ADT, LHRH agonists,Lockerbie bomber,ProstaScint,Hormone refractory prostate cancer,and…questions from Janice

July 22, 2010 
Dear Dr. McHugh – Your primer is very interesting, but after reading it, I have a few general questions. First if all, if a patient has a rising PSA after his initial treatment, how far do you let the PSA rise before initiating more treatments, and are the additional treatments always the same? Secondly, how do you find out where the cancer has recurred? I have read that scans, etc. do not show much when the PSA us relatively low. When you start a patient on androgen deprivation do you also recommend he go to an oncologist?

And, yes, BP is certainly looking like the villain. Thanks for all of your insight.

Janice

 
Excellent questions and more nuances to consider. 

1. How far do you let the PSA rise before additional treatments? This depends on the initial treatment. If the prostate was removed then as soon as you establish a trend upward i.e.  < .1 then .2 and then .4. In the case of surgery the next treatment would be external beam radiation. Radiation begins after surgery as soon as a verifiable trend upward in the value of the PSA  has been determined. If radiation, either seeds or external beam, was the first treatment then surgical options in terms of removal is not an option. In the case of seeds, if the PSA rises you do nothing initially. I mention in my  book that when you choose radiation, particularly seeds, you are “attached at the hip” with it. With seeds the timing of hormonal therapy depends on the anxiety level of the urologist or the patient. No benefit to initiating ADT at .5 or a PSA or 10. Usually the hormonal therapy would commence at a level somewhere less than 10. With external beam radiation you have the potential of using cryosurgery if it can be proved that the PSA is only on the basis of intra-prostatic recurrence. A ProstaScint scan can be done to help determine this.
2. How do you find out where the cancer has recurred? This answer will probably surprise you. In the case of a rising PSA after surgery, because we are talking about a very low PSA trending up, we assume that the cancer is local i.e. in the cells around where the prostate was removed. We rarely will do a study like a C.T. scan because we are talking about microscopic recurrence (Traditional x-rays would not detect prostate cancer on the basis of a PSA at these low levels). The ProstaScint scan can detect early recurrence but some insurances don’t cover the expense. Since historically the rising PSA after surgery is local, the Prostascint is skipped and usually radiation is done on the basis of the PSA alone. The path report is helpful in this regard if it showed periprostatic extension microscopically.  In the case of radiation as mentioned earlier, hormonal therapy would commence when the PSA got to the 10 range depending on the anxiety, bias and wishes of the patient-urologist relationship. If the PSA goes up after prostatectomy and subsequent radiation, then you would use the same rationale as the radiation alone patient to begin hormones.
3. To physically detect recurrent prostate cancer by x-rays or bone scan the disease would have been large and late stage; and would be associated with a very high PSA i.e. greater than 20.
4. When do you refer to an oncologist? This may vary from urologist to urologist. I manage my prostate cancer patients untill it is clear that they are hormone refractory. I am comfortable with the manipulations that can be done with the type or timing of the ADT as long as it is making progress. Once I determine that hormones are not doing the job, it is at that point I refer to the oncologist. There are some chemotherapeutic drugs available to him or her that urologists don’t customarily do.
5. In a lot of ways the saying ….” Medicine is an art and not a science” holds true for the hormone management in the treatment of prostate cancer. No one way is absolutely correct. I view hormone manipulations as trying to keep the prostate cancer cells off-balance giving them a little hormone, watching the effect of the PSA, taking a little away, adjusting all the while untill it ( the prostate cells ) figures it out. It is at this point  they go to the oncologist for the next phase of treatments targeting other aspects of the prostate cancer.
6. We used to do ADT on a routine basis i.e. a LHRH shot every 6 months. Now it is more common for me to use a 3-month LHRH shot and then monitor the PSA every 3 months. The patient would get another shot only if the PSA went back up (intermittent therapy). I have had patients that go years on one shot others many months past the known effective duration of that particular LHRH preparation. This is another nuance that is poorly understood and again explains why it would have been foolhardy to predict the time of death of the LB unless it was known that he was indeed end stage and all forms of therapy exhausted in the face of a very high PSA and demonstrable bone and nodal metastasis.

Janice… I appreciate your interest in my site. I appreciate your kind words from time to time. I also appreciate the questions and hope you do not mind using your comment to take the androgen discussion forward. Much of the research time and money in the future will be to figure out ways to deal with the ” androgen insensitive” cells in the prostate cancer population.