So, when it comes to 18 months of hormone therapy, that sounds like a lot of time. So
can you explain to the audience why there'd be a benefit in taking that hormone therapy
in comparison to maybe getting surgery or other options?
Yeah, it is a big investment in terms of quality of life issues and we have videos, thankfully,
that you can look up and find out how to minimize those side effects, but the logic is pretty
strong. If there's a high likelihood of spread of cancer outside of the gland when someone
has a high Gleason score or a high PSA, the idea of doing surgery and then waiting for
the cancer to come back basically gives those specks of cancer that are already out there
a head start and by the time they're detected one, two, or three years later they are much
more entrenched and more difficult to dislodge. So, the thinking of hormone treatment at the
time of radiation (and you can even do it at the time of surgery) is to eliminate those
little tiny specks when they're still vulnerable with hormone therapy which we know is a very
powerful anti-cancer maneuver. So, this idea of adjuvant hormone therapy is effective.
It's used in breast cancer, there's adjuvant immune therapy in melanoma, adjuvant chemotherapy
in lung cancers and pancreas cancers. This whole idea of going after microscopic metastases
at the get-go rather than waiting and giving it a head start is the rationale for the hormone
treatment.
You had mentioned that maybe a short course of hormone therapy as well when it comes to
Gleason 8 including the radiation, so with that hormone therapy is it standard first-generation
Lupron? Do you see a better effect with any of the other hormone therapies?
So, short course hormone therapy—which that would be four months; longer course would
be 12, 18, to 20 months—I would say with most high-grade cancers we're looking at longer
term hormone therapy, but this is being modified with these new scans and, of course, people
that have little amounts of 4+4 have what we call "favorable high-risk," they could
probably go with a short course of hormone therapy. But to answer your questions, you're
alluding to the second-generation hormones like Xtandi, Erleada, and Nubeqa, or Zytiga
and if you are embarking upon hormone therapy to try and take care of any microscopic metastases,
I really believe you should be on the most efficacious most powerful hormone therapy
possible. The side effects really aren't much worse than Lupron, so a combination of Lupron
plus Xtandi, Erleada, Nubeqa, Zytiga for 12-18 months would be a very logical thing to do.
With that being said, do most oncologists do that type of course? Are they automatically
going to add a second-generation hormone therapy to the first or is that uncommon?
Well, of course, policies vary to a shocking degree and this is why patients need to educate
themselves about what's going on. There's good data showing that in people that have
confirmed spread to their lymph nodes right around the prostate, that they should be on
a second-generation hormonal agent from the get-go. If there's no proof of lymph nodes,
if it's just a suspicion, we don't have solid data showing that men will benefit by being
on a second-generation hormone therapy, but I think it's logical considering that there's
little of any additional side effects and we know it's more effective. So, logical is
not something that all the doctors that are doing general medical oncology have thought
through. I mean, most of these doctors are treating a hundred different cancers so they'll
probably tend to go more by the book, but I think patients might want to broach that
subject as to, "doctor, wouldn't it be better for me to be on the best and most efficacious
hormone therapy since we're trying to optimize my cure rates."
So in regard to sequencing, does the patient start the hormone therapy and then go into
IMRT or brachytherapy? What in what order would they normally get those treatments?
Right, so based on some work by Dr. Mack Roach, a very famous radiation therapist at UCSF,
the historical process was to go on hormone therapy for 60 days and then start on the
radiation thereafter. The data on recent recheck didn't hold up as clearly, so there's actually
quite a bit of flexibility. It's still common for people to get the hormone therapy for
a period of time and then start the radiation. Hormone therapy is so powerful it takes the
pressure off and think, "oh, we've got to get to the radiation right away, the cancer
will spread." People's PSAs after the first 30 days usually drop 90% when they get on
the hormone therapy. It's very powerful as an anti-cancer maneuver. So, there's a lot
of flexibility honestly. The traditional approach is to wait about 60 days then do the radiation,
but that's no longer chipped in stone like it used to be.
And when you get the radiation you're getting the seed implant and then the IMRT on top
of that possibly?
Yes, they can sequence it either way. Usually, the lion's share of the radiation is by the
brachytherapy, by the seed implant, and the brachytherapist may not be the same
radiation doctor that does the IMRT or the SBRT and so the brachytherapist sort of becomes
the captain of the radiation ship, sets the agenda, and they'll often want to do the treatment
first, wait 3-4 weeks, and then they start the beam radiation portion.
So, after a patient goes on hormone therapy, has the brachytherapy, and then does IMRT,
what should their PSA be, and after what time frame to know that that was an effective course
of treatment?
Right, so with no radiation at all the PSA should drop to less than 0.1 within about
five months of starting hormone therapy, so we expect the PSA on hormone therapy to go
to undetectable levels and to remain there throughout the time that men are on hormone
treatment. After the hormone treatment is stopped, the testosterone levels will recover
and because men with radiation still have a prostate their PSA will come up a little
bit—maybe up to 0.2, 0.4—and it should remain there for the rest of their lives assuming
they've been cured, which most men with high-risk disease will be cured. The only confusing
thing is that sometimes a year or two, three, four years down the line you can develop delayed
radiation prostatitis, a form of inflammation in the gland that can artifactually cause
the PSA to jump around. It's called a PSA bump. In the past, we just kind of waited
it out and the PSA would come back to normal without any treatment whatsoever. In this
modern era, we can do these PSMA/PET scans and make sure that there's no cancer lurking
even though we know that bumps are fairly common.
So, how long do the bumps normally last? The radiation bumps?
They can vary from two months to two years. Yeah, and how high does the PSA go? The highest
PSA I've seen is—PSAs that have gone all the way up to 15 in men that did not have
cancer. So, a typical bump might be 1, 2, or 3 points and probably lasting 3-6 months.
When it comes to that bump, how many times do they need to get imaging to keep checking?
So is it every three months, every six months? What is the course of action to know that
we don't have cancer somewhere lurking?
We, historically, didn't have an accurate scan, so the scans I would say aren't even
mandated. It's just nice to know that we can look. The pattern of a bump is for the PSA
to kind of jump up and if you were graphing it you'd see sort of a zigzag pattern showing
inflammation. Cancer recurrences tend to rise in a steady unremitting predictable up, up,
up, and up, and so you can kind of tell by the pattern if you are checking the PSA every
month during a bump. Is it a bump or is it a recurrence?
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