Re: Re: I have a question regarding salvage radiation with hormone therapy.

[Guest guest]

On August 11, Sheila replied to Harry:

(snip)

> My husband was on Zoladex for one year. The doctor wanted him to be

> on hormones for 2 years. But after doing research Dr. Strum did a

> paper on hormones and it stated that one year was good enough.

With respect, I must correct this; it's not the whole story.

Strum et al. recommend at least one full year of undetectable PSA

(defined as =/< 0.05 ng/mL) before considering an off-phase (*not* total

cessation) of ADT. When/if the PSA rises to a pre-selected level,

restart ADT. During the off-phase, use a 5-alpha reductase inhibitor

such as dutasteride (Avodart) 0.5 mg qd (per day).

> That the hormones could cause more harm than good, with their side

> effects.

I have not seen Strum say that. He has, however, written on the subject

of relieving side effects (SEs).

See, http://www.prostate-cancer.org/education/sidefx/Strum_ADS.html

Note: It was published in 1999 and some medics *still* have no idea what

to do about androgen deprivation syndrome.

There is also a 2007 article by Brad Guess:

http://www.prostate-cancer.org/education/andind/Guess_TestosteroneSideEffects.ht\

ml

The devil, as 'tis said, is in the details.

Regards,

Steve J

" Know your enemy. Get educated. But also know that it won't be easy.

It will be confusing, overwhelming and depressing. That is the nature

of cancer and thus the very educational process as you regain

control. "

-- Young, PCa Mentor

Phoenix 5

[Guest guest]

On August 11, Sheila replied to Harry:

(snip)

> My husband was on Zoladex for one year. The doctor wanted him to be

> on hormones for 2 years. But after doing research Dr. Strum did a

> paper on hormones and it stated that one year was good enough.

With respect, I must correct this; it's not the whole story.

Strum et al. recommend at least one full year of undetectable PSA

(defined as =/< 0.05 ng/mL) before considering an off-phase (*not* total

cessation) of ADT. When/if the PSA rises to a pre-selected level,

restart ADT. During the off-phase, use a 5-alpha reductase inhibitor

such as dutasteride (Avodart) 0.5 mg qd (per day).

> That the hormones could cause more harm than good, with their side

> effects.

I have not seen Strum say that. He has, however, written on the subject

of relieving side effects (SEs).

See, http://www.prostate-cancer.org/education/sidefx/Strum_ADS.html

Note: It was published in 1999 and some medics *still* have no idea what

to do about androgen deprivation syndrome.

There is also a 2007 article by Brad Guess:

http://www.prostate-cancer.org/education/andind/Guess_TestosteroneSideEffects.ht\

ml

The devil, as 'tis said, is in the details.

Regards,

Steve J

" Know your enemy. Get educated. But also know that it won't be easy.

It will be confusing, overwhelming and depressing. That is the nature

of cancer and thus the very educational process as you regain

control. "

-- Young, PCa Mentor

Phoenix 5

[Guest guest]

Thank you Sheila

I forgot to mention that my seminal vessicles and lymphnodes were negative and the bone scan and pelvic scan was also negative for adenocarsinoma. The penetration to the bladder margin was not present at the bladder neck if that means anything. I do have chronic fatigue and a bit of loose bowels but I have been on radiation for only 9 treatments and will have a total of 40. My post surgery side effects are pretty good I have a minimum of incontenance. As for ED they were not able to spare the nerves so that is the sad prart of that.

Thank you for your concern I will look for Dr. Strums book. I have read Dr. Walsh's book on Surviving Prostate Cancer and I think it is excellent.

I wish you and your husband the best and you both are in my thoughts and prayers.

Harry

Subject: Re: I have a question regarding salvage radiation with hormone therapy.To: ProstateCancerSupport Date: Tuesday, August 11, 2009, 1:35 PM

>> I am a 75 year old who had prostate surgery on April 13, 2009. The surgical pathology report assigned a Gleason sum of 4+5 = 9, Extensive polynureal invasion, and capsular penetration on the bladder margin.> > Pre op PSA of 6.43 Clinical stage was T3a N0 MX. Post surgical PSA at 5 weeks was .689, at 8 weeks .144 and at 9 weeks post surgery of .080.> > I presume these decreases are due to the half life clearing of PSA from the system.> > I elected for salvage readiation and began that a couple of weeks ago. I was given a short course of casodex and then Zoladex shots to be given at six month intervals as well.> > I

have read that hormone therapy does enhance radiation therapy but that long term use vs short term administration (six months) studies do not show a significant difference in survival time.> > My Urologist told me that he expects to keep me on zoladex at least 2 years post my 40 radiation treatments.> > This has me concerned since hormones are at best pallative treatment and they preclude using PSA tests to determine the effect of the radiation treatment.> > I am inclined to stop the Zoladex at the end of my next 6 month treatment and wait for another six months to get rid of its effects and then resume PSA testing to determine the effect of the radiation treatment.> > I am in pretty good shape overall for my age. I would appreciate any comments as right now I do not look forward to the possiblility of waiting 2 and a half years on pins and needles to determine the effect of the radiation.>

> Thanks for bearing with this long post.> > Harry Trentes>Dear Harry,My husband was on Zoladex for one year. The doctor wanted him to be on hormones for 2 years. But after doing research Dr. Strum did a paper on hormones and it stated that one year was good enough. That the hormones could cause more harm than good, with their side effects. My husband had a PSA of 7.9 and Gleason of 9. The doctors put him on hormones to stop the spread of the cancer and to shrink the prostate. We did argue with the doctor but I printed out Dr. Strum's paper and gave it to the doctor and he finally agreed that one year would be fine. But you have to do your research. The hormones have caused my husband to have miserable hot flashes and real fatigue. The only thing for the fatigue is exercise. So my husband goes to the gym three times a week. And that helps. But there is no help with the ED. My husband started using the VED to help keep

the blood flowing. He was first going to have surgery, but decided to go with Proton Beam radiation, but because of his Gleason being so high they suggested IMRT treatments. All went well and he finished last August. He had his last three month injection of Zoladex in November 2008. But he still has the hot flashes and the fatigue and the ED. Hopefully the hormones will be out of his system in about 6 months.I wish you all the best. I'll keep you in my thoughts and prayers.Best Wishes,Sheila

[Guest guest]

Thank you Sheila

I forgot to mention that my seminal vessicles and lymphnodes were negative and the bone scan and pelvic scan was also negative for adenocarsinoma. The penetration to the bladder margin was not present at the bladder neck if that means anything. I do have chronic fatigue and a bit of loose bowels but I have been on radiation for only 9 treatments and will have a total of 40. My post surgery side effects are pretty good I have a minimum of incontenance. As for ED they were not able to spare the nerves so that is the sad prart of that.

Thank you for your concern I will look for Dr. Strums book. I have read Dr. Walsh's book on Surviving Prostate Cancer and I think it is excellent.

I wish you and your husband the best and you both are in my thoughts and prayers.

Harry

Subject: Re: I have a question regarding salvage radiation with hormone therapy.To: ProstateCancerSupport Date: Tuesday, August 11, 2009, 1:35 PM

>> I am a 75 year old who had prostate surgery on April 13, 2009. The surgical pathology report assigned a Gleason sum of 4+5 = 9, Extensive polynureal invasion, and capsular penetration on the bladder margin.> > Pre op PSA of 6.43 Clinical stage was T3a N0 MX. Post surgical PSA at 5 weeks was .689, at 8 weeks .144 and at 9 weeks post surgery of .080.> > I presume these decreases are due to the half life clearing of PSA from the system.> > I elected for salvage readiation and began that a couple of weeks ago. I was given a short course of casodex and then Zoladex shots to be given at six month intervals as well.> > I

have read that hormone therapy does enhance radiation therapy but that long term use vs short term administration (six months) studies do not show a significant difference in survival time.> > My Urologist told me that he expects to keep me on zoladex at least 2 years post my 40 radiation treatments.> > This has me concerned since hormones are at best pallative treatment and they preclude using PSA tests to determine the effect of the radiation treatment.> > I am inclined to stop the Zoladex at the end of my next 6 month treatment and wait for another six months to get rid of its effects and then resume PSA testing to determine the effect of the radiation treatment.> > I am in pretty good shape overall for my age. I would appreciate any comments as right now I do not look forward to the possiblility of waiting 2 and a half years on pins and needles to determine the effect of the radiation.>

