possible. I.P. >> that cancer had already gotten out of the barn. > > In his case I see no strong incentive to bother with, let alone risk, SRT. ==> I concur. Though, I am not an expert, much less a doctor. > At least one renown oncologist with mets quit ADT because it was worse FOR > HIM than the all-too-obvious alternative. ==> I am all for quitting ADT, just not before you've tried it. There are some people who just cannot handle the side effects (SEs), or who have greater SEs, or unwilling or unable to do those things than counteract SEs. For those people, a knowledgeable choice to quit is available. Up to that point, it's all theory and anecdotal stories. > ADT is likely to strap a normal personality into an emotional roller > coaster; it's *extremely* likely to convert an already strong-willed man > into an ogre. ==> Lately, I sometimes feel like a strong-willed ogre. I'm taking Vicadan for my back. ADT never caused me to be a strong-willed ogre. I've heard lots of men (and women) tell us of SEs involving ADT and none mentioned this one (that I can recall). >> Later, you agreed you would probably take the ADT if that were the only >> option. > > Again, it's never the only option. I'd take ADT if it improved my QOL, ==> Better yet. You would take it even if it were not your only option. 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 PSAD 0.19 years EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 PSAD .056 years Lupron 07/03 (1 mo) 8/03 and every 4 months there after PSA .07 .05 .06 .09 .08 .132 .145 PSAD 1.4 years Casodex added daily 07/06 PSA <0.04, <0.05, <0.04, <0.04, <0.1 2/12/08 Non Illegitimi Carborundum > There are > some people who just cannot handle the side effects (SEs), or who have > greater SEs, or unwilling or unable to do those things than counteract SEs. > For those people, a knowledgeable choice to quit is available. Up to that > point, it's all theory and anecdotal stories. Well, not really. Tens of thousands of anecdotal stories is called "statistics", at which point they become evidence, not just theory. > ==> Lately, I sometimes feel like a strong-willed ogre. I'm taking Vicadan > for my back. ADT never caused me to be a strong-willed ogre. I've heard > lots of men (and women) tell us of SEs involving ADT and none mentioned this > one (that I can recall). Emotional swings, sometimes extreme and usually in both directions, in each patient, are documented in virtually all studies, books, and anecdotes I've seen. I.P. >> There are some people who just cannot handle the side effects (SEs), or >> who have greater SEs, or unwilling or unable to do those things than >> counteract SEs. For those people, a knowledgeable choice to quit is >> available. Up to that point, it's all theory and anecdotal stories. I swear, if there were a third side to anecdotal evidence, you would argue it. :-) I concur with you 100% wherein it relates to the past tense. But, not for someone trying to decide whether or not they are going to have SEs. 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 PSAD 0.19 years EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 PSAD .056 years Lupron 07/03 (1 mo) 8/03 and every 4 months there after PSA .07 .05 .06 .09 .08 .132 .145 PSAD 1.4 years Casodex added daily 07/06 PSA <0.04, <0.05, <0.04, <0.04, <0.1 2/12/08 Non Illegitimi Carborundum >>> There are some people who just cannot handle the side effects (SEs), or >>> who have greater SEs, or unwilling or unable to do those things than [quoted text clipped - 6 lines] > I concur with you 100% wherein it relates to the past tense. But, not for > someone trying to decide whether or not they are going to have SEs. I don't quite follow your point(s?), but getting ADT SEs, even future ones, is virtually to literally guaranteed, in many ways by many published sources. Examples include: 1. Strum insists that some specific SEs are by themselves almost guaranteed (p > 0.9), so mathematical extrapolation of his SE statistics puts the likelihood of at least one severe SE at well over 0.99. That's a practical certainty in my book. 2. His partner and co-founder of the PCRI, Sholz, said ADT is guaranteed to curtail active lifestyles. Since active lifestyles prolong QOL and life itself significantly, that's a significant SE. It could be argued that, in many cases, the very common impact of ADT on the vast majority's capacity for exercise could shorten their lives. I would love to see a panel discussion among oncology and cardiovascular and longevity experts on the tradeoffs between ADT's cancer benefits and non-cancer SEs in ADT pts who would exercise much more if they could. We don't get to "decide whether we will have SEs." What we get to do is consider the list and their likelihoods in light of our cancer status and our priorities, try ADT if warranted, mitigate the SEs we get -- because we *will* get some -- as best we can, and revisit the ADT question once our remaining benefit and SE profile is identified. I.P. On March 3, Señor Freely wrote: More alarmism about SEs of ADT. Never forget (1) SEs can be treated and mitigated, and (2) if the patient cannot or will not tolerate whatever he experiences, he can (ta da!) Stop! (3) The SEs of *failing* to treat with this proven regimen can seriously degrade one's QOL, even unto death, something that seems to be ignored by some. Regards, Steve J "We must tailor the treatment to the nature of the disease. We must listen to the biology." -- Stephen B. Strum, MD Medical Oncologist > I don't