In your experience, really, what is the—I guess—the effect of the
outcome of a person who decides to not have adjuvant therapy versus having it?
So, if they're high risk and they're undergoing radiation then of course there's a greater chance
that the cancer will come back.
The difference will vary depending on how high the risk of return is, but let's say someone
has a projected cure rate of 80 percent with radiation plus hormone blockade—that
would be someone perhaps with a basic or a favorable azure category or stage of prostate
cancer—if they skip the hormone blockade their cure rates may drop down to 65 to 70 percent.
And who would be a candidate for this type of adjuvant hormone therapy?
In the prostate cancer world, of course, we look at stage: low, intermediate, and
high — and high-risk patients who are undergoing radiation, it's probably malpractice for them
not to get adjuvant hormone treatment in 2020 unless they're 85 or 90 years old and
the men that are intermediate risk—this is changing—but typically a short course
of hormone therapy is given along with the radiation. It isn't the policy with surgery.
And when it comes to hormone therapy, we have first generation, second generation, so when we're
talking about adjuvant therapy are we talking only about first-generation hormone therapy?
Well, most of the studies have been done with just Lupron or Lupron type medications, but
it's clear that what you call the second-generation medicines like Xtandi, Erleada,
Zytiga, and Nubeqa have greater anti-cancer horsepower and little if any additional side
effects, so anyone that is gunning for a cure, I think, has to logically consider
using one of these second-generation hormone blockade agents in conjunction with Lupron.
Is there a certain age you would not suggest for them to have adjuvant therapy just for the sake
of tolerating maybe the side effects of hormone therapy plus either the surgery or the radiation?
Definitely, there's actually a certain age when you don't even treat
treatable cancers because, you know, it takes more than 10 years for people to get sick and die from
even from high-risk prostate cancer so if someone's already 90 years old
you might just watch it or if someone feels there's a role for hormone therapy this is a
good place to talk about something like Casodex which is a much milder pill than lupron and has
pretty significant anti-cancer effects but without all the same side effects.
And is adjuvant hormone therapy advisable for patients doing radical prostatectomy, period?
Well, definitely not in men that have intermediate-risk prostate cancer. In fact,
there are some issues now that raise the question whether intermediate-risk prostate cancer patients
need hormone therapy either when they undergo radiation and that's because the radiation has
gotten so much better and then really we have to mention that these new PSMA PET scans are
so much better at detecting early metastatic disease that when they're clear one has to
wonder do we really need to do hormone therapy to treat micro-metastatic disease since we know
that the chances of something being out there is much less when the PSMA PET scan is clear.
I know that when we have conversations with patients and we're talking about
hormone therapy we mention, always, the concept of osteoporosis and taking
medications to prevent that. On short-course hormone therapy, and adjuvant the case,
do they need to be taking those osteoporosis drugs?
Maybe not. You know, men, as they get older, can get osteoporosis without hormone treatment
so probably starting at age 65 or 70 men should consider getting a bone density scan
and certainly if they have pre-existing osteoporosis whether they take hormone therapy
or not, they need treatment. Should a short course of hormone therapy be routinely administered for
osteoporosis therapy? Probably not, but we typically do administer
prophylactic osteoporosis treatment in men that have long course hormone blockade.
So, have you ever had patients embark upon treatment, they experience so many side effects,
and they just decide that they cannot handle this anymore and they want to stop?
No one immediately comes to mind, but it is comforting for people to know that they can stop
early if they want to and the measures that we're implementing to try and counteract side effects
like weight training and diet are very effective. Generally, people who embark down this pathway
have given it serious thought, they sort of count the cost in advance, they make preparations,
and they get through it pretty nicely. Some men do have lingering effects, especially when they get
in their mid to late 70s where their testosterone doesn't recover completely, and perhaps sometimes
we should talk about uh giving testosterone to those people after all the treatment should
have worn off and it hasn't. That doesn't happen too often, but maybe one out of five or six men
over age 75 will have lingering low testosterone even after the treatment should have worn off.
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