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Posted 8/23/2011 7:57 PM (GMT 0)
Well, yesterday I saw Dr. Hussain, another top-notch medical oncologist who specializes in PC. She has authored numerous rsearch papers. She sees patients at Umich Medical Center (Comprehensive Cancer Care Center).

So, I've now seen two of the best specialist, Dr. Scholz and Dr. Hussain. Dr. Scholz indicated that I should get monthly PSA tests and when it gets above 1.0 then it's time to start HT. In other words, he is in the "sooner is much better than later" camp. (For those who are unfamiliar with my situation, I'll try and include my signature. But the bottom line is that I failed surgery and SRT).

To my surprise, Dr. Hussain is certainly not in the same camp. While I would not classify her as a "delay HT as long as possible " camp, she did say that I should just get a PSA every 2 months, so the next one will be October rather than September. If it goes above 1.0, we should get some scans just to have as a baseline. But she seeme to emphasize NOT rushing into HT. She said if the PSA got to 3, then I could consider it, but I got the impression that waiting until double digits is not at all out of the question.

I told her that I had the impression that the latest research/studies seemed to indicate that sooner is better than later. She said that is not true. There seems to be growing anecdotal reports that indicate this is the case, but absolutely nothing that is worth hanging your hat on.

I also asked about a fast PSADT auguring bad news for the success of HT. She said (and so did Dr. Scholz) that no studies have been done (oddly enough) to address that issue. She also said that the success or failure of HT is EXTREMELY complicated. She agreed with me that it depends on the percentage of PC cells that are hormone sensitive. But the major key is really how fast the cells adjust to the HT and circumvent the impact of the HT. They really have no way of knowing. She also indicated that a PSADT of <= 3 months is bad news regarding mortality. But she also added that with my low numbers (<1) the PSADT is hard to gauge.

So, I now have two very differing opinions. Oh, they both agree that HT will often delay spread to the bones, so that is a good thing.

What to do?

At this point, I am going to delay getting my next test, from Sept. 11th to Oct. 11th. I will then consult with her again. I am thinking that perhaps a PSA of 3 is a better line in the sand.

I am VERY surprised. Frankly, I did expect some SMALL variation of opinion on when to start HT and possibly what HT to do (eg: casodex, triple blockade, etc.).

I don't mind delaying matters.

My next big appointment is with my orthopedic guy. I am still having significant knee pain.

Mel

Posted 8/23/2011 8:13 PM (GMT 0)
Mel -- i asked my radiation oncologist is he was in the sooner or later camp regarding HT after other treatments have failed.  he said he thought PSA 4 was the right time.

ed

 

Posted 8/23/2011 8:17 PM (GMT 0)
Mel, did she say that there is any downside to starting HT early, or just that there is not a proven benefit. I had HT will SRT. Dr Myer told me that if my PSA started to rise again that he would have it increase for a bit so that it's location could be detected with a MRI. We would then hit it with radiation if possible. He didn't say how far he would let the PSA go. I suspect that it wouldn't be double digits. Perhaps Hussain is thinking along the same lines. Bb
Posted 8/23/2011 8:41 PM (GMT 0)
Mel, the conflicting opinions are a good demonstration of the complexity of this disease.  I guess the only thing I don't undestand about your plan is the delay in getting your PSA work done.  Knowledge is power.  Why not get it done in September anyway?  At least then you retain the option of staying with Dr. Scholz' plan yet don't give up anything if you opt for the Dr. Hussain plan.  I mean do you really want to wait until October and then find a 2.0 reading and decide to go back to Scholz then and have him say "what the h***?"  Get an much knowledge as possible and keep all of your options open, IMHO...

Tudpock (Jim)

Posted 8/23/2011 9:03 PM (GMT 0)
Mel, thanks for a very clear report.

Opinions are (still!) divided on the best time to start HT. With some saying PSA 1 and others 10, the best compromise may turn out to be 3-4, as per your Dr Hussain and F8's oncologist.

I too am glad to see that waiting is still a reasonable option!
Posted 8/23/2011 9:39 PM (GMT 0)
Mel,

Having been to Dr. Hussein, I respect her immensely. She is one sharp lady.

I think the main thing is to have a plan. We have seen guys with PSA of 3500 who went in HT and are still walking around, so apparently for at least some, starting HT at .1 is not critical.

Hopefully you can get your orthopedic issues resolved, and then get back to the HT discussion.

Goodlife
Posted 8/23/2011 10:09 PM (GMT 0)
i agree with having a plan but not delaying the next test.  Mel you seem to suggest that hussein might be all right with double digits but did she actually say that? 

ed

 

Posted 8/23/2011 10:46 PM (GMT 0)
F8--yes, she definitely did say I could even wait until double digits.