> Thanks for bearing with this long post.> > Harry Trentes>Dear Harry,My husband was on Zoladex for one year. The doctor wanted him to be on hormones for 2 years. But after doing research Dr. Strum did a paper on hormones and it stated that one year was good enough. That the hormones could cause more harm than good, with their side effects. My husband had a PSA of 7.9 and Gleason of 9. The doctors put him on hormones to stop the spread of the cancer and to shrink the prostate. We did argue with the doctor but I printed out Dr. Strum's paper and gave it to the doctor and he finally agreed that one year would be fine. But you have to do your research. The hormones have caused my husband to have miserable hot flashes and real fatigue. The only thing for the fatigue is exercise. So my husband goes to the gym three times a week. And that helps. But there is no help with the ED. My husband started using the VED to help keep

the blood flowing. He was first going to have surgery, but decided to go with Proton Beam radiation, but because of his Gleason being so high they suggested IMRT treatments. All went well and he finished last August. He had his last three month injection of Zoladex in November 2008. But he still has the hot flashes and the fatigue and the ED. Hopefully the hormones will be out of his system in about 6 months.I wish you all the best. I'll keep you in my thoughts and prayers.Best Wishes,Sheila

[Guest guest]

> (snip)

>

> > My husband was on Zoladex for one year. The doctor wanted him

> > to be on hormones for 2 years. But after doing research Dr.

> > Strum did a paper on hormones and it stated that one year was

> > good enough.

>

> With respect, I must correct this; it's not the whole story.

>

> Strum et al. recommend at least one full year of undetectable

> PSA (defined as =/< 0.05 ng/mL) before considering an off-phase

> (*not* total cessation) of ADT. When/if the PSA rises to a

> pre-selected level, restart ADT. During the off-phase, use a

> 5-alpha reductase inhibitor such as dutasteride (Avodart) 0.5

> mg qd (per day).

Steve,

I understand that that is Dr. Strum's recommendation for

intermittent hormone therapy, but is it also his recommendation

for ADT used as an adjuvant to radiation?

That might be a different case.

Harry,

I researched this question six years ago when I was looking at

treatment options. I found one clinical trial indicating that 6

months of ADT gave full benefit as adjuvant radiation therapy,

and some others that said more is desirable, up to 3 years.

I don't know if there are definitive answers to this question. I

expect that the answers are statistical rather than definitive.

With your particular disease characteristics, 6 months ADT with

radiation results in X% of men with complete cancer control while

2 years (or 1 or 3 years, whatever) results in X% + Y%. But we

don't know the value of X or Y.

For myself, I decided, against my doctor's advice, to get off

after six months. So far, I appear to be okay. However, I only

had a Gleason 7 cancer (4+3) which may not have been as

aggressive as yours.

> I am a 75 year old who had prostate surgery on April 13, 2009.

> The surgical pathology report assigned a Gleason sum of 4+5 =

> 9, Extensive polynureal invasion, and capsular penetration on

> the bladder margin.

That sounds pretty serious.

> Pre op PSA of 6.43 Clinical stage was T3a N0 MX. Post surgical

> PSA at 5 weeks was .689, at 8 weeks .144 and at 9 weeks post

> surgery of .080.

>

> I presume these decreases are due to the half life clearing of

> PSA from the system.

I don't think I've seen anything like that before. Had you

already had a Zoladex injection before the last two tests? If

so, then the cause of your declining PSA was not PSA clearing the

system, but Zoladex suppressing the tumor cells.

> This has me concerned since hormones are at best pallative

> treatment

I don't think that's right. I believe that the current theory is

that the ADT starves the " hormone dependent " cancer cells and

keeps them from growing and dividing. Those cells will kill you

if left untreated. The only real issue is, is it better to treat

those cells while there are only a relative few of them, or to

wait until they're all over the body. The experts used to

believe that the results of either approach are the same, but

there are many today who say that is not so, and you get more

life extension if you attack the cancer when it's small.

However, if you also have some hormone independent cells, and it

is thought that all men have some or will develop them, the ADT

will not stop those. So even if you shut down all the hormone

dependent cells, the others will eventually grow enough to kill

you.

If that theory is true, then ADT does extend life. It eliminates

some of the cancer, but not all of it. And it least some

specialists believe that it extends life more when given earlier.

Unfortunately however, with the current state of the science, no

one can tell in advance how much time you'll get, or how hormone

dependent your cells are. As I recall, Dr. Strum's theory is

that, if the PSA goes below 0.05 on hormone therapy, your cancer

cells are highly hormone dependent and you'll get more years of

life on ADT than average.

> ... and they preclude using PSA tests to determine the effect

> of the radiation treatment.

Yes. That is a significant problem.

I'm not the best person to advise you on this but here are some

thoughts about how you might approach it.

1. Try the ADT for the full six months and see how you're doing.

If you find it pretty tolerable, get another injection. If

you don't, stop.

2. When you do stop, get regular, at least every 3 months, PSA

and testosterone tests.

If the PSA stays low, you're golden. The radiation worked.

If it begins to rise, the radiation failed and you've got

some hard decisions to make about whether to go back on ADT

or wait it out for a while.

I _think_ if I were in your shoes with a Gleason 9 cancer and

a rising PSA after radiation, I'd go back on ADT. I would

exercise hard every day to try to counteract its negative

effects. But you may hate the ADT so much that you would

prefer to risk a shorter life with better quality.

It's really an individual decision.

Ideally, you should discuss these questions with a medical

oncologist before you make your final decisions. The urologist

and radiation oncologist you're seeing may be fairly

knowledgeable about these issues, but they aren't specialists in

them. What you want is a medical oncologist who specializes in

prostate cancer, if you can find one.

But in the end, it's still your decision. The doctors can tell

you what they would do but you will still do best to think this

out for yourself, guided but not ruled by their advice.

Best of luck.

Alan

[Guest guest]

> (snip)

>

> > My husband was on Zoladex for one year. The doctor wanted him

> > to be on hormones for 2 years. But after doing research Dr.

> > Strum did a paper on hormones and it stated that one year was

> > good enough.

>

> With respect, I must correct this; it's not the whole story.

>

> Strum et al. recommend at least one full year of undetectable

> PSA (defined as =/< 0.05 ng/mL) before considering an off-phase

> (*not* total cessation) of ADT. When/if the PSA rises to a

> pre-selected level, restart ADT. During the off-phase, use a

> 5-alpha reductase inhibitor such as dutasteride (Avodart) 0.5

> mg qd (per day).

Steve,

I understand that that is Dr. Strum's recommendation for

intermittent hormone therapy, but is it also his recommendation

for ADT used as an adjuvant to radiation?

That might be a different case.

Harry,

I researched this question six years ago when I was looking at

treatment options. I found one clinical trial indicating that 6

months of ADT gave full benefit as adjuvant radiation therapy,

and some others that said more is desirable, up to 3 years.

I don't know if there are definitive answers to this question. I

expect that the answers are statistical rather than definitive.

With your particular disease characteristics, 6 months ADT with

radiation results in X% of men with complete cancer control while

2 years (or 1 or 3 years, whatever) results in X% + Y%. But we

don't know the value of X or Y.

For myself, I decided, against my doctor's advice, to get off

after six months. So far, I appear to be okay. However, I only

had a Gleason 7 cancer (4+3) which may not have been as

aggressive as yours.

> I am a 75 year old who had prostate surgery on April 13, 2009.

> The surgical pathology report assigned a Gleason sum of 4+5 =

> 9, Extensive polynureal invasion, and capsular penetration on

> the bladder margin.

That sounds pretty serious.

> Pre op PSA of 6.43 Clinical stage was T3a N0 MX. Post surgical

> PSA at 5 weeks was .689, at 8 weeks .144 and at 9 weeks post

> surgery of .080.

>

> I presume these decreases are due to the half life clearing of

> PSA from the system.

I don't think I've seen anything like that before. Had you

already had a Zoladex injection before the last two tests? If

so, then the cause of your declining PSA was not PSA clearing the

system, but Zoladex suppressing the tumor cells.

> This has me concerned since hormones are at best pallative

> treatment

I don't think that's right. I believe that the current theory is

that the ADT starves the " hormone dependent " cancer cells and

keeps them from growing and dividing. Those cells will kill you

if left untreated. The only real issue is, is it better to treat

those cells while there are only a relative few of them, or to

wait until they're all over the body. The experts used to

believe that the results of either approach are the same, but

there are many today who say that is not so, and you get more

life extension if you attack the cancer when it's small.

