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Cancer: Prostate Message Board

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[COLOR="DarkGreen"]Hi Ronnie,

Your question pushes me nearer to a thread I've been thinking about some time - primary hormonal blockade therapy, with "primary" meaning that it is used as the sole therapy, at least until it fails or the patient elects another option. It's the class of therapy your wife is asking about. I'm enthusiastic about it, largely because it has worked so well for me for nearly ten years as my sole therapy (no surgery, no radiation, etc.) in battling my challenging cancer. :D

However, while I've learned through talks, newsletters, several peer-reviewed medical journal papers, and informal publications that versions of hormonal blockade can work amazingly well for many men, I've been hesitant to do a thread because there are fewer than five medical research papers on the version I think is head and shoulders above the others, intermittent triple hormonal therapy with finasteride or Avodart during the off-therapy periods and countermeasures for preventing or minimizing side effects. We need to see the experts publish more of their work. The Strum/Scholz/Lam and colleagues team has some first rate medical research publications to their credit, but the Leibowitz/Tucker/Roundy team has yet to hit the big time with recent work. Dr. Myers has not published on his triple blockade practice in peer-reviewed journals, but he has described it in his Prostate Forum newsletter and in his book, mentioned below.

I'll lay out some of the key groundwork here and answer questions if you or anyone else has them, and then maybe I'll do a fresh thread that integrates what we've covered and add more for a comprehensive picture.

I'll add comments below in an excerpt of your post.

I'm sure I speak for all of us veteran board participants when I say that we are glad to help. For many of us, we are "paying it forward." (By the way, when Dr. Strum was the moderator of the National Conference on Prostate Cancer 2000 in Long Beach, CA, my first conference, "Pay It Forward" was his theme.)



I have a question, (what else is new) I was given a shot of "Trelstar", my Doc said that this freezes the cancer

[COLOR="darkgreen"]Your doc is using "freeze" in a figurative sense, of course; if you want a true freeze, you can get that with cryosurgery. But, for the vast majority of men on hormonal blockade, Trelstar or an equivalent "LHRH-agonist" class drug (Lupron, Zoladex, Viadur) will stop the cancer in its tracks and knock it backward, killing many cancer cells if continued for an adequate length of time. (A new drug, in the LHRH-antagonist class," is about to be released commercially :) (maybe it has been already as it was approved by the FDA on 12/31/2008); it is known scientifically as "degarelix".)[/COLOR]

and shrinks the prostate and I go back to him in 3 months.

[COLOR="darkgreen"]For me, a guy with a "rock hard" prostate full of cancer, triple hormonal blockade made my prostate flat and soft, but it took more than 3 months. For most men with more typical cases, the prostate is going to start substantial shrinking in three months, and the PSA is going to plunge. With triple blockade, many guys get their PSA to less than 0.05 in around 3 to 6 months.

It is almost a sure bet that you will be in that group if you move to triple blockade, but many of us will be able to get to less than 0.05 with just one drug, :) though keeping it there without the additional two drugs is another question. :( Research on two drug blockade strongly indicates that it is not as effective as triple blockade in achieving long remissions.[/COLOR]

I need to take a PSA test 2 weeks prior to the appoinment.

It's very likely that Trelstar is going to drive your PSA below the lower limit of conventional PSA tests, which these days is often .1 or < [meaning "less than"] .1. What you need is an ultrasenstive PSA test, and it's better if the test is capable of reliably measuring PSA down to <0.01 (a hundred times better than a conventional test!). Chances are your PSA will be somewhat higher than that lower limit after just three months, so a less sensitive ultrasensitive test would probably be okay, but it would be nice to use the better test for future comparability. (I can expand that if you wish.) Your doctor probably uses ultrasensitive tests, but it would be worth a phone call to check, and why not now, well in advance? Then, if you need to work to convince the doc to go to the ultrasensitive, you will have time. I was the first patient in my oncologist's large practice to get the ultrasensitive tests, and, after I had convinced him, it took some work and mistaken attempts by his staff to get the routine down. :(