quite follow your point(s?), but getting ADT SEs, even future > ones, is virtually to literally guaranteed, in many ways by many published > sources. Examples include: ADT causes SEs. There is no debate. Virtually every man who undergoes treatment involving current ADT meds will experience some issues that they have never dealt with in their lives. Some will be mild. Some will be moderate but can be made mild. Some will be serious but can be made moderate. Some will be so strong that a few will stop using them though they may die sooner. But, nobody knows how many or which SEs he will experience or how severe they will be or how easily they can be mitigated by other medications or activities. I think you and I agree on all of this. As such, I just cannot understand your motive for scaring the sh.t out of prospective ADT patients. 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 PSAD 0.19 years EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 PSAD .056 years Lupron 07/03 (1 mo) 8/03 and every 4 months there after PSA .07 .05 .06 .09 .08 .132 .145 PSAD 1.4 years Casodex added daily 07/06 PSA <0.04, <0.05, <0.04, <0.04, <0.1 2/12/08 Non Illegitimi Carborundum > ADT causes SEs. There is no debate. > [quoted text clipped - 9 lines] > > I think you and I agree on all of this. Fully, with some reservations about the ease, likelihood, and extent of mitigating fatigue. > I just cannot understand > your motive for scaring the sh.t out of prospective ADT patients. I just remind people of the facts when a) they ask for them and/or b) I see misleading claims about them. This thread in particular, and my history here in general, I submit, are consistent examples of both (a) and (b), even though I've had to get obnoxious in some unrelenting cases. If we find the facts of PC and/or its treatments too "scary", I guess we should have picked another disease. I tried another one, and, frankly, I'm damned glad I "chose" PC over my other, far more scary, cancer. Yes, PC is scary, but at least it's a toxic tortoise rather than a rabid hare; it may -- or may not -- catch us in the long distance run, but at least it gives us time to study, contemplate and maybe even try out various strategies. It would be a crying shame to watch a PC pt run a long-distance race against his PC tortoise given misleading data about the race's distance, course, rules, and opponent. I've been surprised how often new studies reported in the various medical newsletters and this forum have reinforced my ADT viewpoints, which include its highly debatable and very personal therapeutic index (ratio of benefit to harm) for previously treated pts who aren't certain their cancer still poses a serious threat. I just cannot understand some experienced people's motive for glossing over the scary facts, including statistics, of ADT. Being scared in the short term beats the hell out of having to live or die based on uninformed and/or misinformed treatment choices. I.P. > Fully, with some reservations about the ease, likelihood, and extent of > mitigating fatigue. Well, then, I guess at least we've entertained a few. Until next time.... >> Fully, with some reservations about the ease, likelihood, and extent of >> mitigating fatigue. > > Well, then, I guess at least we've entertained a few. Until next time.... Whaddaya mean, "next time"? You gotta have some faith. Whuzzat? You DO? Oh, I get it. ;-) Just so you won't feel singled out, my 10th grade English teacher told me I will argue with my undertaker. I.P. > Just so you won't feel singled out, my 10th grade English teacher told me > I will argue with my undertaker. I had a boss like that once. He didn't much care which side he was on, just so as there was an argument about it. 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 PSAD 0.19 years EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 PSAD .056 years Lupron 07/03 (1 mo) 8/03 and every 4 months there after PSA .07 .05 .06 .09 .08 .132 .145 PSAD 1.4 years Casodex added daily 07/06 PSA <0.04, <0.05, <0.04, <0.04, <0.1 2/12/08 Non Illegitimi Carborundum >> Just so you won't feel singled out, my 10th grade English teacher told me >> I will argue with my undertaker. > > I had a boss like that once. He didn't much care which side he was on, just > so as there was an argument about it. Unless I'm playing Devil's advocate for some valid reason, I argue for cause, not the sake of argument. And if I argue with my undertaker, the very fact that I'm arguing pretty much wins THAT argument for me. '-) I.P. > And if I argue with my undertaker, the very fact that I'm arguing pretty > much wins THAT argument for me. '-) Ha! I believe that is a perfect and non-debatable assertion. > Whuzzat? You DO? Oh, I get it. ;-) > > Just so you won't feel singled out, my 10th grade English teacher told me > I will argue with my undertaker. > > I.P. Hope you win that argument >> my 10th grade English teacher told me >> I will argue with my undertaker. > Hope you win that argument Some people might argue that we in this and the other cancer forums have already won the first round of that argument. I.P. Guys, I've dropped out for awhile, but I'm back with not-so-good news. As my situation is relevant to this thread, I hope I can butt in w/ my story. I had my prostatectomy in Dec. 2000. Gleason 7 (4+3) and extracapsular penetration, but clear margins and no lymph node involvement. Was told that I should be fine. In the early summer of '05, I had my first detectable PSA, 0,10. I had SRT and by