ADT protocol? I suspect that I am about to start IADT/HT after 93 mos.
Bill
then off, then back on at some indeterminate point, and so on. Is this
the standard protocol for intermittent ADT/HT at this time?
Bill/Memphis
Heather
"Bill" <zero...@midsouth.rr.com> wrote in message
news:e05d05ce-cede-4804...@a31g2000yqn.googlegroups.com...
FWIW, Ron will be doing exactly that in 2010. He has been off HT for almost
4 years now. It stayed undetectible for over a year while on it but he was
also on Casodex and Megace. His Toronto oncologist will be putting him back
on JUST Lupron or similar once his PSA rises to a certain point. It is over
2.5 as of last August.
I think the reasoning is that he had an overload of HT, particularly with
the Megace. Not needed, frankly......but the local oncologist put him on
it. Didn't stay with him long. He was living in the Dark Ages and said "no
one can ever come off HT.....EVER". Wrong!! Oh, and he said that the SE's
he had were not from HT, but that he must have some other *serious illness*
and should see his family doctor!! What a jerk!!
HTH.....Heather
Steve Jordan
Yes and no.
The standard is to reduce PSA via ADT to <0.05 ng/mL, and
maintain that level for at least a year. Then ADT may be suspended.
Restart can occur at whatever point is comfortable for the patient.
Here is an excellent article:
http://www.prostate-cancer.org/pcricms/node/199
Dozens of clinical studies can be found on PubMed, a service of
the US National Library of Medicine, at www.pubmed.gov
A couple of points:
(1) Unless the uro is very exceptional in his training, he is a
first and foremost a surgeon. The regimen outlined above causes
me to wonder whether he is knowledgeable about ADT. Frex, why no
Avodart or Proscar? Why no Casodex?
(2) For example, has he briefed on side effects and how to
treat/prevent them?
(3) For example, has he briefed on the SE of inevitable loss of
bone mineral density, which leads to osteopenia and
osteoporosis,, and how to prevent it?
Regards,
Steve J
"I believe it is a mistake for many urologists to be involved in
the endocrine therapy of prostate cancer. Let me state why.
Urologists are surgeons and many times surgeons rush to a
treatment without
really understanding what they are doing.
The old joke in medical school was that surgeons do everything
and know nothing,
that internists know everything and do nothing, that
psychiatrists know nothing and
do nothing and finally that pathologists know everything and do
everything -- but it is
too late."
-- Stephen B. Strum, MD
Medical Oncologist
PCa Specialist
Bill
that level for at least a year."
That's what I was thinking. I know that's Strum's practice; but then
again, that's Strum. Oops, I wrote that before I went to the article
- and lo and behold see who it is. Anyone else?
"The regimen outlined above causes me to wonder whether he is
knowledgeable about ADT. Frex, why no Avodart or Proscar? Why no
Casodex?"
Me too; that's why I'm asking. I asked him last time I saw him if he
had something in writing that explained his protocol and he acted like
it wasn't needed because this is the way to do it. Monotherapy or ADT1
so no other agents. He told me once before that he does not worry
about flare unless you already have mets and the jump could cause
irreversible damage. I.e. the flare will be wiped out in a few weeks
and you will be right back where you would have been had you had anti-
androgen.
"(2) For example, has he briefed on side effects and how to treat/
prevent them?
> (3) For example, has he briefed on the SE of inevitable loss of bone mineral density, which leads to osteopenia and osteoporosis,, and how to prevent it?"
I suspect that that would take place when the decision point has been
reached. I know all that stuff anyway but he does have a legal
obligation to get informed consent.
It looks like I'll have at least another 3 mos. to bone up on ADT
because I just got my last my PSA and it actually dropped a tenth. It
has taken a stair-step course through the years but jumped the last 2
times. Looks like I'm on a plateau again. :-)
Anyone here been to Dr. Bob or Snuffy Myers?
Bill/Memphis
Steve Jordan
(Entries in quotes are from me)
> "The standard is to reduce PSA via ADT to <0.05 ng/mL, and
> maintain that level for at least a year."
