when are hormone shots necessary in the treatment of prostate cancer

[butch121]

when are hormone shots necessary in the treatment of prostate cancer

[IADT3since2000]

Originally Posted by butch121

when are hormone shots necessary in the treatment of prostate cancer

Butch,

You used the word "necessary," but I would like to expand that slightly to desirable, and when you wrote "hormone shots," I would like to expand that to "hormone therapy" since some hormonal blockade therapy is delivered by an implant in the arm and not a shot (for example, Viadur is delivered that way). I'm not going to describe use of hormonal blockade as the primary therapy for low-risk patients, because that is an optional and not "necessary" use and is not clearly more desirable than other therapy options; in fact, it has a much shorter and less researched track record as primary therapy. (It still looks highly promising to me.)

Basically, hormonal blockade therapy, usually with an LHRH-agonist drug that stops the production of testosterone as the foundation, is necessary when prostate cancer is recognized as being systemic, meaning it is no longer localized in and immediately around the prostate, and also is beyond the likely range of radiation therapy. Usually systemic disease is thought of as being spread out in the body, but sometimes it is located in only one or a few places.

Hormonal therapy is also typically at least part of treatment when a man develops metastatic prostate cancer. It can be remarkably effective against metastases for a while.

Another use that I would class as desirable but almost necessary is to support radiation therapy. For cases that are somewhat challenging, patients getting radiation often do much better if they also get some hormonal blockade therapy, and there is evidence that several years of blockade is better than just a few months. There is a little evidence that hormonal therapy may also help boost effectiveness of surgery for some men, but that is controversial.

There are other options to the shots and implants, and they work basically by blocking testosterone and its relatives from docking with the cancer cell, which is necessary for growth. Some therapies just use antiandrogen drugs, like Casodex or flutamide, perhaps with either finasteride or Avodart. Those drugs do not stop the production of testosterone, and therefore they don't cause the side effects that stopping testosterone often causes to some degree (which can be fairly well managed for most of us). However, the antiandrogens often have some side effects of their own, and the antiandrogens are not as good as controlling the cancer for most of us. But, that said, I've heard one leading doctor say that this approach works for some patients as it delivers 80% of the benefits but only 20% of the side effect burden. Choosing this antiandrogen option depends on the balance between controlling the cancer and quality of life. For example, for a man in his 70s with low-risk, slow growing disease or a mild recurrence after surgery or radiation, this approach might work well. New research involving estrogen patches is showing some promise as another alternative.

I have been on intermittent hormonal blockade therapy for just over eight years for my challenging case of prostate cancer, and I am doing very well. For most of the time I have been on therapy, it has been the triple hormonal blockade version with Lupron, Casodex and finasteride, with Fosamax or Boniva in support of bone density. I am a fellow survivor and have never had any enrolled medical education.

I hope this long answer to your short question is not overwhelming, and I hope you get to see some other viewpoints.

Take care,

Jim

[able5]

Originally Posted by butch121

when are hormone shots necessary in the treatment of prostate cancer

Hormone therapy is the most effective treatment for men with metastatic prostate cancer. The effectiveness of treatment is evaluated by serial assessment of symptoms, scans and PSA. Nearly all men initially benefit from treatment and most will continue to benefit for at least 18 months before additional treatment is necessary.

[IADT3since2000]

Originally Posted by able5

... Nearly all men initially benefit from treatment and most will continue to benefit for at least 18 months before additional treatment is necessary.

I can really understand where able5 is coming from, and he includes the words "at least" in the statement, which makes it correct and optimistic, which is appropriate. But so many people focus on the "18 months" that they have a severly warped, pessimistic concept of the effectiveness of blockade, and I want to address that.

There is some very good news for anyone who is under the impression that the benefit of hormonal blockade treatment is limited to 18 months. Bottom line: it is a MYTH; blockade is effective for far longer for the vast majority of us, with the exception being those with widespread (and especially, if painful) metastases to the bone when the hormonal blockade drugs are started. As Mona Lisa Vito responded in the movie My Cousin Vinnie when asked if her explanation of that tell-tale photograph of tire tread marks was just a theory, the statement that the 18 to 24 months view is a myth is not just a theory, "It's a fact!"

As a veteran of eight years of intermittent triple hormonal blockade and a survivor-representative participant in a number of cancer research medical conferences, research proposal reviews and FDA hearings, I have heard that figure or a variation, 18 to 24 months, stated a number of times, usually without able5's "at least", sometimes by some highly respected physicians, though none of them experts in hormonal blockade. I've heard the figures stated confidently about both patients who were detectably metastatic and those, like me and the vast majority of us, who were not. Those figures also figured prominently in the initial prognoses of five years survival (three good quality of life, two declining) that I received from two respected physicians. So if I seem to be on a soapbox, I am! (By the way, I'm not the only one on this soapbox. This myth also drives the expert blockade doctors nuts who hear it frequently from their physician colleagues who are not well-versed in blockade treatment (but who frequently are managing their patients on blockade), and it also includes fellow survivors like myself who have had to learn the ins and outs of blockade for their own well being and even survival.)