However, if you also have some hormone independent cells, and it

is thought that all men have some or will develop them, the ADT

will not stop those. So even if you shut down all the hormone

dependent cells, the others will eventually grow enough to kill

you.

If that theory is true, then ADT does extend life. It eliminates

some of the cancer, but not all of it. And it least some

specialists believe that it extends life more when given earlier.

Unfortunately however, with the current state of the science, no

one can tell in advance how much time you'll get, or how hormone

dependent your cells are. As I recall, Dr. Strum's theory is

that, if the PSA goes below 0.05 on hormone therapy, your cancer

cells are highly hormone dependent and you'll get more years of

life on ADT than average.

> ... and they preclude using PSA tests to determine the effect

> of the radiation treatment.

Yes. That is a significant problem.

I'm not the best person to advise you on this but here are some

thoughts about how you might approach it.

1. Try the ADT for the full six months and see how you're doing.

If you find it pretty tolerable, get another injection. If

you don't, stop.

2. When you do stop, get regular, at least every 3 months, PSA

and testosterone tests.

If the PSA stays low, you're golden. The radiation worked.

If it begins to rise, the radiation failed and you've got

some hard decisions to make about whether to go back on ADT

or wait it out for a while.

I _think_ if I were in your shoes with a Gleason 9 cancer and

a rising PSA after radiation, I'd go back on ADT. I would

exercise hard every day to try to counteract its negative

effects. But you may hate the ADT so much that you would

prefer to risk a shorter life with better quality.

It's really an individual decision.

Ideally, you should discuss these questions with a medical

oncologist before you make your final decisions. The urologist

and radiation oncologist you're seeing may be fairly

knowledgeable about these issues, but they aren't specialists in

them. What you want is a medical oncologist who specializes in

prostate cancer, if you can find one.

But in the end, it's still your decision. The doctors can tell

you what they would do but you will still do best to think this

out for yourself, guided but not ruled by their advice.

Best of luck.

Alan

[Guest guest]

Do not discuss with JLL. $19. 5 mon free base. Will paint, carpet move wall and door. Need 4 weeks to build. Sent from my Verizon Wireless BlackBerryFrom: Alan Meyer Date: Tue, 11 Aug 2009 12:32:17 -0700 (PDT)To: <ProstateCancerSupport >Subject: Re: Re: I have a question regarding salvage radiation with hormone therapy. On Tue, 8/11/09, Steve Jordan <mycroftscj1> wrote: > (snip) > > > My husband was on Zoladex for one year. The doctor wanted him > > to be on hormones for 2 years. But after doing research Dr. > > Strum did a paper on hormones and it stated that one year was > > good enough. > > With respect, I must correct this; it's not the whole story. > > Strum et al. recommend at least one full year of undetectable > PSA (defined as =/< 0.05 ng/mL) before considering an off-phase > (*not* total cessation) of ADT. When/if the PSA rises to a > pre-selected level, restart ADT. During the off-phase, use a > 5-alpha reductase inhibitor such as dutasteride (Avodart) 0.5 > mg qd (per day). Steve, I understand that that is Dr. Strum's recommendation for intermittent hormone therapy, but is it also his recommendation for ADT used as an adjuvant to radiation? That might be a different case. Harry, I researched this question six years ago when I was looking at treatment options. I found one clinical trial indicating that 6 months of ADT gave full benefit as adjuvant radiation therapy, and some others that said more is desirable, up to 3 years. I don't know if there are definitive answers to this question. I expect that the answers are statistical rather than definitive. With your particular disease characteristics, 6 months ADT with radiation results in X% of men with complete cancer control while 2 years (or 1 or 3 years, whatever) results in X% + Y%. But we don't know the value of X or Y. For myself, I decided, against my doctor's advice, to get off after six months. So far, I appear to be okay. However, I only had a Gleason 7 cancer (4+3) which may not have been as aggressive as yours. > I am a 75 year old who had prostate surgery on April 13, 2009. > The surgical pathology report assigned a Gleason sum of 4+5 = > 9, Extensive polynureal invasion, and capsular penetration on > the bladder margin. That sounds pretty serious. > Pre op PSA of 6.43 Clinical stage was T3a N0 MX. Post surgical > PSA at 5 weeks was .689, at 8 weeks .144 and at 9 weeks post > surgery of .080. > > I presume these decreases are due to the half life clearing of > PSA from the system. I don't think I've seen anything like that before. Had you already had a Zoladex injection before the last two tests? If so, then the cause of your declining PSA was not PSA clearing the system, but Zoladex suppressing the tumor cells. > This has me concerned since hormones are at best pallative > treatment I don't think that's right. I believe that the current theory is that the ADT starves the " hormone dependent " cancer cells and keeps them from growing and dividing. Those cells will kill you if left untreated. The only real issue is, is it better to treat those cells while there are only a relative few of them, or to wait until they're all over the body. The experts used to believe that the results of either approach are the same, but there are many today who say that is not so, and you get more life extension if you attack the cancer when it's small. However, if you also have some hormone independent cells, and it is thought that all men have some or will develop them, the ADT will not stop those. So even if you shut down all the hormone dependent cells, the others will eventually grow enough to kill you. If that theory is true, then ADT does extend life. It eliminates some of the cancer, but not all of it. And it least some specialists believe that it extends life more when given earlier. Unfortunately however, with the current state of the science, no one can tell in advance how much time you'll get, or how hormone dependent your cells are. As I recall, Dr. Strum's theory is that, if the PSA goes below 0.05 on hormone therapy, your cancer cells are highly hormone dependent and you'll get more years of life on ADT than average. > ... and they preclude using PSA tests to determine the effect > of the radiation treatment. Yes. That is a significant problem. I'm not the best person to advise you on this but here are some thoughts about how you might approach it. 1. Try the ADT for the full six months and see how you're doing. If you find it pretty tolerable, get another injection. If you don't, stop. 2. When you do stop, get regular, at least every 3 months, PSA and testosterone tests. If the PSA stays low, you're golden. The radiation worked. If it begins to rise, the radiation failed and you've got some hard decisions to make about whether to go back on ADT or wait it out for a while. I _think_ if I were in your shoes with a Gleason 9 cancer and a rising PSA after radiation, I'd go back on ADT. I would exercise hard every day to try to counteract its negative effects. But you may hate the ADT so much that you would prefer to risk a shorter life with better quality. It's really an individual decision. Ideally, you should discuss these questions with a medical oncologist before you make your final decisions. The urologist and radiation oncologist you're seeing may be fairly knowledgeable about these issues, but they aren't specialists in them. What you want is a medical oncologist who specializes in prostate cancer, if you can find one. But in the end, it's still your decision. The doctors can tell you what they would do but you will still do best to think this out for yourself, guided but not ruled by their advice. Best of luck. Alan

[Guest guest]

On August 11, Alan Meyer replied to me:

> I understand that that is Dr. Strum's recommendation for

> intermittent hormone therapy, but is it also his recommendation for

> ADT used as an adjuvant to radiation?

>

> That might be a different case.

ADT given as an adjuvant to RT is not primarily intended to treat the

PCa. It is intended to reduce the size of the prostate gland so as to

increase the effect of the RT. Killing of the PCa cells is the job of

the RT.

But I don't think that that was the topic in this case.

Clearly, Harry's case, a Gleason nine, is high-risk; just as is mine

and, IIRC, Alan's. Seems to me that in such cases, it's best to haul

out the big guns and bang away. It's no time for subtlety.

Regards,

Steve J

" When dealing with malignant conditions you do not save your weaponry

until you are surrounded by the enemy. "

-- B. Strum, MD

Medical Oncologist

PCa Specialist

[Guest guest]

On August 11, Alan Meyer replied to me:

> I understand that that is Dr. Strum's recommendation for

> intermittent hormone therapy, but is it also his recommendation for

> ADT used as an adjuvant to radiation?

>

> That might be a different case.

ADT given as an adjuvant to RT is not primarily intended to treat the

PCa. It is intended to reduce the size of the prostate gland so as to

increase the effect of the RT. Killing of the PCa cells is the job of

the RT.

But I don't think that that was the topic in this case.