>
> That's what I was thinking. I know that's Strum's practice;
> but then again, that's Strum. Oops, I wrote that before I
> went to the article - and lo and behold see who it is. Anyone
> else?
I hope that Bill is not one who denigrates Strum as "an outlier."
That's correct, but not in the denunciatory sense so often used
by people
who know or understand little or nothing about him and his
practices.. He is a
leader, and leaders are always "outliers."
Go to http://www.ncbi.nlm.nih.gov/sites/entrez and find 495 reports.
Including Strum, et al, "Intermittent androgen deprivation in
prostate cancer patients: factors predictive of prolonged time
off therapy" PMID 10706649
and
Scholz, et al., "Intermittent use of testosterone inactivating
pharmaceuticals using finasteride prolongs the time off period."
PMID 17905106
And so on. What Strum writes is not a product of his overheated
imagination; nor is he a quack, as some seem comfortable in
believing.
BTW, I wonder whether anyone has taken the time to check the
33 references included with the essay I referenced in my post of
earlier today (11/16).
Or the 157 references in _A Primer on Prostate Cancer_.
> "The regimen outlined above causes me to wonder whether he is
> knowledgeable about ADT. Frex, why no Avodart or Proscar? Why
> no Casodex?"
>
> Me too; that's why I'm asking. I asked him last time I saw him
> if he had something in writing that explained his protocol and
> he acted like it wasn't needed because this is the way to do
> it. Monotherapy or ADT1 so no other agents. He told me once
> before that he does not worry about flare unless you already
> have mets and the jump could cause irreversible damage. I.e.
> the flare will be wiped out in a few weeks and you will be
> right back where you would have been had you had anti-
> androgen.
I recommend finding a med onc who knows what (s)he is doing.
It seems evident that the uro is practicing "cookbook medicine."
> "(2) For example, has he briefed on side effects and how to
> treat/ prevent them?
> (3) For example, has he briefed on the SE of inevitable loss
> of bone mineral density, which leads to osteopenia and
> osteoporosis,, and how to prevent it?"
>
> I suspect that that would take place when the decision point
> has been reached. I know all that stuff anyway but he does
> have a legal obligation to get informed consent.
Seems to me that there is little by way of well-founded
information in play. But it's Bill's ultimate choice.
Good luck.
Steve J
"Flagrantly, we docs ignore the declaration of biology. We do
this out of ignorance, greed or both. The prime directive of the
physician, the real physician, is patient outcome & not physician
income (or ego)."
Heather
"The regimen outlined above causes me to wonder whether he is
knowledgeable about ADT. Frex, why no Avodart or Proscar? Why no
Casodex?"
Me too; that's why I'm asking. I asked him last time I saw him if he
had something in writing that explained his protocol and he acted like
it wasn't needed because this is the way to do it. Monotherapy or ADT1
so no other agents. He told me once before that he does not worry
about flare unless you already have mets and the jump could cause
irreversible damage. I.e. the flare will be wiped out in a few weeks
and you will be right back where you would have been had you had anti-
androgen.
=====> Sorry Bill and Steve.....I was thinking of the general picture and
totally forgot that Ron would obviously have to take Casodex for 2 weeks
before he restarts the HT. But the reason Dr. Loblaw is only giving him
Lupron or Zoladex is due to his rather bad reaction to all 3 of the drugs.
The Megace was really not needed as his hot flashes were few and far
between.
Heather
Steve Kramer
: My uro recommends "Lupron" monotherapy until PSA goes undetectable,
: then off, then back on at some indeterminate point, and so on. Is this
: the standard protocol for intermittent ADT/HT at this time?
I would say that off, on, off, on, is the definition of IADT. However, when
they go off and when they go back on has never been standardized, to the
best of my knowledge.
Those who have tried it hear are all over the target as to milestones for
changes. I suspect a lot of it is done by 'feel.' If one immediately
begins to show a rising PSA after going off, they are most likely to go back
on quickly. Those who very, very slowly rise are usually the ones who will
wait to the larger PSAs before going back on. Those who have years of
undetectable readings seem more likely to get back on ADT at a certain
predetermined level.