If you want to really know how well hormonal blockade is working for [U]you,[/U] or if you want better information to see if it would be a viable option for you, there are two other blood tests you should get with that PSA test. They would be done in the same blood draw - just two extra vials. The two tests are (1) testosterone and (2) DHT, or, spelled out, dihydrotestosterone. You need a testosterone test to see how well Trelstar is working at nearly the three month point. What most docs following conventional good practice want to see is a testosterone of 50 or below (down from around 300 to 800 as a rough normal range), and they consider that satisfactory hormonal blockade. However, the experts in hormonal blockade want to see testosterone lowered to below 20 and get increasingly concerned that hormonal blockade is inadequate as the testosterone score is increasingly higher than 20.

Also, a few men (5 - 10% as I recall) clear the drug much faster than planned for in the dosing schedule :(, and the testosterone score can signal that that is happening. (A solution is to tweak the dosing schedule to shorter than 3 months of 28 days each.) Additionally, for some of the other LHRH-agonist drugs and perhaps for Trelstar, flaws in storing, mixing, and injecting the drug can lead to partial or total ineffectiveness. :( That's rare, but the testosterone test can signal that possibility too. :cool:

Another issue is that the body may bootleg testosterone production, getting it in by the back door. The body will sense the deficit from the shut down in testicular production of testosterone. While the adrenal glands can indirectly produce about 5% of testosterone in many men, in some, after the body senses a shortage, they can really ramp up production. I can't put my fingers on the document, but I believe that up to 40% of normal can be made up in this way for some men, which would wreck a program of hormonal blockade. :( Again, a high testosterone level can indicate that this extra adrenal production of testosterone may be a problem. The "antiandrogen" class drug Casodex is typically used to solve this problem; it does it not by stopping production, but by pre-emptively occuping the testosterone and DHT docking sites on the prostate cancer cells - their fuel ports. Hopefully your Primer will arrive soon, because it has a superb explanation of this, backed with great graphics.

The DHT test is also key. DHT is converted from testosterone to DHT, and it is far more potent as a fuel for prostate cancer than testosterone, perhaps ten times as potent in many men. Sharply reducing testosterone should sharply reduce DHT as well, but it does not always happen. That's where the other drugs, such as Casodex and Avodart or finasteride, typically, play key rolls in triple blockade.

If testosterone is below 20, all is well in that department. But if not, there are other blood tests that can be used, such as the LH (luteinizing hormone) level test. The other tests can pin down the problem. DHT should be very low too. Mine is below 3 right now, which is the lower limit of the test.

My wife said, why can't you just keep taking those shots instead of having to choose the other intrusive alternatives?

[COLOR="darkgreen"]Actually, that [U]is[/U] an option! :angel: Here are some [B]advantages[/B]: (1) it provides [U]excellent cancer control[/U] for the vast majority of men with low-risk cases - possibly virtually all such men (supported by as yet impressive but unpublished research by Leibowitz, Tucker and Roundy), and also provides excellent control for many men with intermediate and even high-risk cases, with the few problems detectable with PSA and simple blood tests, and occasional other monitoring, as well as monitoring of side effects; (2) it can be done [U]intermittently[/U], with your particular subset of the fairly typical side effects reversing and disappearing over several months when you go off-therapy; (3) many lower-risk men, particularly in the Leibowitz practice (Compassionate Oncology, formerly with Steven Tucker as a partner) have required [U]only one round of the heavy duty drugs[/U] (the LHRH-agonist and Casodex) for about 13 months and then go off the drugs with excellent cancer control and disappearance of side effects, maintaining with finasteride (Avodart preferred in other practices); (4) [U]incontinence is not a problem[/U]; (5) reduction in libido and ED, which occurs to some degree while on the heavy duty drugs for 90% of us, goes away when those drugs are stopped, after decreasing gradually for several months, and [U]we get most of our normal quality of sex back[/U], including true ejaculate (not just from the Cowper's gland), though somewhat less of it as the prostate is somewhat smaller; (6) [U]countermeasures[/U] are fairly to completely effective for most of the side effects for most of us, and for the few that find the regime intolerable, the program can be discontinued; (7) [U]other options remain open[/U], and at least radiation is probably enhanced by having had hormonal blockade; (8) [U]many doctors can manage hormonal blockade care[/U] if they take a little time to learn about it, though experts provide the best care; and (9)[U]the approach gains time for medical research[/U] to improve other therapies and perhaps find that silver bullet easy cure that is the holy grail of research.

