These questions and answers are in addition to the frequently asked questions on this topic. They are archived questions and answers which were asked and answered on this website.
Please read the FAQs on this topic before going through these Q&As.
HORMONAL THERAPY: In a recent Quest article on intermittent hormonal therapy, you
said the treatment can work from a few months to 18 years. How can a man in treatment know which time period applies to him?
At the present, no one can predict the duration of response to hormonal therapy.
Eventually, genetic studies will show us which tumors are going to be responsive to hormonal therapy for a long time and which are destined not to respond as well. Most likely, when a biopsy is performed, the tumor tissue will be tested on a gene chip array to see which genes are "turned on" and which are "turned off."Gene expression patterns will show which are characteristic of hormonally-responsive tumors and which are characteristic of non-responsive tumors. Thus, therapy will be tailored somewhat to the pattern of gene
expression in the individual patient's tumor.
POSTOPERATIVE RADIOTHERAPY: After surgery is radiation required?
Sometimes it is strongly advised when the pathology report shows positive surgical margins or extension of the tumor beyond the prostate gland. It is also sometimes advised when the PSA begins to rise after surgery. See Quest articles posted on this topic on this website for additional information.
ANTIESTROGENS: Should an anti-estrogen be prescribed for a post-prostatecomy patient (contained cancer/Gleason 6) with high estrogen and low testosterone?
Antiestrogens, such as tamixifen, have been tested in prostate cancer. Although, some studies have reported a benefit, the results have not been consistently good. Most experienced clinicians do not use antiestrogens routinely in prostate cancer patients.
TESTOSTERONE REPLACEMENT THERAPY AFTER RADICAL PROSTATECTOMY: I had low testosterone before I had surgery. I had the nerve sparing surgery and the cancer was contained to the prostate. I was not on any hormones prior to the surgery. It has been 5 months since my surgery and I am still experiencing problems with desire and erections. Can I take hormones? If not is there something I can do to raise my testosterone level?
It is possible that the testosterone level is low. It would be useful to measure free and total testosterone. If they are low, and it is believed that all of the prostate cancer has been removed, you could have testosterone replacement therapy by injection (more reliable and less expensive) or by patch. I advise my patients to monitor their PSA level monthly for the first three months after starting replacement therapy. If the PSA rises, the treatment should be stopped and adjuvant therapy for prostate cancer should be considered.
REMOVAL OF TESTICLES INSTEAD OF LUPRON: My father is currently on the Lupron shot that is administered every four months. He has recently had to switch doctors and was told that if he has a vasectomy, he no longer may need to get the injection. A combination of the Lupron injections and a daily casodex pill has kept his PSA level down to almost 0. Will the vasectomy be an answer to not having to get this costly shot every four months but also keep his PSA level down?
I believe that your are referring to an operation for removal of the testicles, called orchiectomy, not vasectomy. Yes, orchiectomy is virtually equivalent to Lupron in terms of its therapeutic benefits.
PERSONALITY CHANGE WITH HORMONAL THERAPY: My dad was diagnosed prostate cancer a year ago. He received hormone therapy and his PSA level decreased from 180 to <0.1 ng/mL. Currently his cancer is well under control. I believe that he has a total change of character. His changed into a dominant, unreasonable man. What information do you have about this side effect of the hormone therapy?
Usually, patients are characterized as being less "perky" on hormonal therapy. The diagnosis of prostate cancer is usually devastating to patients, at least at first, and that alone can make it more difficult to interact with them.
TESTOSTERONE REPLACEMENT THERAPY: I had a radical prostatectomy 12 months ago. It was a small cancer and my current PSA reading has been .1 the last two checkups. I have now been diagnosed with low testosterone. What is your opinion of testosterone replacement therapy?
Testosterone replacement therapy should be used with caution. If there are any cancer cells remaining in your body, testosterone replacement therapy could stimulate their growth.
However, if you wish to take the risk, you should monitor your PSA monthly for at least 6 months, in my opinion.
I know that this is a very controversial subject, but in your opinion, what do you feel is the length of time that a person should be on the Lupron/Casodex protocol? Background Info: Diagnosed 4/03, PSA 33, Gleason 8, T3a, no bone mets, 40 IMRT's. PSA one month after completion of RT 0.04. Thank you.