Furthermore, much of it seems to be decided by the patient based on his side
effects when going off and anticipation of side effects when he goes back
on.
--
PSA 16 10/17/2000 @ 46
Biopsy 11/01/2000 G7 (3+4), T2c
RRP 12/15/2000 G7 (3+4), T3cN0M0 Neg margins
PSA <.1 <.1 <.1 .27 .37 .75 PSAD 0.19 years
EBRT 05-07/2002 @ 47
PSA .34 .22 .15 .21 .32 PSAD .056 years
Lupron 07/03 (1 mo) 8/03 and every 4 months there after
PSA .07 .05 .06 .09 .08 .132 .145 PSAD 1.4 years
Casodex added daily 07/06
PSA undetectable since; last checked on 06/04/09
Illegitimati non carborundum
Bill
going to blindly accept what he says as being the "standard
prototcol." He is not "standard" and is proud of it.
That said, I believe that Dr. Bob starts w/ an initial 13-mo. on
period of ADT3. Although I'd like to be on as little as possible, I
have not heard of a protocol that could have an initial period as
short as a single 3-mo. shot. So, yea, that concerns me. There are no
med-oncs around here who concentrate on PCa.
Bill/Memphis
Andre
I have metastatic prostate cancer, both in my lymph system and in my bones.
I was diagnosed with a PSA of 67 and treatment started on 18 March 2009 with
Eligard (6 months) and Zometa (every 3 months). Two months later, PSA was
0.5 and has now stabilised since 5 months to 0.3.
My doctor has proposed to stop the Eligard treatment (after a total of 11
months) and try IAD (Intermittent Androgen Deprivation). He will restart
with Eligard when my PSA reaches 10. This is apparently the value used in
Europe, in the USA 20 is more popular.
He claims tthat he has a positive experience with this method and it is what
he would do himself if it was his own problem. He also warned me that it
still is experimental and that it is up to me to decide if I will accept the
risk. Most of the problem seems to be psychological : you know that you
have cancer, but you stop the treatment and you see your PSA rising.
I think that it is also a question of systematically measuring your PSA
every month (instead of the recommended 3 months) so that you know exactly
what is happening. The speed at which your PSA is doubling is also an
indication of your chances of survival (which may or may not be something
you want to know).
Have a look at this paper which summarises the trials in IAD done during the
last 10 years :
http://www.europeanurology.com/article/S0302-2838(09)00797-0/fulltext
Steve Jordan
> Say what you will about Strum and his former colleagues but I am never
> going to blindly accept what he says as being the "standard
> prototcol." He is not "standard" and is proud of it.
"Blindly??"
Indeed, he is a proud man. Who does pro bono work such as P2P.
I think that much of the condemnation by a few other medics and
their followers is based upon the fact that Strum does not gladly
suffer fools. And says so.
Anecdote warning:
I began six years ago with extensive Gleason 4+5=9 and 4+4 PCa.
After
failed, clumsy, cryo, I asked Strum for advice, which he freely
and in detail
gave me.
So far as I'm concerned, he saved my life.
As my med onc tells me, I'm doing very well, much better than she
anticipated.
Of course, I'm aware that the wheels could fall off at any time.
Regards,
Steve J
>
> That said, I believe that Dr. Bob starts w/ an initial 13-mo. on
> period of ADT3.
Does he consider the PSA results during that period?
> Although I'd like to be on as little as possible, I
> have not heard of a protocol that could have an initial period as
> short as a single 3-mo. shot. So, yea, that concerns me.
Well, time is only one factor. The other is PSA.
> There are no med-oncs around here who concentrate on PCa.
The primary practice of my med onc is BCa, which as you know is
clinically similar to PCa. She has several PCa patients. Consults
with
Scholz and Lam at Prostate Oncology Specialists in Marina del Rey,
California.