Nov. '05 my PSA dropped down to undetectable. (Please note that our lab reports undetectable as < 0.03.) Now fast forward to Sept. '07. My PSA reported as 0.04. It's repeated in October, and came back as 0.03. It's repeated early this February, and it's 0.05. Since 2005, I have had a new urologist, a young woman w/ not much experience, but w/ very the good education and training credentials. She believes that the numbers are "real", not an artifact, but her recommendation is watchful waiting, since the doubling time is long, and to repeat PSA in another 3 months. Now, here's my question. Has anybody ever heard of the watchful waiting practice ever applied to a 62 y.o., otherwise reasonably healthy for his age man with the second recurrence? I expressed to her my doubts very clearly, but she maintains that the literature supports her. What do you, guys, think? It seems to me that my options are as follows: (1) follow her recommendation, (2) get a second (and possibly a third) opinion from another urologist ASAP, or (3) bid the urologists good-bye and ASAP make an appointment w/ the medical oncologist. This is on a rational basis. On the irrational one, I don't want to believe that this is really a recurrence and I dread the SEs of ADT. Thanks in advance. You've always been a great help and support. SY Guys, I've dropped out for awhile, but I'm back with not-so-good news. As my situation is relevant to this thread, I hope I can butt in w/ my story. I had my prostatectomy in Dec. 2000. Gleason 7 (4+3) and extracapsular penetration, but clear margins and no lymph node involvement. Was told that I should be fine. In the early summer of '05, I had my first detectable PSA, 0,10. I had SRT and by Nov. '05 my PSA dropped down to undetectable. (Please note that our lab reports undetectable as < 0.03.) Now fast forward to Sept. '07. My PSA reported as 0.04. It's repeated in October, and came back as 0.03. It's repeated early this February, and it's 0.05. Since 2005, I have had a new urologist, a young woman w/ not much experience, but w/ very the good education and training credentials. She believes that the numbers are "real", not an artifact, but her recommendation is watchful waiting, since the doubling time is long, and to repeat PSA in another 3 months. Now, here's my question. Has anybody ever heard of the watchful waiting practice ever applied to a 62 y.o., otherwise reasonably healthy for his age man with the second recurrence? I expressed to her my doubts very clearly, but she maintains that the literature supports her. What do you, guys, think? It seems to me that my options are as follows: (1) follow her recommendation, (2) get a second (and possibly a third) opinion from another urologist ASAP, or (3) bid the urologists good-bye and ASAP make an appointment w/ the medical oncologist. This is on a rational basis. On the irrational one, I don't want to believe that this is really a recurrence and I dread the SEs of ADT. Thanks in advance. You've always been a great help and support. SY > Has anybody ever heard of the watchful > waiting practice ever applied to a 62 y.o., otherwise reasonably [quoted text clipped - 7 lines] > urologists good-bye and ASAP make an appointment w/ the medical > oncologist. This is on a rational basis. My post-RP (Oct 04, Gleason 8, negative margins, SVI, now 64 yo) PSA went up to 0.029 a year or two ago, then back to something like 0.012-0.018 for a few quarters, then most recently to 0.015, 0.030, and 0.033 in successive quarters. None of my highly experienced and diversified team of oncs is alarmed yet, particularly since they don't even do supersensitive PSA checks at their big teaching hospital; they consider it noise based on their broad experience in the clinic, the classroom, and the research arena. If I recall correctly, they won't get concerned until it approaches 0.050 and may recommend action by 0.060 ... or was that 0.500 and 0.600 ... yeah, I think it was the latter. [I'm unclear because until it shows a clearer and higher trend, I'm more involved with many other things, from the arrival of spring (our winter ended weeks ago) to watching Donkey Kong on the news channels. I have my local VA clinic check my PSA quarterly and then I e-mail notice to my distant onc to look at the results on his VA computer. If it alarms me, him, and/or the onc team, or if I haven't met with him in a few quarters, we'll meet. Unless it goes ballistic some quarter, they'll have plenty of time to discuss my case and advise me and I'll have plenty of time to put my research hat back on. With any luck your cancer and mine may play out slowly enough to benefit from maturation of better tests, prognostication, and treatments. I'm not screwing up an apparently healthy body with a bunch of nasty chemicals until I see a clearer benefit. I haven't offered any facts for you, but maybe my and my oncs' studied low alert level conveys some useful fuzzy data. I.P. >My post-RP (Oct 04, Gleason 8, negative margins, SVI, now 64 yo) PSA >went up to 0.029 a year or two ago, then back to something like [quoted text clipped - 9 lines] >involved with many other things, from the arrival of spring (our winter >ended weeks ago) to watching Donkey Kong on the news channels. I.P., I'm curious what is the sensitivity of the PSA test in your lab? Below what level do they report as undetectable? > I.P., I'm curious what is the sensitivity of the PSA test in your lab? > Below what level do they report as undetectable? 