Join Date: Nov 2007
Location: Annandale, VA, USA
Re: Hormonal Therapy or No Hormonal Therapy:
Hi again and happy 4th of July ,
I'll respond here, as this thread is a better fit title wise than your parallel question in the other thread. I suspect you did not get responses because most of us are busy because of the July 4th celebration. My wife and I have enjoyed making preparations, but it has taken some time.
I'll intersperse some comments in green in your post below.
Originally Posted by bwhitney
I seem to have three options here. Met with a radiation oncoligist here in Charleston. Wants to due bracytherapy and beam therapy and start me on hormonal therapy with a planned duration of up to 2 years - because the numbers support its use for best results. That strikes me (remember my layman status, now savvy but no medical credentials) as a sound and standard approach. That combination will allow a heavy dose of radiation inside the prostate plus a lighter but still ample dose outside. At least one study indicated that two years of hormonal therapy in support of radiation was better than just six months. For cases that have at least one higher risk characteristic (such as a Gleason of 8), studies have also shown that there is a significant advantage to using hormonal therapy in support. For lower risk cases, there is still some advantage, but it is pretty small; you can make a good argument that for most men with low-risk cases this minor advantage is not worth the time on hormonal therapy. I'm impressed that your doctor is using an approach well supported by research.
Won't the effects be permanent by that time? It's highly unlikely that the results will be permanent in just two years. Permanency is also far from a sure thing beyond two years , though the risk steadily increases for men of age 70 and older. It is possible for men younger than 70 to have permanent effects with hormonal blockade for just two years or less, but my strong impression is that that is quite unlikely.
While prostate cancer is so variable that you cannot conclude much from a single case, mainly just what is possible - not what is likely or typical, I started hormonal therapy (Lupron) at age 56, soon adding Casodex, and adding finasteride nine months later. I remained on the heavy duty drugs (Lupron and Casodex) for 31 months - well over two years, making me 59 at the time. After stopping the drugs, side effects had eased greatly after two to four months and were virtually gone by the sixth month away from the heavy duty drugs. Thus, I had no problem with permanency. (By the way, my time on therapy, my strategy, was based on the time it would take me to get my PSA below 0.05 and keep it there for a year. Now, a number of years later in 2009, some of the same experts (such as Dr. Mark Scholz, MD) are satisfied just to get the PSA down to 0.05 without being so concerned about the year. Most men will get it that low (below 0.05) within a few months, but it took me longer, as I had (and probably still have) a prostate that is loaded with cancer.) By the way, the 0.05 target was probably based on PSA technology that had been available in the latter 90s. Now, at least one test (Immulite Third Generation by the Diagnostics Product Corporation), can reliably measure PSA in a routine clinical setting with routine test procedures in the lab to less than 0.01. At least one expert, Dr. Charles Myers, aims to get PSA to that level before switching to intermittent therapy, as I recall.
I had been aware that I was running a modest risk of permanent side effects, but I was (and am) a lot more interested in controlling the cancer, and thought it a risk worth taking. Also, some of the leaders in intermittent hormonal therapy are not so concerned with permanent side effects of blockade because countermeasures during therapy can reduce the risk, and supplemental testosterone, if needed, can be given safely to most of us during off-therapy periods (or post-therapy for you, since you are expecting just one round of blockade that lasts two years). I know that supplemental testosterone sounds like a strange prescription for prostate cancer patients who have had hormonal blockade therapy aimed at minimizing testosterone, but it seems to work well for many AFTER the heavy-duty drug phase the minimizes testosterone, based on what I've heard and read.
Dattoli Clinic wants to use hormonal therapy short term, perhaps a total of 6 mo's. before, during and for 2 mo's after treatment. With most radiation doctors, I believe I would want a longer period of hormonal therapy. But Dr. Dattoli is one of the brilliant pioneering radiation physicians treating prostate cancer, and his special case staging techniques and therapy delivery techniques, would have an excellent chance to lead to a fine result. (One of his techniques is to use the results of a simple blood test known as Prostatic Acid Phosphatase.)
Dr. Dattoli has had his research on its usefulness published in peer reviewed medical journals. He also is very ready to use Combidex or Fusion ProstaScint scans, as well as a number of other scans, tests and staging procedures, where he deems them wise. For most of two decades he has paid close attention to results in his patients, and he is confident in what works. Moreover, he has had the confidence, talent and respect to have his studies published in prestigious journals. He is also one of the leaders in teaching other doctors how to perform radiation for prostate cancer patients. Dr. Charles "Snuffy" Myers, MD, an eminent medical oncologist specializing in prostate cancer who has had to cope with his own challenging case of metastatic prostate cancer, chose Dr. Dattoli to handle the radiation part of his combined therapy. (Incidentally, he has an undetectable PSA, ultrasensitve test, now at the ten year point.) I would have the highest confidence in having Dr. Dattoli and his team handle my case.
Here's one of his recent papers demonstrating remarkable long-term success in treating intermediate and high-risk patients with his approach. (By the way, he has been steadily improving that approach throughout his career, so results for patients treated today would almost certainly be even better than the already remarkable results described in the paper:
"Long-term outcomes after treatment with brachytherapy and supplemental conformal radiation for prostate cancer patients having intermediate and high-risk features."
Dattoli M, Wallner K, True L, Cash J, Sorace R.
Cancer. 2007 Aug 1;110(3):551-5.
You can go to www.pubmed.gov, a site we can use on this board because it is Government sponsored, and find that paper; for instance, try the search string " dattoli m AND prostate cancer " (without the quotation marks). If you click on the hypertext authors list you can get a free abstract of the paper. PubMed also happens to provide a free link to the entire paper.