Regards,
Steve J
Gourd Dancer
"standard of care" when it comes to this bastard. I'm just a schmuck who
believes in being very, very aggressive. I went advanced in May 2004 when
PSA jumped to 32.3 and scans showed mets at L2 & T3. I wnet to a MO who
researches PCa and started a chemo trial 60 days later. I am still
undetectible with Lupron and the mets have disappeared - scans are clear.
I asked my MO in January 2007, if I could come off of the injections. He
answered as thus, "Do you want your PSA to climb?"
I enjoy reading what people write about IADT, but I have cast my lot with
this particular researcher and follow his teatment plan to a tee. In 2004 I
figured that I had a short time and considered retirement (I am 62 today);
however he said that he could buy me 10 years. This summer he told me that I
have extended to another ten years. If so, then I have had a full live.
I noted in the article that Steve Jordan provided, that the rules change
with APC.. I wish you the Best of luck in your treatment.
Gourd Dancer
"Andre" <patro...@hotmail.com> wrote in message
news:lDBMm.53029$8q4....@newsfe25.ams2...
fred
Bill; Setting aside financial and insurance issues for the purposes of
this discussion, what's wrong with working with a cooperative local
oncologist, and also you occasionally seeing, and having the local onc
consult with a prostate cancer specialist at Hopkins, Anderson or
similar? Obviously, you'd have to have 2 drs and a patient with the
right personalities to make it work....
Has anyone used that model? If so, any insurance reimbursement
problems? And has it worked out satisfactorily?
Fred
Steve Kramer
news:feCMm.5404$cX4....@newsfe10.iad...
: On November 17, Bill replied to me:
: I began six years ago with extensive Gleason 4+5=9 and 4+4 PCa.
: After
: failed, clumsy, cryo, I asked Strum for advice, which he freely
: and in detail
: gave me.
:
: So far as I'm concerned, he saved my life.
Your personality and demeanor lulls me into a sense of indefinite presence
such that I generally fail to recall that you started out with a Gleason 9
and a failed initial treatment. And yet here you are, six years later, a
74-year-old survivor with, at last report, a .003 PSA blessing us with your
intelligence, references, and wise counsel. I wish for you - and for us -
that you have many more years of good health.
You've done well pilgrim, to keep so much hair when so many are after it. I
hope you will fare well.
-- Bear Claw Chris Lapp
Steve Kramer
news:lDBMm.53029$8q4....@newsfe25.ams2...
: My doctor has proposed to stop the Eligard treatment (after a total of 11
: months) and try IAD (Intermittent Androgen Deprivation). He will restart
: with Eligard when my PSA reaches 10. This is apparently the value used in
: Europe, in the USA 20 is more popular.
I'm all for inventive attempts to knock this bastard upside the head when
he's already taken over your lymph nodes and several bones. However, I have
never heard that waiting for a PSA of 20 being popular here in the US. I
have heard of 1.0, 2.0, and 5.0 but never 10.0 or 20.0. Again, not speaking
against the therapy, just hoping you have the decimal correct.
: I think that it is also a question of systematically measuring your PSA
: every month (instead of the recommended 3 months) so that you know exactly
: what is happening. The speed at which your PSA is doubling is also an
: indication of your chances of survival (which may or may not be something
: you want to know).
I think when you're going on IADT, frequent PSA tests are a great idea.
Andre
attractive idea. As you have put it in the past : kill the bastard.
What worries me is that this is barely mentioned in the literature and I
know of no comparative trials. Are you not afraid that you have run out of
options if your PSA is rising again (which I hope not) ?
Steve, my doctor really said that a PSA of 10 is the moment to restart with
Eligard. It is also the value which is mostly mentioned in the literature.
As you can see in the study which I mentioned, some doctors use 15 or 20 as
the limit.
Bill
surprised that no one here has been to them.
While I value the discussion, we have gotten a bit away from my
initial query re the standard IADT protocol. Is there anyone here who
went off as soon as PSA went undetectable? (I think Dr. Bob keeps you
on ADT3 for 13 mos. regardless of PSA, similar to Strum's 1 year after
undetectable PSA.)