0.006, at or below which it stayed for much of the first year. I.P. > Guys, I've dropped out for awhile, but I'm back with not-so-good news. > As my situation is relevant to this thread, I hope I can butt in w/ my > story. Welcome back, Simon. I remember you being here in '05 and marveling at the rapidity with which your doctor took you to SRT. Most docs wait for a higher number, but you definitely showed a pattern and he acted aggressively. > Now fast forward to Sept. '07. My PSA reported as 0.04. It's > repeated in October, and came back as 0.03. It's repeated early this [quoted text clipped - 3 lines] > an artifact, but her recommendation is watchful waiting, since the > doubling time is long, and to repeat PSA in another 3 months. I think she is right. After surgery, PSA is pretty much cut and dry (usually). But, after radiation, there seems to be some give and take that I don't fully understand. In your case, you're talking about a fluctuation of 2/100ths of a nanogram (which is itself 1/millionth of a gram) of PSA. As you will note in my signature, mine has fluctated at that level for years (disregard that last PSA; they used the wrong assay). I think you sould wait to see if a pattern develops. > Now, here's my question. Has anybody ever heard of the watchful > waiting practice ever applied to a 62 y.o., otherwise reasonably > healthy for his age man with the second recurrence? I don't see this as watchful waiting (WW). Usually WW pertains to people who have cancer, know they have cancer, and are watching the PSA to see how long they can go before getting it treated. You, however, are certainly not certain you have cancer. All you have is fluctuating PSA. > What do you, guys, think? It seems to me that my options are as > follows: (1) follow her recommendation, (2) get a second (and > possibly a third) opinion from another urologist ASAP, or (3) bid the > urologists good-bye and ASAP make an appointment w/ the medical > oncologist. This is on a rational basis. I would got with #1 and, if you're worried about it, #2 and #3. You may need a uro, I don't know, but if you lost your lost your last uro, for PCa you should have gone to an onc. I'd be at an onc by know if my uro wasn't so damned good at this. 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 PSAD 0.19 years EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 PSAD .056 years Lupron 07/03 (1 mo) 8/03 and every 4 months there after PSA .07 .05 .06 .09 .08 .132 .145 PSAD 1.4 years Casodex added daily 07/06 PSA <0.04, <0.05, <0.04, <0.04, <0.1 2/12/08 Non Illegitimi Carborundum >Welcome back, Simon. I remember you being here in '05 and marveling at the >rapidity with which your doctor took you to SRT. Most docs wait for a >higher number, but you definitely showed a pattern and he acted >aggressively. Hi, Steve. If I remember correctly, back in '05 there was also a difference of opinion as to what the climbing numbers meant. I looked through my PSA lab reports of that time -- usually I live pushing all this stuff out of my consciousness -- and it was interesting to see how the numbers changed over time. I was surprised to see that my first detectable PSA, 0.03 (acc. to the way our lab reports them), came out as early as April '03, less than 2 1/2 years after the surgery. Apparently, everybody, myself included, didn't make much of it at the time, since it was repeated only in Oct. '03, 0.05. I didn't even have an ongoing relationship w/ a urologist at the time, so I's pretty much scheduling my owm labs. Then, in March '04, it came out as 0.06, and my internist, while reassuring me that it most likely wasn't a big deal, suggested that I talk to a urologist. Interestingly that in June '04 it was still 0.06, but in July '04, it came out as 0.05. At that time, I spoke w/ the chief endocrinology tech at the lab, and she said that such, to her, minor fluctuations may very well be due to laboratory factors. In fact, she checked her logs and found that at least on one occasion a reagent was changed between two of my tests. And the roller-coaster continued: Jan. '05 -- 0.08, Feb. '05 -- 0.06. At that point, the same specimen was sent to another lab in the state that uses a different technology, and it came out as 0.10, w/ the caveat that it was their lowest reportable limit. I believe it was at that point that my current urologist unequivocally recommended SRT. Still, another specimen was collected that same month and flown to Houston, to my original, high power urologist, because his lab was using this newest, super-duper procedure. It came back as 0.059, and he concurred about SRT. I was again retested locally in May '05, and the result was 0.1. I guess at that point even I became convinced, but because of a severe case of sciatica and the opinion that I may not be able to lie flat still long enough for the mapping and Tx, the mapping didn't take place until Aug. 1, '05, and my first treatment was on Aug. 15, '05. On Aug. 8, '05, my PSA was 0.14. It dropped back to < 0.03 in Nov. '05. Now that I've bored you to tears w/ this minutae, the question is whether any of that experience is applicable to my current situation. Is this another time when the words of that lab tech should be considered? Or is it plausible to assume that if back then I reacted more aggressively to the first detectable PSA in '03 and didn't wait w/ SRT for over 2 years, I may not even would've been in this quandary today? >After surgery, PSA is pretty much cut and dry >(usually). But, after radiation, there seems to be