Spoke with the Radiation Centers of Georgia today. They have a very similar course of treatment as the Dattoli Clinic but do not like to use hormonal therapy.
That sounds better to me but is that the wisest decision? RCOG has an excellent reputation for their ProstRCision approach and a highly commited core of former patients. Their approach actually has a significant difference from the Dattoli approach: RCOG inserts seeds first and then does external beam therapy, while Dr. Dattoli does the reverse. Dr. Dattoli is convinced doing it his way is superior, but RCOG no doubt would argue the reverse.
One of the two things that worries me about RCOG's approach is that they apparently, from what you have learned, still do not like to use hormonal therapy. I had heard and seen that in the past, but in light of accumulating medical research on the value of hormonal therapy for intermediate and higher risk cases, I had thought RCOG would have changed their position by now.
To me, the evidence in favor of a substantial role for hormonal therapy in support of radiation for higher risk cases is clear: it makes a substantial difference in survival and in avoiding recurrence. If anyone knows and can explain RCOG's take on that, in other words their policy and their view of the accumulated research, I would really like to know, especially if they have some credible evidence to back up their position. Research on low-risk cases does not really count here and should not be mixed with research on intermediate and higher risk cases as doing so would cloud the picture. For low-risk cases, hormonal therapy is certainly useful where needed to shrink the prostate, but that is a separate issue from the question of whether hormonal therapy makes a difference in outcomes. As I mentioned, it looks pretty clear that it does make a substantial impact for the right kind of case.
The other thing that troubles me about RCOG is that they have drastically changed their record of publishing research about their outcomes. You can see that easily if you go to PubMed; here's one search string you could try: " critz fa [au] OR williams wh [au] AND prostate cancer AND radiation ". I just used that string and got ten hits. What's so striking is that between 1995 and 2004 the RCOG team published ten papers - quite impressive for a non-university group that is mainly focused on treatment rather than research: moreover, all of them are in major, peer-reviewed journals, mainly Urology or the Journal of Urology, but also the Journal of Clinical Oncology and Cancer. Then, since 2004. NOTHING! Looking a bit deeper, RCOG was publishing annually: 1 paper in 1995, 1 paper in 1996, 2 papers in 1997, 1 in 1998, 2 in 1999, 2 in 2000. All of these papers had several co-authors, and all had abstracts that we can now read in PubMed; the complete papers were two to eight pages long, with six of them ranging from four to eight pages - pretty typical for medical research papers. Then there's a gap of three years until 2004, and that 2004 paper is authored only by Dr. Critz - no teammates, is only three pages long, and has no abstract. The pattern is especially strange as Dr. Critz had been such an energetic advocate of his approach to his medical peers.
The book many of us think of as the bible for prostate cancer patients - "A Primer on Prostate Cancer - The Empowered Patient's Guide", Dr. Stephen B. Strum, MD and Donna Pogliano, discusses one of the 2000 RCOG papers on pages 101 and 102. The paper shows results to seven years after treatment for men with PSAs up through 20, and to six years for men with PSAs greater than 20. All groups have some fall-off as a percentage of men recur - with little recurrence for those with PSAs not exceeding 10 (94% at the five year point and looks flat - not falling, after that to seven years, and with recurrence rates at five years of 75% for the >10 but not exceeding 20 group, and 69% for the group with PSAs over 20, and both lines looking fairly flat from about the fourth year of followup.
Here's a sentence from the abstract of the Dattoli paper I mentioned - the one on the success of his approach in intermediate and higher risk men: "... Overall actuarial freedom from biochemical progression [means percentage of patients who did not have recurring cancer] at 14 years was 81%, including 87% and 72% having intermediate and high-risk disease, respectively...." You can see that at up to 14 years of followup, with an average of over nine years, compared to the RCOG results at five years, the Dattoli group is achieving 87% freedom from recurrence for intermediate risk patients compared to 75% for RCOG. That is a substantial difference!
What I'm concerned about is that longer follow-up in RCOG's internal, unpublished data might suggest that some of their patients are not doing as well as expected as the length of their follow-ups from time of treatment has increased. Perhaps their low-risk patients are fine, but perhaps not their intermediate and high risk patients. I don't know any of that - I'm just supposing, but I'm really concerned, and, as you can see, there is sound evidence that warrants concern. Personally, I would not accept treatment, even if I had a case like yours, at RCOG until I were satisfied about the research and about their stand on hormonal therapy used in support for intermediate and higher risk cases. Possibly, they have stopped publishing just because they do not want a head-to-head comparison with the Dattoli and other groups. That would be a very poor answer! By the way, the Seattle Prostate Institute, perhaps the other best known radiation group for prostate cancer (also described in the Primer on page 102), like Dr. Dattoli and unlike RCOG has continued to inform the prostate community of their outcomes! That's the way things should be done!
I'll admit to being more than a bit irritated by RCOG's failure to update their results for the benefit of the entire prostate cancer community - patients, doctors, and researchers. I believe they owe that to us! I remain hopeful that RCOG will clear all this up in a favorable way.
Dr. Dattoli is careful, highly expert and discriminating in how he uses hormonal therapy. You can read more about that in his book "Surviving Prostate Cancer Without Surgery - The New Gold Standard Treatment that Can Save Your Life and Lifestyle."
Any answers out there? As you can see, with the aid of PubMed and other sources, there actually are answers out there.
Take care, and good luck with your research,