Bill/Memphis
Steve Kramer
: Steve, my doctor really said that a PSA of 10 is the moment to restart
with
: Eligard. It is also the value which is mostly mentioned in the
literature.
: As you can see in the study which I mentioned, some doctors use 15 or 20
as
: the limit.
Much of PCa treatment is a crap shoot and your dice are as good as anyone
else's. I hope you roll all tens.
Steve Kramer
: Fred, that's why I asked about Drs. Bob and Myers. I'm somewhat
Bill,
I've not paid much attention to doctors' names mentioned here. Of course I
read sometimes names like Walsh and Strum and my ears perk up. I know I
have heard people on this NG who have been treated by Myers. I suspect that
many see the political discussions taking place and don't bother to read
legitamate PCa posts. For some reason, I'm having a hard time getting on
the 'Net, else I would have gone to the Google database and searched on
"Myers".
Califchief
> treatment started on 18 March 2009 with Eligard (6 months)
> and Zometa (every 3 months).
March 2009 to November 2009 is only 8 months.
You've had Eligard in March and September 2009 only?
Zometa in March, June, and September 2009?
> My doctor has proposed to stop the Eligard treatment (after
> a total of 11 months)
Do you mean he proposed to stop it February 2010?
> Two months later, PSA was 0.5 and has now stabilised since
> 5 months to 0.3.
Two months later from when?
___ Blue Wave/QWK v2.12
Steve Jordan
> I wish for you - and for us - that you have many more years of good health.
Many thanks for the kind words. Last PSA was 0.44, up 0.02 from
previous
month. I'm off Trelstar, on Avodart -- a "vacation." Will restart
somewhere
around 1.0.
As I think is evident, I very rarely mention my own situation as
I believe it to
be irrelevant to others. In this case, I thought it relevant to
my view of Dr.
Strum. No, I'm not objective. But I do not slavishly adhere to
everything
he proposes, either.
> You've done well pilgrim, to keep so much hair when so many are after it. I
> hope you will fare well.
> -- Bear Claw Chris Lapp
"Jeremiah Johnson" is a classic.
Regards,
Steve J
Andre
"Califchief" <calif...@fidotel.com> wrote in message
news:1258560256.1...@fidotel.com...
>
> > treatment started on 18 March 2009 with Eligard (6 months)
> > and Zometa (every 3 months).
>
> March 2009 to November 2009 is only 8 months.
> You've had Eligard in March and September 2009 only?
> Zometa in March, June, and September 2009?
YES
>
> > My doctor has proposed to stop the Eligard treatment (after
> > a total of 11 months)
>
> Do you mean he proposed to stop it February 2010?
YES
>
> > Two months later, PSA was 0.5 and has now stabilised since
> > 5 months to 0.3.
>
> Two months later from when?
SINCE START OF TREATMENT
Steve Kramer
: As I think is evident, I very rarely mention my own situation as
: I believe it to
: be irrelevant to others. In this case, I thought it relevant to
: my view of Dr.
: Strum.
You have an interesting idea of what is relevant in a support group. :-)
However, as I mentioned earlier, you are a paragon of relevance now as a G9
with six-year survivorship.
: "Jeremiah Johnson" is a classic.
Yes it is.
Steve Jordan
(snip)
Quoting me:
> : As I think is evident, I very rarely mention my own situation as
> : I believe it to
> : be irrelevant to others. In this case, I thought it relevant to
> : my view of Dr.
> : Strum.
Steve wrote:
> You have an interesting idea of what is relevant in a support group. :-)
Well, I do have backup from at least one medic, Al Bothe, Jr.,
MD, University of Chicago:
"The plural of 'anecdote' is not 'data.'"
> However, as I mentioned earlier, you are a paragon of relevance now as a G9
> with six-year survivorship.
Uh oh. ;-)
Regards,
Steve J
PS: This reminds me of Strum:
"Do not go where the path may lead. Go instead where there is no
path and leave a trail."
-- Ralph Waldo Emerson
Andre
can tell us his experience.