Could you tell us your opinion on the right time to begin androgen deprivation therapy after the failure of primary treatment by surgery or radiation. Should ADT begin:
1. As soon as a recurrence is confirmed?
2. After some PSA threshold is crossed (2.0, 4.0, 10.0, whatever)?
3. After metastasis is confirmed?
4. Just before the onset of symptoms is anticipated?
5. Only after symptoms have actually appeared?
6. Whenever the patient wants it?
Doctors seem to have different opinions about this and I don’t know whether it’s because we don’t have enough information to make a judgment, or because many doctors aren’t keeping up with the latest research.
This is an excellent question. As you so well describe, opinions range widely. My approach is heavily influenced by a series of papers from Johns Hopkins. They show that the danger of recurrent prostate cancer is heavily influenced by the Gleason grade, PSA doubling time and how long it took the cancer to recur. The point of these papers are that recurrent cancer can range from something that can be rapidly lethal to a cancer were trouble can take 15 to 20 years or more to develop.
The first step we take is to see if we can slow the PSA doubling time. The list of agents that slow prostate cancer grows steadily and many are nontoxic. We look at the patient and generate a cocktail that best fits their situation. In slow growing cancers, we can often arrest the cancer without causing any harm.
If surgery was the initial treatment, radiation should also be considered. Here there is a major controversy. Do you radiate the prostate bed or extend the radiation to the pelvic lymph nodes? I am biased because I keep seeing men who had radiation to their prostate bed and now have recurred. When we look, we find the cancer in the pelvic lymph nodes only in many of these patients. Radiation to those pelvic nodes then serves to put the patient into complete remission. So, I am a strong advocate of radiation to the prostate bed and pelvic lymph nodes.
I like to hold hormonal therapy until I develop the optimum program to slow the PSA doubling time. This way, when hormonal therapy is done after 9-12 months, I know that we have a program able to delay cancer recurrence. In those patients who have had their cancer arrested before hormonal therapy, one course of hormonal therapy is all they will likely need as we know we can prevent cancer regrowth.