some give and take that [quoted text clipped - 3 lines] >(disregard that last PSA; they used the wrong assay). I think you sould >wait to see if a pattern develops. If I'm not mistaken, the literature talks about a PSA "bump" around 18 months after SRT, but now it's been 27 months, in my case. >I don't see this as watchful waiting (WW). Usually WW pertains to people >who have cancer, know they have cancer, and are watching the PSA to see how >long they can go before getting it treated. You, however, are certainly not >certain you have cancer. All you have is fluctuating PSA. Indeed, I've never heard the WW term applied to this stage of the game, and that was a part of my scepticism about what she said. >I would got with #1 and, if you're worried about it, #2 and #3. You may >need a uro, I don't know, but if you lost your lost your last uro, for PCa >you should have gone to an onc. I'd be at an onc by know if my uro wasn't >so damned good at this. I'm leaning towards bypassing my current urologist, contacting the one in Houston for his feedback, and having an oncology consult. My equivocation about the latter is that every specialist, almost by definition, has his or her own bias. Surgeons like to cut, radiologists like to radiate, and who's to say that oncologists aren't too eager to jump in w/ their "trinkets?" This from one who, like you, chose to treat aggressively with SRT after 3 successive rises in post-RP PSA put me over 0.1. All you are sure you have right now is fluctuating PSA; no clear trend; no certainty of recurrence. FWIW, if I were in your socks, I would wait 3 months, get new PSA reading and see what that shows. With that data, any consults will be much more meaningful. Not a doctor; my opinion is worth what you are paying for it. Fred > Or is it plausible to assume that if back then I reacted > more aggressively to the first detectable PSA in '03 and didn't wait > w/ SRT for over 2 years, I may not even would've been in this quandary > today? I doubt it. I could be wrong, but I can't think of anyone who attacked it more aggressively. I was a .75 by the time I had SRT. > If I'm not mistaken, the literature talks about a PSA "bump" around 18 > months after SRT, but now it's been 27 months, in my case. I forgot all about the "bump". > I'm leaning towards bypassing my current urologist, contacting the one > in Houston for his feedback, and having an oncology consult. My > equivocation about the latter is that every specialist, almost by > definition, has his or her own bias. Surgeons like to cut, > radiologists like to radiate, and who's to say that oncologists aren't > too eager to jump in w/ their "trinkets?" I guess that points a a surgeon, since there is nothing left to cut. :-) Sy, I'm no expert and my opinion isn't worth much, but for whatever they're worth, here are my thoughts on your situation. First off, as Steve Kramer said, radiation doesn't necessarily eliminate all PSA. I'm not very knowledgeable about this, but my understanding is as follows: The high energy x-rays ionize some of the molecules of DNA in the tumor cells. What that means is that they damage the DNA, knocking electrons off and causing some unexpected chemical reactions, or failure to have expected chemical reactions, within the DNA. This doesn't necessarily kill the cells outright. It just damages them. Using enough energy to kill the cells outright would be risky because of damage it would do to the healthy cells in the path of the radiation. The damaged cells continue to "express" PSA. In fact, they may express more PSA than usual at times (the "bounce") when they are attempting to undergo mitosis - i.e., cell division and replication - and are unable to do it successfully because of the damaged DNA. So, it is possible that you have some damaged tumor cells that aren't dead yet, but aren't healthy enough to metastasize and become dangerous. It is possible that you will not need any further treatment. These cells will eventually age and die, leaving no progeny. Or, on the other hand, it's possible you've got some dangerous cancer cells that will replicate and eventually metastasize. As I understand it, unless and until the PSA shows a steady, regular rise in value, there's just no way to be sure one way or the other. In any case, it appears that you do NOT have a galloping, aggressive, metastasizing cancer. If you did, your PSA would be climbing steadily and not just wandering around at low values. Here are your options I think: ----- 1. Wait and see. This has two big advantages. First of all, it enables you to actually see what's going on. If you go on HT, the hormones will drop the PSA to undetectable and you won't know what's happening. Secondly, it avoids the side effects of HT until you really know that you need it. 2. Get on HT now. It is possible that, if you've got some cancer cells that are under stress but not dead and not going to die, removing all testosterone will be just enough to push them over the edge and finish them off. Whether that's true or not is pure speculation. The general consensus is that HT will not wipe out cancer. On the other hand, we do have evidence that men undergoing both HT and radiation have a higher percentage of good long term outcomes than men getting radiation alone. So maybe it will contribute to a better long term outcome. If it were me, and I got on HT, I would plan to take it for no more than, say, one year. Then I think I'd want to get off and see what happens. ----- Now what should you