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Old 12-09-2009, 03:13 PM   #1
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androgen deprivation and heart risks

Those of you who are taking or are considering taking LHRH agonists (Lupron, etc.), or other androgen deprivation (hormone) treatments may be interested in a study published December 7, 2009, in the Journal of the National Cancer Institute entitled: "Diabetes and Cardiovascular Disease During Androgen Deprivation Therapy: Observational Study of Veterans With Prostate Cancer." You can find some articles about this if you search online for "Prostate Hormone Therapy May Up Heart Risks." None of this suggests that patients should not be on androgen deprivation -- it just says there are non-trivial risks so need to balance the likely beneifts against the risks.

 
Old 12-09-2009, 06:27 PM   #2
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Re: androgen deprivation and heart risks

Hi medved,

I'm responding to your first post in this new thread. I'm glad you brought this up, because many men are not being advised as well as they could and should be about hormonal therapy, its benefits, and its risks, and this new paper and associated commentaries appear to be examples of this substandard advice.

My first reaction to those recently pointing out cardiovascular and diabetic risks, as well as other risks such as the risk of decreased bone density, is "No foolin' Sherlock!" It really is a sign of some progress that many more doctors finally seem to be appreciating these risks, which are potentially serious, as they say. It also really is a sign of the sluggish speed of the spread of medical knowledge that has taken so long for the larger medical community involved with prostate cancer and hormonal therapy to begin to recognize these risks and take them seriously. To me, its further evidence that there are at least two classes of doctors using hormonal therapy and discussing it with patients, and the second class lags far behind the first!

Put bluntly, this is not new knowledge. In fact the first class doctors, the ones I consider experts in hormonal blockade, have not only been advising patients about these risks for years, but they have also researched and confirmed countermeasures that greatly reduce the risks, based on success that they have demonstrated and documented. One way to tell the doctors giving you second class advice is whether they advise you about countermeasures; if not, well, if you want to stick with the doctor, you need to learn about the countermeasures for yourself! (And, maybe educate your doctor, which can be a delicate matter.) I believe many of the doctors giving substandard advice are fine physicians, they just lack the benefits that come from specializing in prostate cancer as the leading experts often do (which means they probably are not as good as the non-specialists in handling other cancers and diseases).

Just as one example of first class advice, check page 153 (2002 edition) of "A Primer on Prostate Cancer - The Empowered Patient's Guide." It summarizes what the authors identified as the seven most common elements of the "Androgen Deprivation Syndrome", giving details of the onset time, grade, severity divided into milder and more serious, with percentages for the likelihood of each as well as the summed total likelihood of the element. The seven were mental/emotional changes; bone and joint pain; gynecomastia; anemia; hot flushes; weakness; and hypercholesterolemia. Elsewhere in the Primer other side effects of androgen deprivation are described, such as a degree of impotency on page 151 and a decrease in bone density on pages 142-143, B20-B22, and elsewhere. There are mentions of diabetes and insulin in the Primer, but the recognition of those threats in relation to ADT has increased since 2002. The Prostate Cancer Research Institute has publications on all of these, I believe. They have been discussed by Dr. Charles Myers in his Prostate Forum newsletter for years. The Primer and the newsletters discuss countermeasures and provide leads to more detailed discussions. I put my own views and some leads in a long reply (#5) in the thread "Disturbing lack of bisphosphonates therapy for bone density , met" (started 4/29/2009).

