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Cancer: Prostate Message Board

Cancer: Prostate Board Index

[COLOR="RoyalBlue"]Hi Baptista,

I'm glad you were able to get the NCCN guidelines, and I'll insert some comments in blue, for contrast with your text and quotation.[/COLOR]

[QUOTE=Baptista;4318573]Hi Jim,

I appreciate your post above. I did my investigation at NCCN as you advised and got an insight of their recommendations for cases like mine. Surely the guidelines confirm HT as my next treatment. However, there is no recommendation on a “trigger” for starting the treatment in asymptomatic cases, neither on a decisive methodology (continuous vz intermittent).

[COLOR="royalblue"]The experts in blockade whom I follow closely all believe that intermittent blockade is clearly superior to continuous blockade. There is a mound of clinical experience that indicates that, but there is not an abundance of studies.[/COLOR]

It seems that individual cases will require different decisions. That may be the reason for Dr. Choo’s report in insufficiency of trials and data to best treat cases of relapse after major treatments..

In regards to the timing, I quote here a summary of the text, for any one that might be interested in knowing its contents;
[I][COLOR="green"](NCCN Guidelines "Prostate Cancer" V.3.2010)
Timing of ADT for Advanced Disease (PSA recurrence or metastatic disease)
1) The timing of ADT for patients whose only evidence of cancer is rising PSA is influenced by PSA velocity, patient anxiety, and the short and long-term side effects of ADT.
2) A significant proportion of these patients will ultimately die of their disease; their prognosis is best approximated by the absolute level of PSA, the rate of change in the PSA level(PSA "doubling time"), and the initial stage, grade, and PSA level at the time of definitive therapy.
3) Earlier ADT may be better than delayed ADT, although the definitions of early and late (what level of PSA) are controversial. Since the benefit of earlier ADT is not clear, treatment should be individualized until definite studies are done. Patients with an elevated PSA (>50 ng/ml)

[COLOR="royalblue"]I am really surprised the NCCN would mention such a high PSA as a trigger point. While there are debates about trigger point considerations, I'm thinking that the experts would want hormonal therapy started at least at a PSA of 10 or lower.[/COLOR]

and/or a shorter PSA doubling time (or a rapid PSA velocity) and an otherwise long life expectancy should be encouraged to consider ADT earlier.
4) Treatment should begin immediately in the presence of tumors-related symptoms or overt metastases (category 1). Earlier ADT will delay the appearance of symptoms and of metastases, but it is not clear whether earlier ADT will prolong survival.

[COLOR="royalblue"]The experts I follow are all convinced that it does, and I'm convinced they are right. The problem here is that NCCN is dedicated to "evidence based medicine," and they prefer evidence from randomized "well-designed" trials, or ideally from double-blind, large, long-term, placebo controlled clinical trials. That kind of evidence is extremely hard to get due to ethical constraints, practicalities of trial design, and logistics. However, the evidence-based-medicine establishment has great difficulty appreciating this, probably because prostate cancer has such long survival, unlike almost all other cancers.[/COLOR]

The complications of long-term ADT have not been adequately documented.[/COLOR][/I]

[COLOR="royalblue"]The experts know a great deal about these side effects and how to avoid or mitigate them. They have published a lot about this. Dr. Mark Scholz, one of the foremost experts in side effects of hormonal blockade, has a new book out - "Invasion of the Prostate Snatchers." I suspect he spends a lot of time on side effects and avoiding them. Conversely, the vast majority of non-expert doctors seem to me to be surprisingly ignorant about not only the side effects but how to deal with them.[/COLOR]

In regards to Optimal ADT, it says;
[COLOR="Green"][I]5) No clinical data supports the use of triple androgen blockade (finasteride or dutasteride with combined androgen blockade).

[COLOR="royalblue"]That is actually a false statement, very likely based on ignorance rather than bad intent. Clinical data has been collected that supports triple blockade in several practices. Some of it has even been published in prestigious medical journals. However, while the statement is false, there have only been a few formal publications in peer reviewed journals on triple blockade, so the basis for the NCCN's impression is understandable.[/COLOR]

6) Intermittent ADT may reduce side effects without altering survival compared to continuous ADT but the long term efficacy of intermittent ADT remains unproven.[/I][/COLOR]
(Your case proves that intermittent ADT works very well)

[COLOR="royalblue"]Again, proof is difficult to come by as mentioned above. However, a number of studies have been done that strongly suggest intermittent ADT works at least as well as continuous ADT.[/COLOR]

Accordingly, in a setting of low PSA velocity<0.75, PSADT>8 moths and asymptomatic, the only trigger would be to soften patients’ anxiety and/or to accept ADT’s side effects. This leads to the consideration of a “long life expectancy”.
I am 61 so I would like to try the earlier ADT, triple blockade.

