the vicissitudes of prostate cancer, androgen deprivation – “hormone” therapy and how it relates to the locerbie bomber

If you comprehend the previous post and this one you will more fully understand the stories that will come out about the Lockerbie bomber’s ” missed life expectancy” prediction and some of the nuances of Androgen Deprivation Therapy. (ADT)

• In the ideal scenario one has his prostate cancer treated with whichever modality he chooses and the PSA stays low i.e. a nadir of .5 or less for radiation and >.1 if surgery. If the PSA goes up after any treatment that is an indication of treatment failure.
• Although the PSA can be unreliable in the diagnosis of prostate cancer (and hence all the hub-bub by the American Cancer Society and the subsequent fallout in the press) it is very reliable in terms of ” if the cancer comes back.”
• hormonal therapy (giving a drug to make the testosterone go down) is used in this scenario initially i.e. treatment failure.
• In the majority of cases, if the PSA goes up after treatment, it will go back down with the initiation of hormonal therapy.
• How long the PSA will go down and the cancer is in “remission” is unpredictable.
• If the prostate cancer has a high population of androgen sensitive cells (those which respond to the taking away of testosterone) then there will be a dramatic response to the level of the PSA i.e. ” PSA goes to zero.”
• If there is a high population of testosterone insensitive cells then the effect of the androgen deprivation will not be as dramatic or as long-lasting.
• Prostate cancers vary as to how long it takes to ” figure out the hormone manipulation” which means that some PSA’s stay low for a long time, others a short time. I tell patients that the effect  could be six months or it could be six years.
• I have had patients that had no response. I have currently several patients that had only one three-month LHRH shot and the effect has lasted several years. Go figure.
• When a prostate cancer initially responds to hormonal therapy and then the PSA begins to rise and continues to rise despite manipulations both in the drug and the timing of the drug then this is referred to hormone refractory prostate cancer.
• The prognosis of the prostate cancer patient that has become hormone refractory is poor but the life expectancy in this scenario varies as well from months to an average of about two years.
• A lot of research dollars are aimed at this class of patients and much has been accomplished in this regard.
• A urologist cannot tell a patient or a family in the hormone refractory phase of this disease how long he will live.
• When a patient’s prostate cancer becomes  refractory the PSA will rise dramatically into the hundreds and sometimes thousands.
• The most common site of metastatic disease in the refractory patient is pelvic lymph nodes and the bone. Both of which can be detected radiographically: the bone mets by way of a bone scan and the pelvic nodes by way of a C.T. Scan. These tests are readily available to most medical centers.
• In the case of the Lockerbie bomber, for any doctor to begin to predict a “three-month life expectancy,” the patient would have to be hormonally refractory, have a very high PSA that has not responded to the Oncologist’s chemotherapy (this is limited at this point in time but much has been done) and have evidence of  either bony metastasis or large pelvic  nodes consistent with nodal metastasis.
• If the patient in question does not meet the above criteria then it should have been known to all that making predictions about life expectancy, now knowing what you know from the above primer,was either purposefully misleading or one having a poor understanding of the disease.  An example of this would be a doctor saying that a patient will probably live a year when hormonal therapy has not been instituted and the subsequent response unknown. You can’t begin thinking about life expectancy predictions unless the patient is in a hormone refractory phase of the disease.
• If and when others review the Lockerbie’s charts, labs, hormonal treatments and the patient’s response, it will be clear whether or not the ” life expectancy ” debacle was a legitimate error of medicine because  the vicissitudes of prostate cancer or…politically or financially motivated.

Now you know the rest of the story. I took the time to do this because it also serves as a nice primer on hormone therapy when the initial treatments fail.

This is the stuff novels are made of…have you noted all the talk and speculation about BP’s possible involvement?