Nobody knows for certain. In practice, most people recommend from as little as a few months to two years. Some recommend continuing it indefinitely. In my opinion, it can be discontinued a few months after radiotherapy and then if the PSA rises, the options would be to resume continuous or intermittent hormonal therapy.
Please tell me about plenaxis.
You should check the internet for a more detailed description, but, briefly, Plenaxis is an injectable drug that is similar to Lupron or Zoladex except that it does not cause an increase in testosterone levels ("flare response") before lowering them. Thus, it is possible to give it without using an antiandrogen, such as Casodex or Flutamide to block the testosterone "flare" response that occurs during the first 10 days or so after an injection. It probably would have been a significant improvement over the drugs currently used; however, disadvantage are that relatively large quantities of the drug have to be injected, and some patients have had an allergic reaction to it. It has been approved by the FDA for use when other drugs cannot be used.
How long to continue Flutamide after Orchiectomy?
I do not believe that it is necessary as long as the PSA level is very low following orchiectomy.
How quickly does Zoladex(the 3 month shot) take effect?
Usually within a month.
My 85-yr old father had PSA 16 and six months later, he started having shoulder pain. PSA at that time was 34. A bone scan was done, showing extensive metastis (lesions in most areas of the skeleton). Biopsy showed prostate cancer (aggressive, fast-growing) in all samples (Gleason 9). In 2 days he will have orchiectomy. There will be no further treatment. We asked about treatment for increasing bone mass to avoid fractures. Is he doing the right thing? Can he take Fosamax to increase bone mass? Can we expect remission with this surgery? Can you suggest prognosis? Is there anything else to do?
Usually it is not necessary to begin medication to prevent bone loss immediately after starting hormonal therapy, because it takes some time for the bones to lose calcium. However, in a patient with known bone metastases, therapy is probably not a bad idea. Most patients respond to hormonal therapy. (please see Quest Articles on Hormonal Therapy Explained and other Q&As on the website). The prognosis is uncertain in an individual patient and will depend on how well he responds to hormonal therapy.
I had Zoladex along with my radiation treatments. I stopped the Zoladex 16 months ago. How long do I have these "hot flashes?"
They can last for a considerable time, but by 16 months, they should be going away. I would advise you to have your testosterone level checked.
I underwent radiation in 1992--and after five years my PSA went up to 5.3. I have undergone treatment with Lupron--I take three four ( 4 } month shots and then I am off the shots for one year. I have taken three series of Lupron shots. Is there any alternative to this procedure. I understand that Lupron may affect my bone mass, but I have never been directed to take any tests for loss of bone mass. Is there any other condition that might be affected by Lupron.
A: I prefer to use one 3-month Lupron injection and if the PSA is undetectable, hold off on the Lupron until the PSA reaches 4.0. With this regimen, the patient has a frequent opportunity to re-calcify his bones and restore his muscle mass.
Do you recommend hormone therapy in conjunction with 3-D radiation in a 69 yr old male 11 years since radical...with a psa of 1.8.
I do because the PSA of 1.8 is pretty high to be just starting radiotherapy, and especially so if the tumor was high-grade.
EFFECT OF PROSCAR ON GLEASON GRADE:I read that Gleason grading should not be used after treatment with Proscar, because the treatment falsely biases the results. This is of interest to me, since I was treated with Proscar in the 3 months leading up to my RRP, and my post-op Gleason was graded at 8, compared with pre-op at 6. Is it possible that my post-op Gleason was actually lower than the 8 grading?
Any form of hormonal therapy can induce changes in the cancer cells that make them more difficult to grade. I believe the jury is still out on this matter, but it is possible that the Gleason grade would have been lower without the Proscar. The question is whether Proscar just makes the tumor cells look more aggressive or whether it encourages them to become more aggressive.
RISING PSA AFTER PRIMARY HORMONAL THERAPY: My husband's PSA has been rising and after having hormone implant and medication for 8 yrs has now been prescribed estraderm MX100 patches plus aspirin. My husband wants to avoid chemotherapy but I think that possibly this would be a better option. What do you think. His psa is now 72.2 and he is 66 yrs old.
It might work. Sometimes secondary estrogen therapy will work for a while. It is worth trying. The down-side risk is that estrogens might predispose to blood clots and fluid retention, and aspirin cannot completely protect against these side effects.
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