Hi everyone! A lot of you have been submitting youtube comments and a lot of
you guys have questions on prostate cancer that you would like us to ask Dr. Scholz
and today we're going to answer those questions.
So, we're moving into hormone therapy which is a huge topic as we know in prostate cancer. The
first question is, "Is hormone therapy an option for intermediate level," and they say "Teal," so
they've read the staging guide. They're 54 years old and two urologists said they either need to do
radiation or remove the prostate completely and they would like to know "is hormone therapy an
option?" and then, also, second, is it eternal or do you stop when the PSA has been lowered?
So, hormone therapy for intermediate-risk prostate cancer is more popular outside the country—say
in Japan—than it is in the United States. It's quite effective. We've done some clinical trials
using hormone therapy as a treatment for teal and about half the patients are still in remission
five years after finishing the treatment. So, treatment would typically in those studies
last for about a year but that may be excessive. So, it's not a popular approach with radiation
therapists and surgeons as a substitute; however, radiation therapists and surgeons
are willing to consider hormone therapy for Teal as men get older, so let's say if they're 75,
80 years old and so you'll see quite a bit of Lupron and/or Casodex
will be administered to older men that maybe have intermediate-risk disease and they can tolerate,
say, Casodex pills well and it gives them the option of skipping surgery and radiation.
And the reason to skip surgery and radiation when you're older is just
because they may not withstand the treatment well?
The primary reason to skip radiation these days is if men are worried about losing
their erections permanently. Hormone therapy can cause temporary erectile dysfunction,
but radiation and surgery can cause permanent erectile dysfunction. So, and then of course
radiation used to be a scary bad treatment and a lot of the elderly people
have recollections of friends that got really bad outcomes with different types of radiation
for prostate or other things and it's hard for them to believe that modern radiation has really
left those ugly aspects behind. Modern radiation is totally different than what was available back
in the 80s and 90s but it's created some really dark memories in some of our older population.
Thank you for debunking that. We have a huge amount of people
that when they talk to us they're like I don't want that radiation whatsoever and
when we talk to them about the data there's still that wall of communication that we
have to keep pounding and going no you it's really an option for when it is obviously.
Yeah
So, going back to hormone therapy our next question is,
"Could the kind doctor"—being you—"please answer a question that's very important to me and my wife?
After my husband and I had"—after her husband—had
his first hormone injection which was Eligard and it was 45 milligrams they had intercourse and it
says that he hasn't started radiotherapy yet but since then I guess the woman has been experiencing
hair loss and this sounds kind of, you know, I've actually seen this question quite often
and so I think she's wondering would the hair loss be caused by Eligard.
So, no. All Eligard does is lower your testosterone levels and that's
not transmissible to your sexual partner. Of course, hair loss could be a result of stress
and it's got to be stressful to have your husband going through these types
of treatments and facing cancer and whatnot. but, no, there's no direct effect from the treatment.
So, our next question is what is the real difference between
Lupron for 90 days and Eligard for 90 days?
Practically no difference at all.
The other Eligard is given in the skin; the Lupron is administered in the muscle,
so the injection is deeper with Lupron but otherwise they're entirely the same.
The next question is ADT, so androgen deprivation therapy,
hormone therapy would that cause diabetes?
Low testosterone levels can predispose to—it doesn't cause diabetes—but there's different
levels of diabetes where blood sugar control is more difficult in some people and may require
more medications. So, if you look at it from the other point of view, if you give testosterone to
men that have sub-optimal testosterone levels it may be easier for them to control their
diabetes. The exact reason isn't well understood; it is easier to keep your weight down if you have
testosterone and it's easier to build muscle mass which increases your metabolic rate.
So, one of the clear-cut advantages for people with low testosterone, whether it be from
treatment or to aging, is that you can get better blood sugar control by having normal testosterone.
The next questions we are going to be going into our radiation
and we have quite a lot of them. So this person says, "You say that radiation
is now better in every category but what about long-term erectile dysfunction?"
Well, when we're talking about erectile dysfunction from treatment that's almost
always being referred to as permanent. So, permanent erectile dysfunction is what people
care about it. If someone has transient erectile dysfunction for a few months and then improves
and goes back to normal, people can survive that, but if you look at stats for erectile dysfunction
from surgery or radiation, it's always referring to permanent erectile dysfunction. So, I think
the question may be pointing out to the fact that with surgery permanent erectile dysfunction
begins immediately after surgery; with radiation, permanent erectile dysfunction may take a year or
two before it happens. But studies have shown that if you get two years out from radiation
and are still functional and still are getting erections that the risk of developing
erection—or erection problems—thereafter after two years is the same as the aging population
in the same age group. So it's the onset of erectile dysfunction from radiation occurs
within the first two years and then after that your risk is just like anybody else.
So, Dr. Scholz, this next question is really—I'll break it down into two parts—so the first question
is can you please explain how and why some men are not suitable candidates for seed implants?
So, assuming that people need a seed implant,
the people that would be problematic are men that have um very very large prostates,
over 100 cubic centimeters for example, that would be about two and a half times the normal size. Men
that already have a ton of pre-existing urinary problems getting up at night three or four times,
lots of urgency, slow urination could also present a problem with the seed implant. The way around
of this is, of course, that men with really big prostates may be better candidates for a focal
seed implant where the radiation is limited to a section of the gland where the cancer is. That's
experimental, but this idea of focal therapy with seeds or other methods (cryo, laser) is picking up
in its popularity and that's easier to do with a big prostate than it is with a small prostate.
So it's actually beneficial sometimes to have a big prostate?
It will make it easier to do focal therapy.
Okay, so the second half of this question is how and why does calcification occur?
Well, I'm not sure i think—but the simple answer is that we have inflammation in our bodies. If you
think of calcification in the arterial walls, the carotid arteries, the cardiac arteries, coronary
arteries—the—it's thought that that occurs because fat gets in the coronary artery wall
(cholesterol) and that creates inflammation and after a while the inflammation creates scar tissue
and then the scar tissue for some reason attracts calcium, and there's quite a bit of inflammation
in men's prostates. Low-grade prostatitis is in over half the male population and as a secondary
result that creates scar tissue and then over time for some reason, scar tissue attracts calcium.
Is it possible to still have a seed implant if you have calcification?
Yes, it really doesn't present a problem for treatment.
Oh, that's good news.
How do you find a doctor who's done a lot of seed implants and would be good at it?
Well I think that, you know, there's a brachytherapy society. So people that
are members of that brachytherapy society would be a good place to start. Dr. John Blasco who
is one of the innovators of brachytherapy up at up in Seattle—he's now retired— but he does
quality control; goes around the country and checks out the quality of people's implants,
and so he would be a good resource. And then, of course, consulting known experts who are already
in the business. Typically they know who their alumni and their compadres are and you're looking
for people that do a lot of work, have a good reputation, and then our reporting good outcomes.
Thank you guys so much for commenting on our youtube videos;
we really appreciate your questions and it's an honor to be able to answer them.
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