Here are some [B]disadvantages[/B]: (1) it is [U]not usually curative [/U]- until recently the experts would have said it is not curative period; however, the superb control it affords for many years, with fall-back therapies available, are arguably the equivalent of a cure in terms of length and quality of life; (2) there are [U]significant side effects[/U], and it can take [U]continuing effort and active involvement to counter them [/U]for those of us who like to avoid those burdens - it's not a wham, bam, done and forget kind of approach; (3) some of the key drugs are still expensive (though Casodex recently went generic and finasteride has been generic for some time), so [U]insurance [/U]might be an issue; (4) there has not [U]been a whole lot published [/U]about it in peer-reviewed medical journals; and (5) therefore [U]many doctors are not familiar with it[/U], with many believing a number of the myths about it, such as that it only works for a couple of years in most patients. (The truth is that first line blockade often works for around ten to eleven years if not indefinitely long.).

So why doesn't everybody do it? Well, several reasons: A lot of us prefer excellent odds of a cure - certainly an attractive prospect - enough to accept the low risk of long-term side effects and the likelihood of temporary incontinence, ED, etc. A lot of us get a misguided, overly frightening picture of side effects from our doctors and rule out the approach before understanding it. Some of us do get a fairly good handle on the side effects and learn about countermeasures, but we just don't want to take the vitamins, change our way of eating, get regular aerobic and strength exercise, etc. to minimize the likely effects, prefering instead some good odds on achieving a cure that will let us forget about prostate cancer (at least in between PSA tests, that is!)


He is on vacation and I cannot wait untill he returns to ask that question. In the meantime, have you ever heard of that for for a long term treatment plan?

[COLOR="darkgreen"]The doctor who has written the most and who has the most experience about primary hormonal therapy for low-risk (and other) cases is Dr. Robert Leibowitz of his Compassionate Oncology practice. His presentation at the special Orlando joint conference with colleagues Tucker and Roundy a few years back is highly informative and encouraging. (The sponsors included the American Society for Clinical Oncology, the American Urological Association, and ASTRO - the radiation doctor's association; it was a big time special conference on prostate cancer.)

However, if you read his articles, you need to know that Dr. Leibowitz is so passionate in favor of his approach that he does not present the worth of some other options as they deserve, in my layman's opinion (and in the opinion of some of his fellow experts in hormonal blockade and in the prostate community generally). For instance, he has been known to focus on rectal incontinence from radiation; yes, it can occur, but my understanding is that it is rare; yes, there are commonly blood clots from surgery, but, again, they rarely cause significant problems. It's that kind of thing with Dr. Leibowitz's criticism of other therapies. (On the other hand, considered as a devil's advocate, he is superb!) That said, "Dr. Bob," as he is known, is one of my heroes! He is certainly a great pioneer in prostate cancer therapy, and to be a pioneer you have to be passionate!

The Primer also has an outstanding long section on hormonal blockade, with emphasis on triple blockade. That's easy to understand as Dr. Strum, medical co-author of the Primer, is one of the leading experts. The Primer addresses some of the side effects and countermeasures.

Dr. Charles "Snuffy" Myers is also one of the leading experts, and he is the only one of the experts to have had that therapy himself as part of his program to defeat his own challenging (metastatic) case of prostate cancer. He has given us key insights that are easy to understand in his book "Beating Prostate Cancer: Hormonal Therapy & Diet."[/COLOR]

Thanks, regards

[COLOR="darkgreen"]You're welcome. If you look into hormonal blockade, you are sure to have questions. I'll be happy to help answer them or steer you toward the answers.

Take care,


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