Clearly, Harry's case, a Gleason nine, is high-risk; just as is mine

and, IIRC, Alan's. Seems to me that in such cases, it's best to haul

out the big guns and bang away. It's no time for subtlety.

Regards,

Steve J

" When dealing with malignant conditions you do not save your weaponry

until you are surrounded by the enemy. "

-- B. Strum, MD

Medical Oncologist

PCa Specialist

[Guest guest]

Thank you for your comments Alan

Rearding the declining PSA's I had asked my urologist to give me repeat PSA's a little later before the next step. He did not think it was necessary. I had taken about 5 days of 50 mg of casodex when I got the second PSA from my primary care MD so it may have affected it. For the third PSA I got it as part of my annual physical from the VA I had gotten my first injection of Zoladex at 2:30 PM on one day and my VA vist occured at 8:30 the next morning. I guessed that with that short of an interval the hormones may not have had enough time to interfere with the PSA but that may not be the case.

Dr Epstein from s Hopkins writes that getting the first post surgical PSA should not be taken for at least 8 to 12 weeks after surgery. He further states that even with capsular penetration it often happens that the surgery may still kill the cancer cells that escaped if they are still close to the prostate because of a severed blood supply and perhaps entrapped by a sticky consistency. This seemed reasonable to me. But as I said I was not able to convince my uro that it would be a good idea to wait a few more weeks before starting hormone therapy. I wish I would have insisted.

I believe we are in great need for the development of a blood test that can determine the spread of cancer that is unaffected by hormone therapy. What ever choice is made seems to be a gamble which is why this is such an emotional situation.

Harry> (snip)> > > My husband was on Zoladex for one year. The doctor wanted him> > to be on hormones for 2 years. But after doing research Dr.> > Strum did a paper on hormones and it stated that one year was> > good enough.> > With respect, I must correct this; it's not the whole story.> > Strum et al. recommend at least one full year of undetectable> PSA (defined as =/< 0.05 ng/mL) before considering an off-phase> (*not* total cessation) of ADT. When/if the PSA rises to a> pre-selected level, restart ADT. During the off-phase, use a> 5-alpha reductase inhibitor such as dutasteride (Avodart) 0.5> mg qd (per

day).Steve,I understand that that is Dr. Strum's recommendation forintermittent hormone therapy, but is it also his recommendationfor ADT used as an adjuvant to radiation?That might be a different case.Harry,I researched this question six years ago when I was looking attreatment options. I found one clinical trial indicating that 6months of ADT gave full benefit as adjuvant radiation therapy,and some others that said more is desirable, up to 3 years.I don't know if there are definitive answers to this question. Iexpect that the answers are statistical rather than definitive.With your particular disease characteristics, 6 months ADT withradiation results in X% of men with complete cancer control while2 years (or 1 or 3 years, whatever) results in X% + Y%. But wedon't know the value of X or Y.For myself, I decided, against my doctor's advice, to get

offafter six months. So far, I appear to be okay. However, I onlyhad a Gleason 7 cancer (4+3) which may not have been asaggressive as yours. > I am a 75 year old who had prostate surgery on April 13, 2009.> The surgical pathology report assigned a Gleason sum of 4+5 => 9, Extensive polynureal invasion, and capsular penetration on> the bladder margin.That sounds pretty serious.> Pre op PSA of 6.43 Clinical stage was T3a N0 MX. Post surgical> PSA at 5 weeks was .689, at 8 weeks .144 and at 9 weeks post> surgery of .080.> > I presume these decreases are due to the half life clearing of> PSA from the system.I don't think I've seen anything like that before. Had youalready had a Zoladex injection before the last two tests? Ifso, then the cause of your declining PSA was not PSA clearing thesystem, but Zoladex suppressing the tumor

cells.> This has me concerned since hormones are at best pallative> treatment I don't think that's right. I believe that the current theory isthat the ADT starves the "hormone dependent" cancer cells andkeeps them from growing and dividing. Those cells will kill youif left untreated. The only real issue is, is it better to treatthose cells while there are only a relative few of them, or towait until they're all over the body. The experts used tobelieve that the results of either approach are the same, butthere are many today who say that is not so, and you get morelife extension if you attack the cancer when it's small.However, if you also have some hormone independent cells, and itis thought that all men have some or will develop them, the ADTwill not stop those. So even if you shut down all the hormonedependent cells, the others will eventually grow enough to

killyou.If that theory is true, then ADT does extend life. It eliminatessome of the cancer, but not all of it. And it least somespecialists believe that it extends life more when given earlier.Unfortunately however, with the current state of the science, noone can tell in advance how much time you'll get, or how hormonedependent your cells are. As I recall, Dr. Strum's theory isthat, if the PSA goes below 0.05 on hormone therapy, your cancercells are highly hormone dependent and you'll get more years oflife on ADT than average.> ... and they preclude using PSA tests to determine the effect> of the radiation treatment.Yes. That is a significant problem.I'm not the best person to advise you on this but here are somethoughts about how you might approach it.1. Try the ADT for the full six months and see how you're doing.If you find it pretty tolerable, get

another injection. Ifyou don't, stop.2. When you do stop, get regular, at least every 3 months, PSAand testosterone tests.If the PSA stays low, you're golden. The radiation worked.If it begins to rise, the radiation failed and you've gotsome hard decisions to make about whether to go back on ADTor wait it out for a while.I _think_ if I were in your shoes with a Gleason 9 cancer anda rising PSA after radiation, I'd go back on ADT. I wouldexercise hard every day to try to counteract its negativeeffects. But you may hate the ADT so much that you wouldprefer to risk a shorter life with better quality.It's really an individual decision.Ideally, you should discuss these questions with a medicaloncologist before you make your final decisions. The urologistand radiation oncologist you're seeing may be fairlyknowledgeable about these issues, but they aren't specialists

inthem. What you want is a medical oncologist who specializes inprostate cancer, if you can find one.But in the end, it's still your decision. The doctors can tellyou what they would do but you will still do best to think thisout for yourself, guided but not ruled by their advice.Best of luck.Alan

[Guest guest]

Thank you for your comments Alan

Rearding the declining PSA's I had asked my urologist to give me repeat PSA's a little later before the next step. He did not think it was necessary. I had taken about 5 days of 50 mg of casodex when I got the second PSA from my primary care MD so it may have affected it. For the third PSA I got it as part of my annual physical from the VA I had gotten my first injection of Zoladex at 2:30 PM on one day and my VA vist occured at 8:30 the next morning. I guessed that with that short of an interval the hormones may not have had enough time to interfere with the PSA but that may not be the case.

Dr Epstein from s Hopkins writes that getting the first post surgical PSA should not be taken for at least 8 to 12 weeks after surgery. He further states that even with capsular penetration it often happens that the surgery may still kill the cancer cells that escaped if they are still close to the prostate because of a severed blood supply and perhaps entrapped by a sticky consistency. This seemed reasonable to me. But as I said I was not able to convince my uro that it would be a good idea to wait a few more weeks before starting hormone therapy. I wish I would have insisted.

I believe we are in great need for the development of a blood test that can determine the spread of cancer that is unaffected by hormone therapy. What ever choice is made seems to be a gamble which is why this is such an emotional situation.