In your post you wrote the following, picking up the gist of what the authors and commentators were saying:
"None of this suggests that patients should not be on androgen deprivation -- it just says there are non-trivial risks so need to balance the likely beneifts against the risks." I do not have a problem with that, provided that the assesment of risks includes countermeasures, which are highly effective for many of us (including me!). I have a huge problem with doctors who blithly, ignorantly tell their patients about the risks without discussing the importance, role and effectiveness of countermeasures! Unfortunately, sadly, as I indicated at the start, my impression is that often there is no discussion of countermeasures. Just last night I saw an example of that. Our support group had a panel of some excellent local physicians treating prostate cancer - a urologist, a radiation oncologist, and a medical oncologist. The urologist did just what I'm highlighting here: he listed some of the key potential side effects of androgen deprivation including those in the research paper you mention, stressed their potential seriousness, but said not a word about countermeasures. I'm not faulting him for that, though I hope he will learn about countermeasures, and I plan to contact him. I'm faulting the system for not doing a better job of helping doctors keep up. Even urology experts like Dr. Eric Klein, MD, from the famed Cleveland Clinic, who commented that hormonal blockade was perhaps used where the risks outweighed the benefits, is probably not well aware of the role of countermeasures.

Thanks for this opportunity to vent some of the steam I build up last night. I did not say anything at the meeting because we are grateful for presentations by the doctors and the last thing any of us want to do is embarrass them.

Here's my own experience with the cardio and diabetes risks and countermeasures over ten years of intermittent hormonal blockade. First, probably the most important, I'm on intermittent therapy - going on and off the heavy duty drugs, especially the LHRH-agonist, which for me is Lupron; the experts I follow are also concerned that long-term continuous hormonal blockade should not be used unless the patient has metastases or other very challenging case features. That is still controversial, but I'm firmly convinced as a savvy layman that intermittent therapy is usually better. Second, I'm on the generic statin simvastatin, which is especially important because I tend to run a high cholesterol without the drug. Third, my diet, food choices, and supplement use are all designed to be healthy from the perspectives of prostate cancer, cardiovascular disease, and diabetes. (There are some trade-offs, but I'm aware of them.) As one example, fish oil and fish have several benefits for prostate cancer and for other health concers; one benefit of taking several thousand units of fish oil a day is a huge drop in the risk of sudden cardiac death , one of the risks mentioned I believe in the study you brought to our attention. Fourth, I exercise regularly, including both aerobic and strength elements, and, related to the nutrition and exercise, I work on keeping my weight within bounds, which is a challenge on hormonal blockade therapy. Fifth, I get monitored regularly, including a lipid battery yearly. The result: this year on July 6 my total cholesterol was 198, my calculated LDL was 101, but my good HDL was a whopping 87, resulting in a quite favorable ratio, and my triglycerides were a low 49, a good number, especially in relation to the HDL.

There are more aspects of this specific study and commentaries that could be discussed, but I'll rest my case for now and get ready to answer any questions. I really am sympathetic to the talented and well-intentioned doctors who don't specialize in prostate cancer, let alone hormonal therapy, who give us substandard advice. I'm convinced that hormonal therapy for prostate cancer is a field where specialization has given a few doctors a great advantage in expertise. Come to think of it, the other docs are really giving us "standard" advice, not "substandard"; it's just that their standard advice is not as good as it needs to be and could be.

That's my two cents as a now fairly savvy layman ten year survivor of a challenging case, but with no enrolled medical education.

Take care,

Jim

 
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Old 12-15-2009, 05:03 AM   #3
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Re: androgen deprivation and heart risks

hi..
these posts got me curious about the cardiovascular effects of hormonal blockade. dad is doing well as far as PC & response to hormone therapy is concerned (knock on wood) but he has a history of heart problems. he suffered from MI (heart attack) 8 yrs back bt their was no blockade evident in angiography and he has been doing quite well since then. he is on continuous statins and his cholesterol levels are well within limits total cholesterol 110 approximately. he exercises regularly and we monitor his diet carefully.
are their any other countermeasures we need to know since he is on hormonal blockade now?

 
Old 12-15-2009, 06:27 AM   #4
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Re: androgen deprivation and heart risks

I am not sufficiently knowldedgeable to answer your question -- I know only enough to spot the issue. But I suggest that your dad consult with his cardiologist, tell the cardiologist that he is on hormonal blockade for prostate cancer, and ask about any measures that should be taken. At a minimum, I wouold think more frequent monitoring would be warranted.

 
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