Tudpock-- she felt that you actually get a better idea of a trend by checking every 2 months rather than every month.

There is something to be said for NOT always being on the verge of getting a PSA test!

The disadvantage of starting HT early is clear: side effects. It's about quality of life. She did not go into details about SE and she said everyone is different, but she did say I am feeling better now than I will be feeling while on HT.

I don't think Dr. Scholz will be too annoyed if I waited until PSA=3.

In all honesty, my knee pain is taking center stage right now.

Mel

Posted 8/23/2011 10:55 PM (GMT 0)
Mel, count me among those that suggest going ahead and getting the PSA test in September. Doesn't mean you have to pull the HT trigger, it just means you have as much info as possible about your particular PCa journey. As you know from my posts I have mine done when I feel the need for more info. Many of my tests have been done because I have called them and placed the orders rather than waiting for the next appointment.

I have a very good picture of my rises and history because of it.

While my onco and I have discussed the future of me and HT he is also of the camp that suggests a 3 month or less PSADT is a cause for concern and pulling the trigger. Even though I have been steadily rising to the 7.2 at last test, my PSADT is still about 9 months.

So we will be discussing it when I get back from DC and the GFMPH gathering.

As John and the others have said "knowledge is power".

Sonny
Posted 8/23/2011 11:47 PM (GMT 0)
Mel,
The decision to start HT is always yours. That said, I need to point one fact:
In the prostate gland there are three types of epithelial cells as related to androgen dependence/sensitivity. The vast majority of the epithelial cells are composed of androgen-dependent glandular cells, with lower numbers of androgen-sensitive basal cells and a limited number of androgen-independent basal stem cells.

That means that most cells are androgen dependent but in the carcinogenic progression process, these androgen dependent and androgen sensitive cells through mutation or genetic instability are able to grow without androgens being present. The normal pathway in the carcinogenic process is then from androgen dependency to androgen in-dependency and when more cells in the tumor load become androgen independent, the disease is more resistant to therapy (in this case androgen deprivation). This is the basis for early versus delayed application of HT.

I am not saying that one or two months might have an effect in terms of survival, but the more tumor cells that turn androgen independent the higher the probability of a poorer response after the therapy is applied. If a PSADT of <3 months has a poor prognosis is because it is an indication that the tumor load is growing and in growing it can become more and more androgen independent. What is the benefit of waiting? I consider that the only “good” androgen independent cell is a dead one and then why not prevent the androgen dependent cells from becoming androgen independent as early as possible.

In your post you mentioned that Dr. Hussain said: “that the success or failure of HT is EXTREMELY complicated. She agreed with me that it depends on the percentage of PC cells that are hormone sensitive.”

If such is the case, why allow them to become insensitive to deprivation and continue to grow without restriction? It is just food for thought as the decision remains in your hands.

RalphV
Posted 8/24/2011 12:19 AM (GMT 0)
Ralph - what is the counter-argument? Surely there must be one. What you say makes perfectly good sense, and I have a lot of respect for your expertise, but Dr. Hussain is also an expert, and I think is motivated to get the best results for her patients. So there must be a credible counter-argument.

Mel - did you discuss with her that you got different advice from Dr Scholz?
(i wish you the best with with tough decision, and knee relief too!)
Posted 8/24/2011 2:19 AM (GMT 0)
one argument i can see is are both doctors looking for the same outcome?  i'm pretty sure scholz thinks getting the jump could "cure" the patient or produce a long remission.  not sure what the other doctor believes.  if you view HT as palliative i could see delaying treatment for QOL reasons....but remember that's just conjecture on my part.  i'm not trying to speak for Dr.  Hussein.

when my radiation oncologist said PSA 4 what was he thinking?  he may be thinking that a bounce could mimic BCR so you would want to make sure that a bounce is ruled out.  again that's conjecture.

ed

Posted 8/24/2011 3:21 AM (GMT 0)
Hello Medved,
I think the response to your question can possibly be answered by the different approach of the two doctors. I am not saying this in detriment of either one of their treatment directions. Dr. Hussain is a well known PCa researcher dedicated to the development of clinical trials. Dr. Scholz is a clinical oncologist specializing in prostate cancer. As recent as 6 years ago Dr. Hussain published the following:
"Two ongoing cooperative-group phase III trials are evaluating the survival impact of intermittent androgen deprivation (IAD) both in patients with metastatic disease and in those with prostate-specific antigen failure post-radiation therapy. There are several unanswered questions regarding this approach, and until more definitive data regarding its safety and impact on survival are available, IAD should be considered experimental."