First, the short-effectiveness view is obviously not true of my own challenging case, featuring an initial PSA of 113.6, GS 4+3=7, all biopsy cores positive, most cores 100% cancer, perineural invasion, and staging T3 with suspected seminal vesicle involvement, though CT, bone and ProstaScint scans were essentially negative. I have been on hormonal blockade intermittently since December 1999, and in the last phase of both full therapy periods my PSA nadir was less than 0.01 using an ultrasensitive PSA test (spring/summer 2002 and December 2006). That proves hormonal blockade has been effective for me.

I have also been in close touch with fellow survivors on continuous and intermittent hormonal blockade as well as several doctors who are expert in that therapy, and their experience is also that hormonal blockade is highly effective for many years for the vast majority of us. It does tend to be less effective for the total group of men with detectable metastases, but it still generally works far longer than 18 to 24 months for those with milder metastatic disease, and the outlook is improving even for patients with more serious metastases.

But so far this evidence is just my own case and personal contacts. While that is hopefully somewhat useful to those trying to learn about hormonal blockade, the best evidence requires rising above our own personal experiences and contacts and looking at scientific evidence. Without that, we are essentially mired in the low-level evidence of anecdotes, which may be fine for mutual, supportive commiseration, but does not get you where you need to be in order to make the best choices involving issues of quality of life and life itself. Anyway, that's my story, and I'm sticking with it.

Here's one piece of the key science for those who really want to know and are willing to invest some effort in looking at it.

A key early paper, and apparently an unintentional source for the myth, is "A controlled trial of leuprolide with and without flutamide in prostatic carcinoma. Crawford ED, Eisenberger MA, McLeod DG, Spaulding JT, Benson R, Dorr FA, Blumenstein BA, Davis MA, Goodman PJ. N Engl J Med. 1989 Aug 17;321(7):419-24. PMID: 2503724 (The authors list has some of the major names in prostate cancer research.) Dr. Charles Myers gave us a summary of the results, which involved not just a few men but 603 men, in a presentation at the National Conference on Prostate Cancer 2005, speaking about the average time from starting hormonal therapy until the disease progressed to resistance to that therapy. Here are the key facts:

For men with wide spread bone mets + pain -- 8 months

For men with wide spread bone mets but without pain -- 18 months

For men with few bone mets in the hip and spine -- 4 to 5 years
(30 to 40% still responding to hormonal blockade at 9 years!)

This study only involved men with stage D2 cancer, which means metastasis to distant lymph nodes, or metastasis to bone or visceral organs. It's not hard to realize that men without detectable disease would generally do much better. Also, the trial involved giving the men the equivalent of Lupron or Zoladex with or without flutamide. To me it is virtually certain that they would have done even better with more modern approaches, such as triple blockade with a bone density medication and associated supplements in support. (While I'm writing confidently, please keep in mind that I am a fellow survivor who has studied this for some time but have never had any enrolled medical education.)

You can see the 18 month figure, and bear in mind that in 1989 many men were first diagnosed at a stage where they were already metastatic. In other words, such men were typical. Unfortunately, many physicians and researchers seem to have latched on to 18 to 24 months for the "typical" prostate cancer patient without realizing that patients being diagnosed or recurring today have far, far superior case characteristics. When I go to medical conferences, I take copies of some of this data and show it to researchers who have the wrong information. They are usually quite surprised because the "18 to 24 months" figures are so firmly imbedded in the conventional wisdom.

You can see from the data in the paper that we should be thinking of the effectiveness of hormonal blockade in terms of a minimum of years of effectiveness except for very advanced patients, and even some of them are doing very well today, as a percentage were even in 1989 with the much less advanced treatments then available.

Other research has produced results that generally confirm this much more upbeat view of hormonal blockade. One of the experts in hormonal blockade therapy, Dr. Mark Scholz, says that it typically works for 10 to 11 years if not indefinitely. The "indefinitely" part especially applies to very low risk patients.

Okay, time to get down from my soap box and get some lunch.

Thanks for bringing this issue up.

Jim

[able5]

Originally Posted by IADT3since2000

I can really understand where able5 is coming from, and he includes the words "at least" in the statement, which makes it correct and optimistic, which is appropriate. But so many people focus on the "18 months" that they have a severly warped, pessimistic concept of the effectiveness of blockade, and I want to address that.

There is some very good news for anyone who is under the impression that the benefit of hormonal blockade treatment is limited to 18 months. Bottom line: it is a MYTH; blockade is effective for far longer for the vast majority of us, with the exception being those with widespread (and especially, if painful) metastases to the bone when the hormonal blockade drugs are started. As Mona Lisa Vito responded in the movie My Cousin Vinnie when asked if her explanation of that tell-tale photograph of tire tread marks was just a theory, the statement that the 18 to 24 months view is a myth is not just a theory, "It's a fact!"