Harry> (snip)> > > My husband was on Zoladex for one year. The doctor wanted him> > to be on hormones for 2 years. But after doing research Dr.> > Strum did a paper on hormones and it stated that one year was> > good enough.> > With respect, I must correct this; it's not the whole story.> > Strum et al. recommend at least one full year of undetectable> PSA (defined as =/< 0.05 ng/mL) before considering an off-phase> (*not* total cessation) of ADT. When/if the PSA rises to a> pre-selected level, restart ADT. During the off-phase, use a> 5-alpha reductase inhibitor such as dutasteride (Avodart) 0.5> mg qd (per

day).Steve,I understand that that is Dr. Strum's recommendation forintermittent hormone therapy, but is it also his recommendationfor ADT used as an adjuvant to radiation?That might be a different case.Harry,I researched this question six years ago when I was looking attreatment options. I found one clinical trial indicating that 6months of ADT gave full benefit as adjuvant radiation therapy,and some others that said more is desirable, up to 3 years.I don't know if there are definitive answers to this question. Iexpect that the answers are statistical rather than definitive.With your particular disease characteristics, 6 months ADT withradiation results in X% of men with complete cancer control while2 years (or 1 or 3 years, whatever) results in X% + Y%. But wedon't know the value of X or Y.For myself, I decided, against my doctor's advice, to get

offafter six months. So far, I appear to be okay. However, I onlyhad a Gleason 7 cancer (4+3) which may not have been asaggressive as yours. > I am a 75 year old who had prostate surgery on April 13, 2009.> The surgical pathology report assigned a Gleason sum of 4+5 => 9, Extensive polynureal invasion, and capsular penetration on> the bladder margin.That sounds pretty serious.> Pre op PSA of 6.43 Clinical stage was T3a N0 MX. Post surgical> PSA at 5 weeks was .689, at 8 weeks .144 and at 9 weeks post> surgery of .080.> > I presume these decreases are due to the half life clearing of> PSA from the system.I don't think I've seen anything like that before. Had youalready had a Zoladex injection before the last two tests? Ifso, then the cause of your declining PSA was not PSA clearing thesystem, but Zoladex suppressing the tumor

cells.> This has me concerned since hormones are at best pallative> treatment I don't think that's right. I believe that the current theory isthat the ADT starves the "hormone dependent" cancer cells andkeeps them from growing and dividing. Those cells will kill youif left untreated. The only real issue is, is it better to treatthose cells while there are only a relative few of them, or towait until they're all over the body. The experts used tobelieve that the results of either approach are the same, butthere are many today who say that is not so, and you get morelife extension if you attack the cancer when it's small.However, if you also have some hormone independent cells, and itis thought that all men have some or will develop them, the ADTwill not stop those. So even if you shut down all the hormonedependent cells, the others will eventually grow enough to

killyou.If that theory is true, then ADT does extend life. It eliminatessome of the cancer, but not all of it. And it least somespecialists believe that it extends life more when given earlier.Unfortunately however, with the current state of the science, noone can tell in advance how much time you'll get, or how hormonedependent your cells are. As I recall, Dr. Strum's theory isthat, if the PSA goes below 0.05 on hormone therapy, your cancercells are highly hormone dependent and you'll get more years oflife on ADT than average.> ... and they preclude using PSA tests to determine the effect> of the radiation treatment.Yes. That is a significant problem.I'm not the best person to advise you on this but here are somethoughts about how you might approach it.1. Try the ADT for the full six months and see how you're doing.If you find it pretty tolerable, get

another injection. Ifyou don't, stop.2. When you do stop, get regular, at least every 3 months, PSAand testosterone tests.If the PSA stays low, you're golden. The radiation worked.If it begins to rise, the radiation failed and you've gotsome hard decisions to make about whether to go back on ADTor wait it out for a while.I _think_ if I were in your shoes with a Gleason 9 cancer anda rising PSA after radiation, I'd go back on ADT. I wouldexercise hard every day to try to counteract its negativeeffects. But you may hate the ADT so much that you wouldprefer to risk a shorter life with better quality.It's really an individual decision.Ideally, you should discuss these questions with a medicaloncologist before you make your final decisions. The urologistand radiation oncologist you're seeing may be fairlyknowledgeable about these issues, but they aren't specialists

inthem. What you want is a medical oncologist who specializes inprostate cancer, if you can find one.But in the end, it's still your decision. The doctors can tellyou what they would do but you will still do best to think thisout for yourself, guided but not ruled by their advice.Best of luck.Alan

[Guest guest]

(snip)

> I believe we are in great need for the development of a blood test

> that can determine the spread of cancer that is unaffected by

> hormone therapy.

There are blood tests that can be very useful in evaluating a

high-risk case such as Harry's,

Here is what Dr. Strum has written:

" Patients with high Gleason score prostate cancer often do not secrete

very much PSA, and often their tumors make other biologic products such as

CGA (chromogranin A), NSE (neuron specific enolase), CEA

(carcino-embryonic antigen) and PAP (prostatic acid phosphatase).

Before any treatment is initiated it is important to obtain baseline

values of these markers so that if any are abnormally elevated they

can be used as parameters of successful treatment. "

Unfortunately, I see all too few of my brothers being offered these tests.

I suspect that all too few medics are aware of them.

Regards,

Steve J

[Guest guest]

(snip)

> I believe we are in great need for the development of a blood test

> that can determine the spread of cancer that is unaffected by

> hormone therapy.

There are blood tests that can be very useful in evaluating a

high-risk case such as Harry's,

Here is what Dr. Strum has written:

" Patients with high Gleason score prostate cancer often do not secrete

very much PSA, and often their tumors make other biologic products such as

CGA (chromogranin A), NSE (neuron specific enolase), CEA

(carcino-embryonic antigen) and PAP (prostatic acid phosphatase).

Before any treatment is initiated it is important to obtain baseline

values of these markers so that if any are abnormally elevated they

can be used as parameters of successful treatment. "

Unfortunately, I see all too few of my brothers being offered these tests.

I suspect that all too few medics are aware of them.

Regards,

Steve J

[Guest guest]

> Rearding the declining PSA's I had asked my urologist to give

> me repeat PSA's a little later before the next step. He did

> not think it was necessary. I had taken about 5 days of 50 mg

> of casodex when I got the second PSA from my primary care MD so

> it may have affected it. For the third PSA I got it as part of

> my annual physical from the VA I had gotten my first injection

> of Zoladex at 2:30 PM on one day and my VA vist occured at 8:30

> the next morning. I guessed that with that short of an interval

> the hormones may not have had enough time to interfere with the

> PSA but that may not be the case.

I think your second two PSA tests are unreliable. Casodex alone

will suppress the PCA and I would think that 5 days is more than

enough time for it to work. In some countries, Casodex is the

only form of hormone therapy given.

I believe that the first PSA result is the real one. You still

had cancer after surgery.

> Dr Epstein from s Hopkins writes that getting the first

> post surgical PSA should not be taken for at least 8 to 12

> weeks after surgery. He further states that even with capsular

> penetration it often happens that the surgery may still kill

> the cancer cells that escaped if they are still close to the

> prostate because of a severed blood supply and perhaps

> entrapped by a sticky consistency. This seemed reasonable to

> me. But as I said I was not able to convince my uro that it

> would be a good idea to wait a few more weeks before starting

> hormone therapy. I wish I would have insisted.

I strongly suspect that your doctor was right. I don't mean to

argue with Dr. Epstein. He's an internationally renowned expert.

But I bet he is not talking about PSA values at five weeks of

..689. I think that's WAY too high to be residual PSA that hasn't

broken down yet, and I think it's also WAY too high to hope that

it will die off due to residual effects of surgery.

It is still possible that the salvage radiation (SRT) will kill

it. PSA values of 1.0 are sometimes treated as a cutoff for SRT.

If the PSA is above that, the odds of success are pretty low.

With a PSA of .689, from what I've read, the odds in your favor

of SRT killing all the cancer are less than 50/50. I think you

should hope for the best here, but be prepared for the worst.

Steve Jordan said:

> Clearly, Harry's case, a Gleason nine, is high-risk; just as is

> mine and, IIRC, Alan's. Seems to me that in such cases, it's

> best to haul out the big guns and bang away. It's no time for

> subtlety.

Before I thought maybe that you had a real PSA of .080. But now

I don't think that's a real reading. I think the real reading

was .689. Combine that with the Gleason 9, and I think Steve,

and your doctor, have nailed the right strategy.

You're on hormone therapy now. Over a period of the next few

months, more side effects will kick in. If you can bear them

(and many of them can be alleviated with lots of exercise and

with help from a medical oncologist, if needed), and if you value

life extension highly, then I would go with your doc's

recommendation of two years of ADT.

If you find them unbearable and would rather die sooner than keep

taking ADT, well, that's a perfectly legitimate choice too. But

it's a choice you should make with a full understanding of the

risks.

Maybe the SRT will cure you. Maybe not. If not, I strongly

suggest that you face the hormone therapy with an open mind.

Your life won't be the same under ADT, but that goes with the

territory of aging. It's still the case that life is what we

make of it, ADT or not. Your libido will disappear. You'll be

more tired than you were. You will need to exercise regularly to

maintain energy and joint health and you may need a little extra

sleep each night. If you play active sports like tennis, you'll

tire out and play worse than before. You will get hot flushes.

But most of the really good things of life are undiminished with

ADT. You will still enjoy the same family, friends, music,

books, travel, cooking, or whatever it is that you enjoy now.