do? First, I think getting a consultation with a medical oncologist specializing in prostate cancer (I know, they aren't always easy to find) is a good idea. I don't think your urologist is doing a bad job in any way, but you're now in a realm where, as Steve J likes to say, urologists are not trained. Seeing a real specialist can't hurt. Getting a second opinion is almost always a good thing. Second, I think I would start taking all of the supplements that are thought to help with PCa. I'm thinking of, for example, pomegranate juice or extract, tomato juice or sauce or lycopene (I think the natural tomato products are thought to be better), and maybe vitamins C and D. Again, a real medical oncologist may be able to advise you. I personally believe that whatever effect these supplements have is probably pretty small. But then your PSA rise is very small. So maybe a small treatment will actually work. Thirdly, I _think_, if it were me, I'd be inclined towards the watchful waiting. I wouldn't wait long. If I started to see a genuine rising trend and it got above some fairly low figure like 0.5 or 1.0, or if the doubling time started to look aggressive, I'd hop on HT. However, I'd not want to take HT if I really didn't need it and, so far, you don't have solid evidence that you need it. But before I made any decision, I'd want to consult with a real expert if possible, not some Internet buddies who care, but don't have any serious expertise. Good luck. Alan >I had my RP 5 weeks ago but have advanced pca. My psa is already > starting to rise (0.8 at 3 weeks, 1.37 at 5 weeks). I know I have to > go on hormone therapy, most likely Lupron and Casodex, although the > specifics have not been discussed. May I assume that radiation treatment (RT) has been dismissed as a option at this point? If so, I guess because of the lymph node involvement. > I understand there are two schools of thought on when to begin > treatment, as eventually ADT stops working. > One is to start as soon as possible, given my psa, and be aggressive > with the treatment so as to give a knockout punch. The down side > being the clock starts ticking right away. Recent studies have shown longer life with agressive treatment. I cannot cite them, but they have been posted in this NG within the last six months. I credit my 'long life' partially to aggressive treatment by my doc. Every indication pointed to this being my last year on this rock, as opposed to buried 6 feet within it, but I'm still walking around with an undetectable cancer. I still doubt that I'll see 2015 (when the 'cure' had been predicted), but I will almost certainly see my retirement plans come to fruition in 2011; my Godson become a LasVegas Metropolitan Police Officer and marry; at least four of my grandchildren start Elementary School; etc. We have repeatedly said we are not doctors, but with your PSA climbing so fast after surgery, I sincerely don't believe you have an option of waiting. > The other is to wait for signs of mets, and/or symptoms, and then > start treatment, the thought being the time spent without treatment is > that much extra time I will have before the ADT timetable runs its > course. I don't believe I have heard anyone in modern medical history purposely wait for signs of mets or symptoms (which would me generated from mets). I would suspect that ADT is much less effective once mets have established themselves in bone. > I have appts. with my uro and a med. onc but they are a month away, > hence this post. I'd say your uro is out of a job, wherein your cancer is concerned. Nothing personal, but all he can do now is help with any urinary or sex issues you might have. I think that I would call the onc and tell him how fast your PSA is rising and ask if he can see you sooner. Ordinarily, I would say a month is good, but not when your PSA has nearly doubled in two weeks. > I also suspect radiation will be advised, so I have the same question > about that as well. I addressed that above. I will be very interested to see if it is. On one hand, having found it in your lymph nodes, most doctors would have stopped the surgery so that you didn't suffer the effects of having your prostate cut out for no good reason. Few doctors believe that de-massing the cancer is good for you and worth a little incontinance and impotence. My uro and I discussed this beforehand and agreed that if there were lymph in the nodes, I was going to keep the cancer prostate. As it turned out, I lost the prostate and still had cancer outside -- Dammit!! Well, you can only do what you can do. > For the record, this was not an easy topic to post, as I don't expect > any encouraging answers, but I do have to make a decision, don't > I........ All of us have gotten that first diagnosis that you suffered through last year. Most of us have had that second punch to the gut telling us we still have cancer in us. By the second one, most of us were ready to handle it. But, I can tell you I was not ready at Week 5 and cannot imagine that you are either. My only encouragement I can offer is that you do have years to live. Furthermore, when you and I are finally planted, you will have seen more years than I. No, sir. I think we can offer you support and assistance with your decisions at this point. Once you get your post ADT PSAs, we might be able to offer encouragement. I sincerely hope so. 