As a veteran of eight years of intermittent triple hormonal blockade and a survivor-representative participant in a number of cancer research medical conferences, research proposal reviews and FDA hearings, I have heard that figure or a variation, 18 to 24 months, stated a number of times, usually without able5's "at least", sometimes by some highly respected physicians, though none of them experts in hormonal blockade. I've heard the figures stated confidently about both patients who were detectably metastatic and those, like me and the vast majority of us, who were not. Those figures also figured prominently in the initial prognoses of five years survival (three good quality of life, two declining) that I received from two respected physicians. So if I seem to be on a soapbox, I am! (By the way, I'm not the only one on this soapbox. This myth also drives the expert blockade doctors nuts who hear it frequently from their physician colleagues who are not well-versed in blockade treatment (but who frequently are managing their patients on blockade), and it also includes fellow survivors like myself who have had to learn the ins and outs of blockade for their own well being and even survival.)

First, the short-effectiveness view is obviously not true of my own challenging case, featuring an initial PSA of 113.6, GS 4+3=7, all biopsy cores positive, most cores 100% cancer, perineural invasion, and staging T3 with suspected seminal vesicle involvement, though CT, bone and ProstaScint scans were essentially negative. I have been on hormonal blockade intermittently since December 1999, and in the last phase of both full therapy periods my PSA nadir was less than 0.01 using an ultrasensitive PSA test (spring/summer 2002 and December 2006). That proves hormonal blockade has been effective for me.

I have also been in close touch with fellow survivors on continuous and intermittent hormonal blockade as well as several doctors who are expert in that therapy, and their experience is also that hormonal blockade is highly effective for many years for the vast majority of us. It does tend to be less effective for the total group of men with detectable metastases, but it still generally works far longer than 18 to 24 months for those with milder metastatic disease, and the outlook is improving even for patients with more serious metastases.

But so far this evidence is just my own case and personal contacts. While that is hopefully somewhat useful to those trying to learn about hormonal blockade, the best evidence requires rising above our own personal experiences and contacts and looking at scientific evidence. Without that, we are essentially mired in the low-level evidence of anecdotes, which may be fine for mutual, supportive commiseration, but does not get you where you need to be in order to make the best choices involving issues of quality of life and life itself. Anyway, that's my story, and I'm sticking with it.

Here's one piece of the key science for those who really want to know and are willing to invest some effort in looking at it.

A key early paper, and apparently an unintentional source for the myth, is "A controlled trial of leuprolide with and without flutamide in prostatic carcinoma. Crawford ED, Eisenberger MA, McLeod DG, Spaulding JT, Benson R, Dorr FA, Blumenstein BA, Davis MA, Goodman PJ. N Engl J Med. 1989 Aug 17;321(7):419-24. PMID: 2503724 (The authors list has some of the major names in prostate cancer research.) Dr. Charles Myers gave us a summary of the results, which involved not just a few men but 603 men, in a presentation at the National Conference on Prostate Cancer 2005, speaking about the average time from starting hormonal therapy until the disease progressed to resistance to that therapy. Here are the key facts:

For men with wide spread bone mets + pain -- 8 months

For men with wide spread bone mets but without pain -- 18 months

For men with few bone mets in the hip and spine -- 4 to 5 years
(30 to 40% still responding to hormonal blockade at 9 years!)

This study only involved men with stage D2 cancer, which means metastasis to distant lymph nodes, or metastasis to bone or visceral organs. It's not hard to realize that men without detectable disease would generally do much better. Also, the trial involved giving the men the equivalent of Lupron or Zoladex with or without flutamide. To me it is virtually certain that they would have done even better with more modern approaches, such as triple blockade with a bone density medication and associated supplements in support. (While I'm writing confidently, please keep in mind that I am a fellow survivor who has studied this for some time but have never had any enrolled medical education.)

You can see the 18 month figure, and bear in mind that in 1989 many men were first diagnosed at a stage where they were already metastatic. In other words, such men were typical. Unfortunately, many physicians and researchers seem to have latched on to 18 to 24 months for the "typical" prostate cancer patient without realizing that patients being diagnosed or recurring today have far, far superior case characteristics. When I go to medical conferences, I take copies of some of this data and show it to researchers who have the wrong information. They are usually quite surprised because the "18 to 24 months" figures are so firmly imbedded in the conventional wisdom.

You can see from the data in the paper that we should be thinking of the effectiveness of hormonal blockade in terms of a minimum of years of effectiveness except for very advanced patients, and even some of them are doing very well today, as a percentage were even in 1989 with the much less advanced treatments then available.

Other research has produced results that generally confirm this much more upbeat view of hormonal blockade. One of the experts in hormonal blockade therapy, Dr. Mark Scholz, says that it typically works for 10 to 11 years if not indefinitely. The "indefinitely" part especially applies to very low risk patients.

Okay, time to get down from my soap box and get some lunch.

Thanks for bringing this issue up.

Jim

Not a problem, it was my pleasure!