You will still be able to play golf and hike and swim and ride

bikes and do other outdoor activities that don't require really

high energy.

My own view is that an extra year or two or three that ADT can

give us (of course I have no idea what the real number is for any

given man, it can be a little or a lot) is worth the extra

burdens it imposes. I think we should look at it as a blessing,

not a curse. Our own grandfathers never got this choice. They

got cancer, it went undetected until the pain started, and then

they died.

I wish you the best of luck.

Alan

[Guest guest]

Thank you Alan and Steve and all others that have replied to my question. I would like to point out that what I wanted to know was how will I know if the SRT was sucessful or not. The answer to that will guide my choice on what to do with continued ADT. It seems to me that from the responses I have received that if one believes that it failed, I then have to continue on ADT till the end.

However, it was pointed out that even with my dissapointing Gleason sum and capsular penetration, that there is a chance that the SRT may be successful somewhat less than 50% of the time. Does it make sense then to continue the Zoladex while on SRT, and interrupt the ADT at the end of the 40 treatments, wait six months to get the Zoladex out of my system and then have a PSA done? If it is then undetectable, the radiation presumeably will have worked. If not, could I not resume the ADT?

The first basic urge is self preservation I place a high value on life. I do not wish to subject my self to the side effects of ADT if I have an alternative. This really is what my question was in the first place.

Harry> Rearding the declining PSA's I had asked my urologist to give> me repeat PSA's a little later before the next step. He did> not think it was necessary. I had taken about 5 days of 50 mg> of casodex when I got the second PSA from my primary care MD so> it may have affected it. For the third PSA I got it as part of> my annual physical from the VA I had gotten my first injection> of Zoladex at 2:30 PM on one day and my VA vist occured at 8:30> the next morning. I guessed that with that short of an interval> the hormones may not have had enough time to interfere with the> PSA but that may not be the case.I think your second two PSA tests are unreliable. Casodex

alonewill suppress the PCA and I would think that 5 days is more thanenough time for it to work. In some countries, Casodex is theonly form of hormone therapy given.I believe that the first PSA result is the real one. You stillhad cancer after surgery.> Dr Epstein from s Hopkins writes that getting the first> post surgical PSA should not be taken for at least 8 to 12> weeks after surgery. He further states that even with capsular> penetration it often happens that the surgery may still kill> the cancer cells that escaped if they are still close to the> prostate because of a severed blood supply and perhaps> entrapped by a sticky consistency. This seemed reasonable to> me. But as I said I was not able to convince my uro that it> would be a good idea to wait a few more weeks before starting> hormone therapy. I wish I would have insisted.I strongly

suspect that your doctor was right. I don't mean toargue with Dr. Epstein. He's an internationally renowned expert.But I bet he is not talking about PSA values at five weeks of.689. I think that's WAY too high to be residual PSA that hasn'tbroken down yet, and I think it's also WAY too high to hope thatit will die off due to residual effects of surgery.It is still possible that the salvage radiation (SRT) will killit. PSA values of 1.0 are sometimes treated as a cutoff for SRT.If the PSA is above that, the odds of success are pretty low.With a PSA of .689, from what I've read, the odds in your favorof SRT killing all the cancer are less than 50/50. I think youshould hope for the best here, but be prepared for the worst.Steve Jordan said:> Clearly, Harry's case, a Gleason nine, is high-risk; just as is> mine and, IIRC, Alan's. Seems to me that in such cases, it's> best

to haul out the big guns and bang away. It's no time for> subtlety.Before I thought maybe that you had a real PSA of .080. But nowI don't think that's a real reading. I think the real readingwas .689. Combine that with the Gleason 9, and I think Steve,and your doctor, have nailed the right strategy.You're on hormone therapy now. Over a period of the next fewmonths, more side effects will kick in. If you can bear them(and many of them can be alleviated with lots of exercise andwith help from a medical oncologist, if needed), and if you valuelife extension highly, then I would go with your doc'srecommendation of two years of ADT.If you find them unbearable and would rather die sooner than keeptaking ADT, well, that's a perfectly legitimate choice too. Butit's a choice you should make with a full understanding of therisks.Maybe the SRT will cure you. Maybe not. If not, I

stronglysuggest that you face the hormone therapy with an open mind.Your life won't be the same under ADT, but that goes with theterritory of aging. It's still the case that life is what wemake of it, ADT or not. Your libido will disappear. You'll bemore tired than you were. You will need to exercise regularly tomaintain energy and joint health and you may need a little extrasleep each night. If you play active sports like tennis, you'lltire out and play worse than before. You will get hot flushes.But most of the really good things of life are undiminished withADT. You will still enjoy the same family, friends, music,books, travel, cooking, or whatever it is that you enjoy now.You will still be able to play golf and hike and swim and ridebikes and do other outdoor activities that don't require reallyhigh energy.My own view is that an extra year or two or three that ADT cangive us (of

course I have no idea what the real number is for anygiven man, it can be a little or a lot) is worth the extraburdens it imposes. I think we should look at it as a blessing,not a curse. Our own grandfathers never got this choice. Theygot cancer, it went undetected until the pain started, and thenthey died.I wish you the best of luck.Alan

[Guest guest]

Thank you Alan and Steve and all others that have replied to my question. I would like to point out that what I wanted to know was how will I know if the SRT was sucessful or not. The answer to that will guide my choice on what to do with continued ADT. It seems to me that from the responses I have received that if one believes that it failed, I then have to continue on ADT till the end.

However, it was pointed out that even with my dissapointing Gleason sum and capsular penetration, that there is a chance that the SRT may be successful somewhat less than 50% of the time. Does it make sense then to continue the Zoladex while on SRT, and interrupt the ADT at the end of the 40 treatments, wait six months to get the Zoladex out of my system and then have a PSA done? If it is then undetectable, the radiation presumeably will have worked. If not, could I not resume the ADT?

The first basic urge is self preservation I place a high value on life. I do not wish to subject my self to the side effects of ADT if I have an alternative. This really is what my question was in the first place.

Harry> Rearding the declining PSA's I had asked my urologist to give> me repeat PSA's a little later before the next step. He did> not think it was necessary. I had taken about 5 days of 50 mg> of casodex when I got the second PSA from my primary care MD so> it may have affected it. For the third PSA I got it as part of> my annual physical from the VA I had gotten my first injection> of Zoladex at 2:30 PM on one day and my VA vist occured at 8:30> the next morning. I guessed that with that short of an interval> the hormones may not have had enough time to interfere with the> PSA but that may not be the case.I think your second two PSA tests are unreliable. Casodex

alonewill suppress the PCA and I would think that 5 days is more thanenough time for it to work. In some countries, Casodex is theonly form of hormone therapy given.I believe that the first PSA result is the real one. You stillhad cancer after surgery.> Dr Epstein from s Hopkins writes that getting the first> post surgical PSA should not be taken for at least 8 to 12> weeks after surgery. He further states that even with capsular> penetration it often happens that the surgery may still kill> the cancer cells that escaped if they are still close to the> prostate because of a severed blood supply and perhaps> entrapped by a sticky consistency. This seemed reasonable to> me. But as I said I was not able to convince my uro that it> would be a good idea to wait a few more weeks before starting> hormone therapy. I wish I would have insisted.I strongly

suspect that your doctor was right. I don't mean toargue with Dr. Epstein. He's an internationally renowned expert.But I bet he is not talking about PSA values at five weeks of.689. I think that's WAY too high to be residual PSA that hasn'tbroken down yet, and I think it's also WAY too high to hope thatit will die off due to residual effects of surgery.It is still possible that the salvage radiation (SRT) will killit. PSA values of 1.0 are sometimes treated as a cutoff for SRT.If the PSA is above that, the odds of success are pretty low.With a PSA of .689, from what I've read, the odds in your favorof SRT killing all the cancer are less than 50/50. I think youshould hope for the best here, but be prepared for the worst.Steve Jordan said:> Clearly, Harry's case, a Gleason nine, is high-risk; just as is> mine and, IIRC, Alan's. Seems to me that in such cases, it's> best