I have also searched other forums on prostate cancer to get answers for similar third-line treatment cases, but couldn’t find posts related to experienced cases. I got the impression that I should keep posting about my experience so that it may help others on the same boat.

[COLOR="royalblue"]There are some areas that you would find interesting. Also, several of the experts in triple blockade will be presenting in September at the National Conference on Prostate Cancer in Los Angeles, as they have in prior years. [/COLOR]

Thanks for the help and interest.

[COLOR="royalblue"]I'm glad to help. Take care,[/COLOR]
[COLOR="DarkGreen"]Hi Baptista,

John may already have replied, but I thought you might like a second perspective on some points I think I've not mentioned before. I found it very useful and reassuring to learn different experiences of men on triple blockade when I was starting out. I'll be very brief where I think you've already seen what my experience has been.[/COLOR]

[QUOTE=Baptista;4329063]Hi John,

Thank you very much for the reply. ...

In regards to your treatment, could you please answer to these questions;
1) When and Why did you start hormonal therapy? [/QUOTE]

[QUOTE]2) How long were the cycles?[/QUOTE]

[COLOR="darkgreen"]I've just posted a long response to Gleason 9 that covers single cycle intermittent blockade as well as multi cycle. While many patients have done fine with just one cycle of thirteen months to a year and a half, some of us with challenging cases take longer. With the goal of achieving a PSA of <0.05 and staying at that low level for a year, my first cycle of triple blockade took 31 months. That's extraordinarily long, but my case was extraordinarily challenging, with the PSA having to drop all the way from 113.6. I was then off therapy for 31 months! :)

My second cycle of full triple therapy, started when my PSA reached about 10, took 19 months. At that point the guidance had eased a bit, and, following advice at a conference from Dr. Mark Scholz, my goal was to just reach <0.05 and then go off therapy, without staying for a year, which is what I did. I was off therapy for 19 months. I substantially recovered from side effects in three to four months, and I was fully recovered by six months. That's been the pattern this time and the middle time.

My third cycle took 19 months, and I have now been off for 5 months with my last PSA at 0.11 and slowly rising, as expected.


[QUOTE]3) What was the third drug you start taking from Jun 2009?[/QUOTE]

[COLOR="darkgreen"]I'll leave that one to John.[/COLOR]

[QUOTE]4) Were you been given any detailed protocol (doses, etc) by Myers to be followed? [/QUOTE]

[COLOR="darkgreen"]My protocol, after my treatment evolved to triple blockade within the first nine months, was Lupron, Casodex (now bicalutamide and much less expensive) 50 mg, plus finasteride at 5 mg, later increased to 10 mg. I was on Fosamax to aid bone mineral density, and later on a statin drug (simvastatin), both to cope with side effects of blockade.

A vital point is that some of us are different enough from the norm that we may need more frequent treatment than usual with the LHRH-agonist, or we may need a higher dose of bicalutamide, or we may need Avodart versus finasteride, or vice versa. The point is that it is vital that at least both testosterone and DHT be tested to see how the patient is responding, and then, if the response is good, every now and then. Other tests, such as for LH (leutinizing hormone), may also be needed.[/COLOR]

[QUOTE]5) Who is directing you to take what and when for the side effects drugs?[/QUOTE]

[COLOR="darkgreen"]It's nice to have an expert managing your treatment. Short of that, the experts have published books and newsletters that provide guidance. While my medical oncologist is a highly educated, highly intelligent doctor, I have helped educate him about triple blockade. That's a role many of us can handle, if needed, once we become empowered patients.[/COLOR]

[QUOTE]6) What tests are you required taking?[/QUOTE]

[COLOR="darkgreen"]In addition to ultrasensitive PSA tests (sensitive down to <0.01), testosterone tests occasionally, and DHT tests occasionally, liver function tests are important to make sure the patient handles the bicalutamide adequately (can be discountinued when that is verified). My oncologist also routinely has me tested for a comprehensive metabolic panel and a complete blood count, and he gives me a focused physical exam every four months. I have more-or-less annual bone mineral density scans to monitor bone density, and I also have occasional vitamin D3 tests as that is related to bone density and to prostate cancer. Of course, I've had no medical training, so please don't regard this as authoritative. Also, individual patients would probably need additional tests that were tailored to their circumstances. Nonetheless, I think this set of tests would cover most patients.[/COLOR]

I hope I did not become “heavy” with so many questions.

I appreciate your helping me.

[COLOR="darkgreen"]I can't speak for John, but please ask all the questions you want. There are enough twists and turns that you cannot learn it all at once. It seems very clear to me now, but it took a while before I got a grasp of the main points.

Take care,

Jim :wave:[/COLOR]

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