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 PSAD 0.19 years EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 PSAD .056 years Lupron 07/03 (1 mo) 8/03 and every 4 months there after PSA .07 .05 .06 .09 .08 .132 .145 PSAD 1.4 years Casodex added daily 07/06 PSA <0.04, <0.05, <0.04, <0.04, <0.1 2/12/08 Non Illegitimi Carborundum > I don't believe I have heard anyone in modern medical history purposely wait > for signs of mets or symptoms (which would me generated from mets). Walsh still supports it, and says other doctors do, too. > I would > suspect that ADT is much less effective once mets have established > themselves in bone. But he agrees that once PC hits bone, ADT must start immediately for the sake of QOL. I.P. >> I don't believe I have heard anyone in modern medical history purposely >> wait for signs of mets or symptoms (which would me generated from mets). > > Walsh still supports it, and says other doctors do, too. I know he was a long-waiter in his 2000 book. He still wants to wait that long? PCa feeds off bones fairly easily. Stopping testosterone after giving it another food source just seems counterintuitive to me. > >> I don't believe I have heard anyone in modern medical history purposely > >> wait for signs of mets or symptoms (which would me generated from mets). [quoted text clipped - 4 lines] > long? �PCa feeds off bones fairly easily. �Stopping testosterone after > giving it another food source just seems counterintuitive to me. Thank you for all that information....I am new to these type of tretaments and appreciate hearing about them. I described my pca as advanced because I have a gleason of 9 (post op biopsy) and 2 lymph nodes were biopsied and removed, so it has spread to the lymphatic system. I do have a bone scan scheduled for the end of the month, otherwise nothing is going on until I see my doc. Ironically, I feel great, finally.. all my bodily functions are working very well (except one, of course...no nerve sparing...but that hasn't prevented :) ...), I have a great appetite, exercise on a treadmill every day and have a pretty good outlook...way better than compared to pre RP. I know a case can be made that I never needed it out to begin with but I have no regrets in that decision....who wants a big ball of cancer spreading around my sensitive areas? I'm just reluctant to give up this little period of finally feeling good and trade it in for the wrong treatment, resulting in fatigue, joint pain, and depression...not good for me. So I will find out how to counter side effects of whatever I end up using and try to stick this out. Thanks again. I think my question was at least answered...I will act sooner rahter than later. > I'm just reluctant to give up this little period of finally feeling > good and trade it in for the wrong treatment, resulting in fatigue, > joint pain, and depression...not good for me. If your testosterone recovers, you can usually reverse most of the SEs within several months by stopping the ADT. > I think my question was at least answered...I will act > sooner rahter than later. I would never base a decision that big on an internet discussion. Our intent is to alert you to some of the decision factors and suggest sources for further reading. This tiny little thread is but a drop in the bucket of ADT discussions in this forum's archives, and the archives are but a drop in the bucket of information available in the real and virtual literature. A drop squared is but a speck in a tub. Because one can always quit ADT (and hope his T recovers), it's not necessary to research ADT for the hundreds of productive hours the literature offers, but in any case I'd read much more than this thread or this forum offers. Of course, your bone scan may answer many of your ADT questions for you. just as your lymph node involvement answered many of your SRT questions. Keep us posted. I.P. Thank you for all that information....I am new to these type of tretaments and appreciate hearing about them. I described my pca as advanced because I have a gleason of 9 (post op biopsy) and 2 lymph nodes were biopsied and removed, so it has spread to the lymphatic system. ==> 9! Damn. I though it was 8. I have a great appetite, exercise on a treadmill every day and have a pretty good outlook...way better than compared to pre RP. ==> If you go on ADT, that will help you greatly with side effects. I'm not saying that I suffer no fatigue, but walking sure does help. I know a case can be made that I never needed it out to begin with but I have no regrets in that decision....who wants a big ball of cancer spreading around my sensitive areas? ==> There is a lot to be said for that. At least whatever your treatment(s) is(are) going to be, there will be a whole lot less cancer for them to work on initially. 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 PSAD 0.19 years EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 PSAD .056 years Lupron 07/03 (1 mo) 8/03 and every 4 months there after PSA .07 .05 .06 .09 .08 .132 .145 PSAD 1.4 years Casodex added daily 07/06 PSA <0.04, <0.05, <0.04, <0.04, <0.1 2/12/08 Non Illegitimi Carborundum On March 1, Steve K replied to "Freely": Quoting "Freely": >>> I don't believe I have heard anyone in modern medical history purposely >>> wait for signs of mets or symptoms (which would me generated from mets). >> Walsh still supports it, and says other doctors do, too. Steve K wrote: > I know he was a long-waiter in his 2000 book. He still wants to wait that > long? PCa feeds off bones fairly easily. Stopping testosterone after > giving it another food source just seems counterintuitive to me. It's