to haul out the big guns and bang away. It's no time for> subtlety.Before I thought maybe that you had a real PSA of .080. But nowI don't think that's a real reading. I think the real readingwas .689. Combine that with the Gleason 9, and I think Steve,and your doctor, have nailed the right strategy.You're on hormone therapy now. Over a period of the next fewmonths, more side effects will kick in. If you can bear them(and many of them can be alleviated with lots of exercise andwith help from a medical oncologist, if needed), and if you valuelife extension highly, then I would go with your doc'srecommendation of two years of ADT.If you find them unbearable and would rather die sooner than keeptaking ADT, well, that's a perfectly legitimate choice too. Butit's a choice you should make with a full understanding of therisks.Maybe the SRT will cure you. Maybe not. If not, I

stronglysuggest that you face the hormone therapy with an open mind.Your life won't be the same under ADT, but that goes with theterritory of aging. It's still the case that life is what wemake of it, ADT or not. Your libido will disappear. You'll bemore tired than you were. You will need to exercise regularly tomaintain energy and joint health and you may need a little extrasleep each night. If you play active sports like tennis, you'lltire out and play worse than before. You will get hot flushes.But most of the really good things of life are undiminished withADT. You will still enjoy the same family, friends, music,books, travel, cooking, or whatever it is that you enjoy now.You will still be able to play golf and hike and swim and ridebikes and do other outdoor activities that don't require reallyhigh energy.My own view is that an extra year or two or three that ADT cangive us (of

course I have no idea what the real number is for anygiven man, it can be a little or a lot) is worth the extraburdens it imposes. I think we should look at it as a blessing,not a curse. Our own grandfathers never got this choice. Theygot cancer, it went undetected until the pain started, and thenthey died.I wish you the best of luck.Alan

[Guest guest]

> Thank you Alan and Steve and all others that have replied to my

> question. I would like to point out that what I wanted to know

> was how will I know if the SRT was sucessful or not. The answer

> to that will guide my choice on what to do with continued ADT.

> It seems to me that from the responses I have received that if

> one believes that it failed, I then have to continue on ADT

> till the end.

>

> However, it was pointed out that even with my dissapointing

> Gleason sum and capsular penetration, that there is a chance

> that the SRT may be successful somewhat less than 50% of the

> time. Does it make sense then to continue the Zoladex while on

> SRT, and interrupt the ADT at the end of the 40 treatments,

> wait six months to get the Zoladex out of my system and then

> have a PSA done? If it is then undetectable, the radiation

> presumeably will have worked. If not, could I not resume the

> ADT?

Harry,

As you correctly pointed out in your first posting, if the ADT

does its job, there is no way to know whether the SRT succeeded

until after you get off ADT and see what happens to the PSA.

It seems logical to take the ADT during radiation, then get off

as soon as radiation is done in order to see what happened, but

it doesn't actually work that way. Here's my understanding of

why.

Radiation doesn't kill very many of the cancer cells right away.

If they gave you enough radiation to do that, it would cause

severe damage to healthy tissue, including nerves and the

urethra, which are embedded in the prostate, and probably other

things outside.

What the radiation does is " ionize " some of the molecules in the

cancer cells, i.e., it knocks electrons off the molecules. This

gives them a positive electric charge and causes them to interact

and combine with other negative ions, damaging their functioning.

The real damage is done by ionizing some of the DNA in the cells.

(Parenthetically, I've wondered if it would be a good idea to

refrain from taking vitamin C or other anti-oxidants during

radiation since it is oxygen " radicals " that are among the most

reactive negative ions in cells.)

Cancer is a disease caused by mutated, damaged DNA. So the

cancer already has poorly functioning DNA and the radiation makes

it much worse - doing more effective damage to cancer cells than

healthy cells.

The cells can function with damaged DNA, but not well, and they

generally can't divide successfully. When they try, they die.

Cancer cells are, by definition, cells that divide, so they are

disproportionately killed. But they don't all try to divide

right away. No one knows how long it takes. In a test tube, on

average, prostate cancer cells divide every couple of months.

But in the body, we don't really know.

ADT not only shrinks the prostate prior to radiation, it also

weakens the cancer cells, making them more susceptible to dying

as a result of radiation effects. Therefore it increases the

odds of a cure from radiation. And since some of the effects of

radiation aren't felt until the cell tries to divide, which could

be months after the radiation ends, keeping the ADT going can

assist in the treatment.

I _think_ that most of the beneficial effects will occur in the

first six months. A six month treatment actually lasts longer

because it takes a few more months for the testosterone to come

beack. Studies have shown a significant difference between high

risk cancers radiated without ADT and those radiated with 6

months of ADT. Beyond 6 months, there is probably still some

effect. We don't know how much. Some studies have indicated

it's significant, some not. It may be that it's more significant

for some particular kinds of patients than others.

When your doctor proposed two years of ADT, he was trying to

maximize your chances, to be on the safe side.

You could take ADT for 6 months, get off, find yourself cured,

and be glad that you had it for only 6 months. You could take it

for 2 years, get off, find yourself cured, and wonder whether it

was all really necessary. But, you could also get off after six

months, find a rising PSA six months after that and wonder

whether you lost your chance at a cure by getting off ADT too

early.

No one can tell you what is right for you, but I hope this gives

you more information about the choices.

Best of luck.

Alan

[Guest guest]

> Thank you Alan and Steve and all others that have replied to my

> question. I would like to point out that what I wanted to know

> was how will I know if the SRT was sucessful or not. The answer

> to that will guide my choice on what to do with continued ADT.

> It seems to me that from the responses I have received that if

> one believes that it failed, I then have to continue on ADT

> till the end.

>

> However, it was pointed out that even with my dissapointing

> Gleason sum and capsular penetration, that there is a chance

> that the SRT may be successful somewhat less than 50% of the

> time. Does it make sense then to continue the Zoladex while on

> SRT, and interrupt the ADT at the end of the 40 treatments,

> wait six months to get the Zoladex out of my system and then

> have a PSA done? If it is then undetectable, the radiation

> presumeably will have worked. If not, could I not resume the

> ADT?

Harry,

As you correctly pointed out in your first posting, if the ADT

does its job, there is no way to know whether the SRT succeeded

until after you get off ADT and see what happens to the PSA.

It seems logical to take the ADT during radiation, then get off

as soon as radiation is done in order to see what happened, but

it doesn't actually work that way. Here's my understanding of

why.

Radiation doesn't kill very many of the cancer cells right away.

If they gave you enough radiation to do that, it would cause

severe damage to healthy tissue, including nerves and the

urethra, which are embedded in the prostate, and probably other

things outside.

What the radiation does is " ionize " some of the molecules in the

cancer cells, i.e., it knocks electrons off the molecules. This

gives them a positive electric charge and causes them to interact

and combine with other negative ions, damaging their functioning.

The real damage is done by ionizing some of the DNA in the cells.

(Parenthetically, I've wondered if it would be a good idea to

refrain from taking vitamin C or other anti-oxidants during

radiation since it is oxygen " radicals " that are among the most

reactive negative ions in cells.)

Cancer is a disease caused by mutated, damaged DNA. So the

cancer already has poorly functioning DNA and the radiation makes

it much worse - doing more effective damage to cancer cells than

healthy cells.

The cells can function with damaged DNA, but not well, and they

generally can't divide successfully. When they try, they die.

Cancer cells are, by definition, cells that divide, so they are

disproportionately killed. But they don't all try to divide

right away. No one knows how long it takes. In a test tube, on

average, prostate cancer cells divide every couple of months.

But in the body, we don't really know.

ADT not only shrinks the prostate prior to radiation, it also

weakens the cancer cells, making them more susceptible to dying

as a result of radiation effects. Therefore it increases the

odds of a cure from radiation. And since some of the effects of

radiation aren't felt until the cell tries to divide, which could

be months after the radiation ends, keeping the ADT going can

assist in the treatment.

I _think_ that most of the beneficial effects will occur in the

first six months. A six month treatment actually lasts longer

because it takes a few more months for the testosterone to come

beack. Studies have shown a significant difference between high

risk cancers radiated without ADT and those radiated with 6

months of ADT. Beyond 6 months, there is probably still some

effect. We don't know how much. Some studies have indicated

it's significant, some not. It may be that it's more significant

for some particular kinds of patients than others.

When your doctor proposed two years of ADT, he was trying to

maximize your chances, to be on the safe side.

You could take ADT for 6 months, get off, find yourself cured,

and be glad that you had it for only 6 months. You could take it

for 2 years, get off, find yourself cured, and wonder whether it

was all really necessary. But, you could also get off after six

months, find a rising PSA six months after that and wonder

whether you lost your chance at a cure by getting off ADT too

early.

