So today Dr. Scholz, we're answering questions that came from our comment section,
and a lot of prostate cancer patients have been leaving questions there, so it's really great we
get to answer them here. Our first question is this person wants to know — they've been
on Zoladex for six years and their PSA is undetectable, and they want to know would
is there a risk in suspending it? Should they even take that chance or just keep on it?
Common situation we encounter — for those of you don't know Zolodex is like Lupron,
and it causes a man's testosterone to become undetectable,
and the patients that have good responses and durable responses like this individual
in my view, based on the science, certainly have the option of taking a holiday
and allowing their testosterone to come back and see what happens. I think this
has become even more relevant in the era we've been talking a lot about PSMA PET scans
and, in the past, we would allow the testosterone return PSA to rise up to three, four, or five,
and then re-institute the hormone treatment. You don't want the situation to get out of control,
but some men would enjoy holiday periods of couple of years enjoying their testosterone and
more energy, some libido, and whatnot, but now with these PSMA PET scans coming out, there's
another upside to taking holidays. When the PSA starts to rise, one can do a scan and possibly
find where the cancer is which may be amenable to some sort of spot radiation to try and eradicate
the residual disease. So, now there are possibly two reasons to think about taking a holiday with
appropriate supervision. Another issue comes up is they stop the Zoladex but the testosterone never
comes back. Some elderly men that have been with low testosterone for many years, their testicles
give up the ghost and they remain with constant low testosterone levels, and the question then
arises, "Well can they take some testosterone?" And I think the answer is yes. We're really
simply restoring testosterone when we stop Lupron, but if it doesn't generate autonomously,
then the thought of taking a little testosterone to establish normal levels seems reasonable to me.
How long have you had a patient do intermittent hormone therapy — like how long have you seen
those instances work where they're going off and going back on something like Lupron or Zolodex?
Well some men, not very commonly, but some men
stop treatment and their PSA remains low, their testosterone recovers, and their PSA remains low
for many many years, so it's another reason to venture into this territory because that
one individual may have a very long holiday period and be able to go back to a normal lifestyle.
You mentioned that, you know, for men who can no longer create testosterone that,
you know, testosterone replacement therapy is an option. Now, a lot of people have a lot of
fear when it comes to testosterone because they think that testosterone feeds cancer,
so can you speak to why it would be safe for men to take testosterone in that instance?
Yes, it turns out that because prostate cancer is often an indolent process and because it is
very sensitive to testosterone deprivation, men with prostate cancer—unlike other cancers—but
men with prostate cancer can take a holiday and with a high degree of confidence that when they
start the hormone therapy again, the cancer will go back into remission very consistently. So,
if there'd been problems with the early studies where men ventured into this area and then they
lost control of the disease, obviously, this type of thinking would have been nixed a long time ago,
but the predictability of prostate cancer is such that you can
pretty much be assured that when you start the Zolodex or the Lupron back up again
that the PSA will go back once again, predictably, to undetectable levels.
So our next question is, "What is the protocol for whether or
not hormone therapy is started before during or after salvage radiation?"
There is no protocol. There are only two clinical trials — one gave Casodex for six months—excuse
me—Lupron for six months, another one gave Casodex for 12 months, and both of them showed more
durable cure rates by adding hormone therapy to salvage radiation. We're talking about radiation
therapy for men that have rising PSAs after surgery typically. That's all we've got;
we've got the experience, of course, with hormone therapy in newly diagnosed and the information we
have there. Timing in the newly diagnosed doesn't seem to make that big a difference.
Most of the radiation therapists are going to want to start the hormone treatment before the
radiation. That has been the policy for so long; it's never been tested clearly but the
typical mindset is start the hormone therapy and then start the radiation. The question comes,
"Well how long? How many months of hormone therapy do you need before you start the radiation?"
and the limited trials that exist suggests that there's
a lot of flexibility there — that it doesn't make that big a difference.
So, a patient said that more than six months ago after their final Lupron injection, they still
have an undetectable testosterone, hot flashes, and night sweats, and a little sexual dysfunction,
but the PSA is undetectable. So, when can they expect to return to like pre-therapy conditions?
When will the hot flashes stop? When will, you know, the fatigue and the night sweats stop?
So, predicting testosterone recovery is as an art that is dependent on how old the patient is
because men that are older they're going to have slower return of their testosterone, and this is
really what they're talking about is the return of the testosterone. That's when things normalize.
Also, men that have had longer treatment periods. So, if someone has three or four
months of treatment, their testosterone is going to come back more quickly. If they've had a year
and a half, it's going to be slower. So, older men that get treated for longer periods, some of those
are never going to recover their testosterone production, and as we've covered it already the
possibility of implementing testosterone, then, is raised to try and restore normalcy.
We typically in patients that are stopping treatment we tell them we want to give the
body six to 12 months to recover on its own, and then if testosterone is not starting to
recover, then we think about giving some testosterone to help hurry things along.
So, getting specific into you know night sweats and hot flashes, is there anything that he can
take in the meantime before maybe his testosterone recovers to help alleviate those issues.
Yes, there are medications such as Gabapentin or Effexor that
can temper the hot flashes. The most effective thing is estrogen. Estrogen patches are quite good
at getting rid of hot flashes. You have to watch out for any type of breast enlargement with that,
but the medications to help hot flashes are good, then acupuncture can help as well. So,
if it's become that big an issue—a lot of men they're already on medicines they don't want
to take more medicines—but if it's waking people up at night, they can't get a good night's sleep,
some sort of intervention starts to become very reasonable.
And in the case of sexual dysfunction, what is your advice for a man who is
looking to recover his testosterone and that hasn't happened yet?
Should he be, you know, on any sort of pills or doing anything in particular for this?
Yeah, well a lot of men with low testosterone don't have that much interest in recovering
their sexual function, but looking ahead to the day when their libidos come back,
men should be—in our opinion—taking something like Cialis or Viagra to restore the nighttime
erections to keep the apparatus functioning normally for the day when the libido does return.
Hi everyone, it's Alex and Hunter. Hunter is our official PCRI mascot.
If you'd like to learn more about men's health tips and prostate cancer you can
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we come up with new prostate cancer videos every week. Say bye!