not only counterintuitive, it's contrary to what real PCa specialists do. Remember, Walsh is a uro, a surgeon, not a cancer specialist. Uros have their appropriate place, and it does not extend beyond surgery. Here's another view, by Stephen B. Strum, MD: "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." Regards, Steve J > I had my RP 5 weeks ago but have advanced pca. My psa is already > starting to rise (0.8 at 3 weeks, 1.37 at 5 weeks). I know I have to [quoted text clipped - 5 lines] > with the treatment so as to give a knockout punch. The down side > being the clock starts ticking right away. I am hardly an expert on this subject, but it was my impression that the time at which you start hormone treatment doesn't limit how long it will be effective. One theory is that it is the hormone resistant cancer cells that get you in the end, and the reason HT eventually fails is that those cells proliferate enough that controlling the hormone dependent cancer cells doesn't do any good. According to this point of view, the reason for delaying HT is to put off the side effects of such treatment as long as it is safe to do so. Walsh and other argue for such a strategy and point out that once HT is begun, PSA levels go way down and stay there. So it would be as if you had some time limit before the hormone resistant cells became the main problem, and when you started HT, it would remain effective for the remainder of that period. Since it wouldn't materially affect your life span, the reason for beginning HT would be primarily to put off symptoms of advanced prostate cancer. On the other hand, the argument for starting HT early is that it may prevent HT sensitive cells from mutating to HT resistant cells, thus giving you a longer period in which the cancer is controlled. Those accepting this point of view argue that you will extend your life span by choosing early treatment. According to either theory, it would seem that the date in the future at which HT became ineffective wouldn't be decreased by the treatment. In the first case, it would stay the same, and in the second case it might be put off for a while. But of course, there are other considerations such as quality of life both because of the treatment and because of the cancer. It is my impression that the science is still unsettled, Noone knows for sure which argument (or possibly some entirely different theory) has more validity. If I were your your situation, I would talk to my doctors, make sure I understood the state of current knowledge as best I could, and then make the best decision I could under the circumstances. As with all aspects of prostate cancer, there is no certainty in any of this, so you have to figure out what you think the odds are and go with that. Even if the science were totally settled, one never knows what will happen in an individual case, and of course we hope that research will come up with better treatments in the near future. > The other is to wait for signs of mets, and/or symptoms, and then > start treatment, the thought being the time spent without treatment is [quoted text clipped - 7 lines] > any encouraging answers, but I do have to make a decision, don't > I........ > I had my RP 5 weeks ago but have advanced pca. My psa is already > starting to rise (0.8 at 3 weeks, 1.37 at 5 weeks). I know I have to [quoted text clipped - 16 lines] > any encouraging answers, but I do have to make a decision, don't > I........ Related article..... Androgen Suppression Improves Outcomes in Some Patients with Early Prostate Cancer http://www.ustoo.org/Article_1.asp?display=article&id=41193 If the lymphatic invasion didn't spread the $64K question then ADT & SRT could offer best outcome. However I only had extracap extension and radiation didn't stop the spread so I don't know. Skeptic, I'd like to make one more point about ADT. There are side effects, no doubt about it. I couldn't imagine what it would be like to look at a beautiful woman and not remember why I got so excited in the past, but that's what happened. My libido dropped to near zero. I also had a significant decline in the amount of exercise I was able to do. And I had hot flushes and some joint pain. Now, having said all that, I'll go on to say that it didn't knock me out. To begin with, I was resolved to go on living a full life. I did not experience mood swings or depression. I had more depression before treatment when I thought I was going to die and hadn't yet resolved to deal with it. But at some point I realized that, while I was still alive, my moods and my feelings were under my control. ADT did not make me depressed. Secondly, I found that, although I couldn't exercise as much as before, I could still exercise. I did plenty of flexibility and strength exercises for my hands and banished the joint pain I had in my fingers. I did some aerobic exercise too and, while I couldn't do nearly what I could do before, I still did more than enough to have plenty of energy available for all the activities of daily life. Finally, to my greatest surprise, I found I could even have sex. I had to go through the motions, as it were, for 10 or 15 minutes before I began to really get excited, but it did happen, and it was just as satisfying as before. I didn't do it often, but I did it. So if you have to go on ADT, and it looks like you do, resolve that you are going to deal with it and come out a winner. It's possible to do. Good luck. Alan
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