No one can tell you what is right for you, but I hope this gives

you more information about the choices.

Best of luck.

Alan

[Guest guest]

Harry,

I'd like to add a few more comments to what I've said about your

idea of getting off ADT early.

I faced the same decision as you are facing now and chose,

against my doctor's advice, to get off ADT early. It appears

that I got away with it. So I don't want you to think that I

believe you are wrong to do that.

However it is a difficult decision and your cancer is more

aggressive than mine was, and you have already failed one

treatment (surgery) whereas I was taking radiation as my primary

treatment.

My recommendation is, don't make the decision now. Wait and see

how you do on ADT. If you really hate it, then decide to get

off. If you find it isn't that much of a bother to you (and some

men do feel that way), then keep it up a little longer. You

don't have to choose now, and you don't have to choose between 6

months and 2 years. You could, at the end of 6 months, get

another 3 month injection and then quit, or two more injections

and then quit. I'd play it by ear, as it were.

And finally. I know you've given this a great deal of thought

and are trying to make the most rational decision that you can.

I believe you'll do that. Whatever the outcome, don't look back

and kick yourself and say, " I should have done it differently. "

Maybe you should have, maybe you shouldn't have, but you will

have made the best decision you could at the time and that's all

that matters.

Best of luck.

Alan

[Guest guest]

Harry,

I'd like to add a few more comments to what I've said about your

idea of getting off ADT early.

I faced the same decision as you are facing now and chose,

against my doctor's advice, to get off ADT early. It appears

that I got away with it. So I don't want you to think that I

believe you are wrong to do that.

However it is a difficult decision and your cancer is more

aggressive than mine was, and you have already failed one

treatment (surgery) whereas I was taking radiation as my primary

treatment.

My recommendation is, don't make the decision now. Wait and see

how you do on ADT. If you really hate it, then decide to get

off. If you find it isn't that much of a bother to you (and some

men do feel that way), then keep it up a little longer. You

don't have to choose now, and you don't have to choose between 6

months and 2 years. You could, at the end of 6 months, get

another 3 month injection and then quit, or two more injections

and then quit. I'd play it by ear, as it were.

And finally. I know you've given this a great deal of thought

and are trying to make the most rational decision that you can.

I believe you'll do that. Whatever the outcome, don't look back

and kick yourself and say, " I should have done it differently. "

Maybe you should have, maybe you shouldn't have, but you will

have made the best decision you could at the time and that's all

that matters.

Best of luck.

Alan

[Guest guest]

Thanks for the feed back Chuck and Sheila

I note the word "after" I have started Zoladex before the start of IMRT and continue to take it. I had my tenth radiation treatment today and will also be on ADT through all 40 sessions. As to how long I will continue ADT after that I have not yet decided but the six month period does sound attractive to me but I have time to consider that. I am very appreciative of the comments from all of you.

Harry

Subject: Re: I have a question regarding salvage radiation with hormone therapy.To: ProstateCancerSupport Date: Wednesday, August 12, 2009, 5:54 PM

>> Harry,> > I too had a Gleason of 9 (4+5) and underwent ADT, IMRT and Brachythearpy last year. My PSA is currently less than .01> > My Uro had just come back from a Urology Conference where they reported that ADT is only necessary for 6 months after IMRT or Brachythearpy. > > Hope this helps and good luck with your treatment.> > Chuck> Harry,My husband was on ADT for six months after IMRT treaments. Just thought I would mention that.Best Wishes,Sheila> > > [ProstateCancerSupp ort] I have a question regarding salvage radiation with hormone therapy.> > > I am a 75 year old who had prostate surgery on April 13, 2009. The surgical pathology report assigned a Gleason sum of 4+5 = 9, Extensive polynureal invasion, and capsular penetration on the bladder margin.> > Pre op PSA of 6.43 Clinical stage was T3a N0 MX. Post surgical PSA at 5 weeks was .689, at 8 weeks .144 and at 9 weeks post surgery of .080.> > I presume these decreases are due to the half life clearing of PSA from the system.> > I elected for salvage readiation and began that a couple of weeks ago. I was

given a short course of casodex and then Zoladex shots to be given at six month intervals as well.> > I have read that hormone therapy does enhance radiation therapy but that long term use vs short term administration (six months) studies do not show a significant difference in survival time.> > My Urologist told me that he expects to keep me on zoladex at least 2 years post my 40 radiation treatments.> > This has me concerned since hormones are at best pallative treatment and they preclude using PSA tests to determine the effect of the radiation treatment.> > I am inclined to stop the Zoladex at the end of my next 6 month treatment and wait for another six months to get rid of its effects and then resume PSA testing to determine the effect of the radiation treatment.> > I am in pretty good shape overall for my age. I would appreciate any comments as right now I do not look forward to

the possiblility of waiting 2 and a half years on pins and needles to determine the effect of the radiation.> > Thanks for bearing with this long post.> > Harry Trentes>

[Guest guest]

Harry,

I actually started ADT before I had IMRT and Brachythearpy. My Uro started me on Flutimide (pills) for about 6 weeks to slowly lower the testosterone level then I got the shot of Lupron, which as you know stops it altogether.

So I've been on ADT for about a year now.

Chuck

[ProstateCancerSupp ort] I have a question regarding salvage radiation with hormone therapy.> > > I am a 75 year old who had prostate surgery on April 13, 2009. The surgical pathology report assigned a Gleason sum of 4+5 = 9, Extensive polynureal invasion, and capsular penetration on the bladder margin.> > Pre op PSA of 6.43 Clinical stage was T3a N0 MX. Post surgical PSA at 5 weeks was .689, at 8 weeks .144 and at 9 weeks post surgery of .080.> > I presume these decreases are due to the half life clearing of PSA from the system.> > I elected for salvage readiation and began that a couple of weeks ago. I was given a short course of casodex and then Zoladex shots to be given at six month intervals as well.> > I have read that hormone therapy does enhance radiation therapy but that long term use vs short term administration (six months) studies do not show a significant difference in survival time.> > My Urologist told me that he expects to keep me on zoladex at least 2 years post my 40 radiation treatments.> > This has me concerned since hormones are at best pallative treatment and they preclude using PSA tests to determine the effect of the radiation treatment.> > I am inclined to stop the Zoladex at the end of my next 6 month treatment and wait for another six months to get rid of its effects and then resume PSA testing to determine the effect of the radiation treatment.> > I am in pretty good shape overall for my age. I would appreciate any comments as right now I do not look forward to the possiblility of waiting 2 and a half years on pins and needles to determine the effect of the radiation.> > Thanks for bearing with this long post.> > Harry Trentes>

[Guest guest]

Harry,

I actually started ADT before I had IMRT and Brachythearpy. My Uro started me on Flutimide (pills) for about 6 weeks to slowly lower the testosterone level then I got the shot of Lupron, which as you know stops it altogether.

So I've been on ADT for about a year now.

Chuck

[ProstateCancerSupp ort] I have a question regarding salvage radiation with hormone therapy.> > > I am a 75 year old who had prostate surgery on April 13, 2009. The surgical pathology report assigned a Gleason sum of 4+5 = 9, Extensive polynureal invasion, and capsular penetration on the bladder margin.> > Pre op PSA of 6.43 Clinical stage was T3a N0 MX. Post surgical PSA at 5 weeks was .689, at 8 weeks .144 and at 9 weeks post surgery of .080.> > I presume these decreases are due to the half life clearing of PSA from the system.> > I elected for salvage readiation and began that a couple of weeks ago. I was given a short course of casodex and then Zoladex shots to be given at six month intervals as well.> > I have read that hormone therapy does enhance radiation therapy but that long term use vs short term administration (six months) studies do not show a significant difference in survival time.> > My Urologist told me that he expects to keep me on zoladex at least 2 years post my 40 radiation treatments.> > This has me concerned since hormones are at best pallative treatment and they preclude using PSA tests to determine the effect of the radiation treatment.> > I am inclined to stop the Zoladex at the end of my next 6 month treatment and wait for another six months to get rid of its effects and then resume PSA testing to determine the effect of the radiation treatment.> > I am in pretty good shape overall for my age. I would appreciate any comments as right now I do not look forward to the possiblility of waiting 2 and a half years on pins and needles to determine the effect of the radiation.> > Thanks for bearing with this long post.> > Harry Trentes>