Posted in gainesville ga urologist, jeff jarvis, john mchugh md, prostate cancer, tagged Active surveillance, book on prostate cancer, catheter, early detection, gainesville ga urologist, hormone therapy prostate cancer, john c mchugh m.d., lockerbie bomber and prostate cancer, prostate cancer book, prostate cancer in bone, psa, wife and prostate cancer on July 22, 2010|
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penelope is beginning to be a problem fishing-she loves plastic worms
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?
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Posted in gainesville ga urologist, john c mchugh m.d., prostate cancer, prostate cancer book, prostate cancer georgia, The "Decision", tagged book on prostate cancer, gainesville ga urologist, hormone insensitivity, lockerbie bomber and prostate cancer, prostate cancer, psa on July 17, 2010|
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no stick is too unimportant or too big for the pepster
Charles B. Huggins
Prostablog post on L.B.
A few nuances about prostate cancer and hormone therapy.
- Hormone suppression does not cure prostate cancer. It will allow a person to live longer. Whether you start hormone suppression early on in the disease or later has very little affect on the ultimate life expectancy.
- Different prostate cancers ( volume of disease and Gleason’s score) respond differently to hormone therapy.
- There are varying populations within a particular person’s prostate cancer of hormone sensitive and hormone insensitive prostate cancer cells. ( The more hormone sensitive cells the better response to hormone deprivation.)
- If there is a beneficial response i.e. the PSA goes down, how long that effect lasts varies from person to person as well.
- If there is a beneficial response… in time the cancer figures that out and begins to populate more hormone insensitive cells.
- As a result hormone therapy delays, to varying lengths of time and degrees, but does not cure prostate cancer.
That is all for now… I will lay out later the most probable scenario for the L.B. For any urologist to even try to predict the life expectancy of a patient, the patient would have had to been well beyond the phase of androgen insensitivity i.e. the PSA went down and then over time it went back up and there was evidence of metastatic bone disease. (Androgen refractory) At the very least a doctor should have said that the time to death was unpredictable given the known nuances of prostate cancer and hormone therapy.
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penelope swimming under old duncan bridge on the Chattahoochee river
Okay…a test question. What is happening here? Why is it they miss calculated the guy’s life expectancy? This issue is not one to be worried about in the decision-making process but may be one down the road if the cancer returns after treatment or is in places other than the prostate (metastatic) at the time of diagnosis.
I’ll explain later but…do any of my readers want to take a stab at why “the experts” missed their mark?
I will send one of my books (oh wow!) to the respondent with the best and most accurate answer.
Cancer specialist who gave Lockerbie bomber 3 months to live last year now says he could live 10 more years
“Libyan authorities, keen to secure Megrahi’s release, asked several experts to put a three-month estimate on the bomber’s life but Professor Sikora was the only one to agree.”
And “War is Deceit.” “Dying Lockerbie bomber ‘could survive for 10 years or more’,” by Alastair Jamieson for the Telegraph, July 4 (thanks to all who sent this in):
Professor Karol Sikora, who assessed Abdelbaset Ali Mohmet al-Megrahi for the Libyan authorities almost a year ago, told The Sunday Times it was “embarrassing” the bomber had outlived his three-month prognosis.
He wrote to his Scottish counterpart to say it was “in the overwhelming interests of the United Kingdom” to make Megrahi eligible for return to Libya…
Megrahi, 58, is the only person convicted of the 1988 bombing of a US Pan Am jumbo jet over Lockerbie, which left 270 dead.
The Scottish government provoked outrage from the United States when it released him from prison in August 2009 on compassionate grounds because he dying of metastatic prostate cancer.
In Scotland, prisoners are eligible for release on compassionate grounds if they have fewer than three months to live.
A report in the Sunday Times said Libyan authorities, keen to secure Megrahi’s release, asked several experts to put a three-month estimate on the bomber’s life but Professor Sikora was the only one to agree.
Professor Sikora, the dean of medicine at Buckingham University and medical director of CancerPartnersUK in London, was paid for his medical assessment of Megrahi at Greenock prison on July last year.
He told the newspaper: “There was always a chance he could live for 10 years, 20 years … But it’s very unusual.
“It was clear that three months was what they were aiming for. Three months was the critical point.
“On the balance of probabilities, I felt I could sort of justify [that].”
He denied he came any under pressure, but admitted: “It is embarrassing that he’s gone on for so long.”
“There was a 50 per cent chance that he would die in three months, but there was also a 50 per cent chance that he would live longer.”
Saif Gaddafi, eldest son of leader Colonel Gaddafi, said in May that Megrahi was still “very sick” with cancer.
The Scottish government insists Kenny MacAskill, the justice minister who took the final decision to release Megrahi, based his ruling on a medical report by Dr Andrew Fraser, director of health and care at the Scottish Prison Service (SPS).
A spokesman said Professor Sikora’s advice to Libya “had no part to play in considerations on the Megrahi case”.
Jack Straw, then Justice Secretary at Westminster, admitted last year that trade and oil agreements were an essential part of the British government’s decision to include Megrahi in a previously planned prisoner transfer agreement with Libya.
Posted by Marisol on July 4, 2010 1:43 PM | 21 Comments
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