On the other hand, Dr. Scholz has been using IAD as the most beneficial form of deprivation for years. This caution by Dr. Hussain to initiate therapy might be related to her research position in which evidence based medicine rules.

Source:

Bhandari MS, Crook J, Hussain M.
Should intermittent androgen deprivation be used in routine clinical practice?J Clin Oncol. 2005 Nov 10;23(32):8212-8.

I admit to be biased for early intermittent androgen deprivation because I have seen too many of support group members fail when avoiding immediate treatment (for their own reasons). In the med literature, there is a slight survival advantage to early versus delayed. Is this a clear cut advantage? No, it is not, but I owe it to myself to pass this on and let the patient make his own decision...and that is always the way it should be.

RalphV
Posted 8/24/2011 4:29 AM (GMT 0)
Well Compiler,

Sounds like you've taken the steps to get the best from some of the best around. I wish you the very best.

Not that my thoughts really have an impact on any person's decision...I'd be scared if that were the case; I'm definately all for the every 2 month PSA idea. In fact, I'm all for waiting until you, yourself are ready for HT...even if it isn't until you hit the 10 or 10+ mark. What you do know for certain is, you will likley be making the decision at some point. I know a number of men who take breaks from HT and don't restart until their numbers are upwards around the 10-20 mark. Some of them didn't begin until their numbers were above 10, after they had failed with other treatments.

Swim

Posted 8/24/2011 11:49 AM (GMT 0)
Mel, Pca sure exercises our power to make decisions, doesnt it? Some very good info in the post above no matter what you decide. Get that knee taken care of and hopefully, while dealing with that, a decision will seem come to you.
Posted 8/27/2011 5:48 AM (GMT 0)
I wil be doing my next PSA in October (the 2 month deal) and then we will see.

More pressing is the problems with my knees. I'll be seeing the orthopedic guy on Thursday.

Mel

Posted 8/27/2011 2:22 PM (GMT 0)
Mel,

I like your report on Hussain's opinion, no one could question her knowlege and reputation in the field. What I find interesting, is that her opinion almost mirrors what my new oncologist has been telling me. What gets me, is that some here felt I was getting bad advice. I said all along, that there are 2 strong schools of thoughts on the subject and that the experts dont even agree.

My doctor says there is no magic number, its depends on the patient's individual case. He feels that too many men panic once the curative treatments fail and rush into HT. He feels that HT is all about the timing, and the more time you can buy without going that route, gives you that much more time with better QOL issues. I still agree strongly with him.

The delay she suggested, I would have no problem with that. My doctor said its not going to help to know monthly, other than create more stress. That's one reason he is having me wait till December for my next PSA test.

I am just personaly glad that you saw an undisputed expert, that presents the other side. Makes me feel more like I am in safe hands at this juncture in my own journey.

And my doctor did plainly say, even when my PSA gets double digit, and it very well may be as we speak, its still no reason to panic.

Now you have two opposing opinions, will be intersting to see what you do with them.

Thanks for posting

David
Posted 8/27/2011 2:52 PM (GMT 0)
David:

Yes, I was quite surprised at the differing opinions. I am probably going to split the difference, so to speak. I will do the 2-month PSA and maybe wait a bit before doing HT.

Right now my knees situation has my attention.

Mel

Posted 8/27/2011 3:07 PM (GMT 0)
Sounds like a good compromise to me, you got two top notch opinions. with all my hip and back pain, no improvement, so i can feel for your knee pain.

I see my oncologist Wednesday afternoon, will let you know his latest thinking on me.

Appreciate you sharing her opinion with us here at HW.

David
Posted 8/27/2011 3:13 PM (GMT 0)
Mel,

Are you using the extra month to get in shape?
I know you can't run, but is there something else you can do to get your heart rate up? Even crunches, push-ups against the wall, ...anything more strenuous than opening a potato chip bag or changing the channel on the remote.
That precious month should be used wisely with a goal of of being in better shape than you are today.

(I'm sorry I sound like your mom. By the way, your mom was talking to my mom and she wants to know "When are you going to get a real job?" Mel, Is this why she worked her fingers to the bone for you to go to school? Cousin Shelly is a dentist and Howie is a doctor already. Please. You're breaking her heart. ) :-)

Jeff
Posted 8/27/2011 5:20 PM (GMT 0)
I am in the wait camp myself. I do not know exactly when I will go back on HT but it will be later than sooner. I think this is also one of those things that has to fit the individual fighting the cancer. For me I am totally cool with waiting. I think I will wait till my PSA is around 5 or my doubling time is around 60 days. Maybe I will not have to worry about it ever again.
Great post thanks for sharing

peace to you
Dale
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