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Cancer: Prostate Message Board


Cancer: Prostate Board Index


[COLOR="DarkGreen"]Hi Rich,

Your making me envious with that moderate duration course of single drug hormonal blockade for twelve or thirteen months and then a PSA that is still just 0.03, with no maintenance blockade - not even finasteride or Avodart, a year later! (I figure that last shot in May 2008 kept you on Zoladex through July or August 2008, hence the twelve or thirteen months.)

The rule of thumb that I see for single drug (LHRH-agonist class) blockade is that most of us will get about a month of vacation, off therapy, for every month we are on the drug. That's counting time from the time the drug should be wearing off - in your case May 2008 plus three months) - through the date when blockade is restarted, using values typically ranging from 2.5 to 10 as the trigger point for restarting, but with some patients and their doctors waiting until the PSA hits 20. (To me, the latter seems much too high, but research is not that clear on the trigger point issue yet.) It seems highly likely that you will have at least six months more of vacation time, and probably considerably more, though my estimate is skewed as I think in terms of triple blockade with finasteride or Avodart continued during the vacation period as maintenance.

[U]Avodart or finasteride as maintenance.[/U] Has your doctor ever discussed this? To me, it makes abundant sense to add one of the drugs, with Avodart (dutasteride) being the one preferred by most of the docs I follow closely. They find their triple blockade patients have longer vacation times, sometimes impressively and indefinitely long, if they use one of those drugs as maintenance. Drs. Scholz, Lam and Strum (the latter the medical co-author of the Primer) have documented such success in a paper published in the prestigious Journal of Urology. Here's the citation to their paper:

Intermittent use of testosterone inactivating pharmaceuticals using finasteride prolongs the time off period. Scholz MC, Jennrich RI, Strum SB, Johnson HJ, Guess BW, Lam RY. J Urol. 2006 May;175(5):1673-8.

Unfortunately, you don't learn key details from the abstract, and some of the terminology in the paper is difficult, if you are not very familiar with their ideas. If you read the abstact or complete paper and have questions, I would be happy to answer them. However, the bottom line is simple and clear: adding finasteride during the maintenance period (following its use in full therapy as well) doubled the off-therapy vacation period! [/COLOR]


[QUOTE=Dickiedo;4056521]HISTORY: 1995 SURGERY
2000 39 EBR treratments due to recurrence
2007 started hormonal therapy due to recurrence

I had my 1st Zoladex shot July of 07 and my PSA went to 0.37. I had a shot every 3 months and my last one was May 30th 2008. My PSA went to 0.01 and has maintained 0.01 up until this week when it went up to 0.03.The nurse said that the oncologist said he would see me in 6 months for another PSA. I said that I think 3 months would be better but she insisted that 6 months would be OK. My question is how high does your PSA have to go before they start the shots again. Thanks Rich[/QUOTE]

[COLOR="darkgreen"]As I mentioned, the trigger point is not well established. I know that the Scholz, Lam, Strum group likes to see a fairly early restart, typically in the range from 5 to a little higher for men on double blockade, and perhaps lower for men on triple blockade, with consideration given to the nature of the case and to the pattern of the PSA increase during recurrence. (They do not believe in single blockade, as I understand it.) Other doctors would be comfortable with a trigger of 10, and, as I said, 20 is used fairly often.

However, I'm concerned that you are using just single drug blockade for a cancer that still may be Gleason 8. There is a very interesting paper (for those of us on hormonal blockade) based on a multi-center Japanese study of various kinds of blockade used in Japan. While triple blockade apparently had not made its way to Japan in time for results to be published, two drug blockade, or its equivalent with surgery plus an antiandrogen, were very well represented in the study, as were single drug blockade and orchiectomy.

Although they emphasize stage as their main indicator of aggressiveness in some of their key figures and tables, their Figure 6, on progression free survival, is striking: while there are clear differences in success among the kinds of blockade to the five year point for Stage II, they are not dramatic; in contrast, for Stage III patients, while all tend to do from quite well to okay through the four year point (with single LHRH-agonist success near or at the back of the pack, success-wise), the level of success for single drug LHRH-agonist blockade falls off the cliff at the five year point, plunging from 40% non-recurrences to just about 12% non-recurrences :(, while the other forms of blockade all stay at 40% or considerably higher (80% at five years for surgical castration plus an antiandrogen drug :D). I'm quite impressed with this study as there were well over a hundred patients in each group (484 in the LHRH-agonist group), except for 1,831 patients in the well-represented LHRH-agonist plus antiandrogen group. They do give some information about Gleason scores, but not the detailed waterfall-type graphs.

They do give overall survival information as well, but it is premature to see high death rates at five years, with all Stage II patient groups having around 80% survival, and even Stage III patient groups having around 70% survival.

I hope the authors will follow-up with papers that illuminate additional aspects of their study and with longer follow-up. Here's the citation:

Current status of endocrine therapy for prostate cancer in Japan analysis of primary androgen deprivation therapy on the basis of data collected by J-CaP. Hinotsu S, Akaza H, Usami M, Ogawa O, Kagawa S, Kitamura T, Tsukamoto T, Naito S, Namiki M, Hirao Y, Murai M, Yamanaka H; Japan Study Group of Prostate Cancer (J-CaP). Jpn J Clin Oncol. 2007 Oct;37(10):775-81. Epub 2007 Oct 26.

PubMed (www.pubmed.gov) provides a link to a free copy of the full paper, which is the way I got my copy. You can get right to the abstract with this search string: " Current status of endocrine therapy for prostate cancer in Japan ".

I've got more to say, but I've got to attend to some other chores.

Take care,

Jim
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