Hormone therapy for prostate cancer

Marc B. Garnick, M.D.

Editor in Chief, HarvardProstateKnowledge.org

Marc B. Garnick, M.D.,* discusses the options and controversies

*Disclosure — Dr. Garnick is currently serving as a consultant to SpecialtyEuropeanPharma, which is developing abarelix (Plenaxis) in Europe.

Androgens, the family of male sex hormones that includes testosterone, function as a fuel for growth — a quality that explains their central role in both normal development and prostate cancer. In adolescent boys, androgens not only trigger sexual development, but also contribute to a deeper voice, a beard, and increased muscle strength and bone mass. When prostate cancer develops, however, this androgen fuel contributes to tumor growth and progression.

About 90% to 95% of androgens are produced in the testicles, while another 5% to 10% are produced by the adrenal glands. Androgen-deprivation therapy, more commonly known as hormone therapy, is one of the most powerful weapons in the fight against prostate cancer because it significantly reduces the fuel supply that is feeding malignant growth. Hormone therapies now available target testosterone production by the testicles or androgen’s activity in the body.

First developed in the 1940s, based on studies by Dr. Charles Huggins and other researchers at the University of Chicago, hormone therapy produced such dramatic early results that investigators thought they had found a way to cure prostate cancer. Unfortunately, long-term clinical trials later showed what we now know to be the case: Eventually prostate cancer becomes resistant to androgen-deprivation therapy and progresses.

We don’t know yet why men with prostate cancer develop androgen resistance, but a leading theory is that prostate tumors contain different types of cells, some of which are resistant to hormone treatment. Eventually, these resistant prostate cancer cells multiply and the disease advances. But even if it doesn’t cure prostate cancer, hormone therapy can keep it at bay for years. In fact, one of my patients has now been on some type of hormone therapy for nearly 16 years.

Once reserved solely as a treatment for metastatic prostate cancer, hormone therapy is now also used in a variety of other ways. And medication options — in terms of both the number of drugs available and choices about the timing and duration of therapy — have also evolved and improved.

This article serves as a basic primer about hormone therapy for prostate cancer. It explains when to consider hormone therapy, what your options are in terms of drugs or combinations of drugs, and what you should know about side effects. Finally, it explores several controversies currently being debated by medical experts, and where I stand on these issues. (If you’d like to learn more on your own, see “History and overviews of hormone therapy.”)

History and overviews of hormone therapy

Garnick MB. Hormonal Therapy in the Management of Prostate Cancer: From Huggins to the Present. Urology 1997;49:5–15. PMID: 9123737.

Sharifi N, Gulley JL, Dahut WL. Androgen Deprivation Therapy for Prostate Cancer. Journal of the American Medical Association 2005;294:238–44. PMID: 16014598.

When to consider hormone therapy

Hormone therapy is a treatment option for men with prostate cancer in any of the following situations:

  • when cancer has metastasized beyond the prostate
  • when cancer is confined to the prostate, but hormone therapy is used to boost the effectiveness of radiation therapy or to shrink the size of a tumor before brachytherapy
  • when PSA begins to rise sometime after initial treatment with surgery or radiation therapy, indicating the cancer may have recurred.

Not all doctors agree on when to use hormone therapy, or how to administer it. Indeed, this is an area that requires a physician to exercise as much art as science in clinical practice. You should also be aware that side effects can be daunting, although most men tolerate treatment reasonably well (see “Side effects of hormone therapy”).

Side effects of hormone therapy

Common

  • hot flashes, which may subside with time
  • decreased libido
  • erectile dysfunction
  • gynecomastia (breast enlargement and tenderness; occurs only with certain types of hormone therapy)
  • osteoporosis (bone erosion that may cause fractures; only with long-term use)
  • weight gain, loss of muscle mass
  • fatigue, anemia
  • changes in blood cholesterol and blood glucose measurements

Uncommon

  • depression, loss of mental “sharpness”
  • abnormalities of the liver and liver function test results

Rare

  • aches and joint pains
  • changes in the heart’s electrical signals

Systemic therapy for metastatic disease

The most common use of hormone therapy today is to treat men whose prostate cancer has metastasized to other parts of the body. If prostate cancer cells escape the prostate, they migrate first to surrounding structures, such as the seminal vesicles and lymph nodes, and later to the bones or, rarely, to other soft tissues.

Hormone therapy is recommended as a palliative treatment, to relieve symptoms such as bone pain. And while hormone therapy is not a cure, in that it can’t eliminate prostate cancer completely, it often extends life for many years. By reducing testosterone levels, hormone therapy can shrink a prostate tumor and its metastases and slow further progression of the cancer for so long that sometimes a man with this disease dies of something other than prostate cancer.

Traditionally, doctors believed that it was best to prescribe hormone therapy as soon as metastatic prostate cancer is discovered, and advised patients to continue hormone therapy for the rest of their lives. Although this strategy extended the lives of many men, concerns about quality-of-life issues sparked a number of studies in which researchers tried to determine if men with metastatic disease that was only detectable in lymph nodes or on bone scans — but was not yet causing symptoms — could delay hormone therapy. For example, if a man had only one or two bone lesions, but no pain and no risk to the spinal cord, was there any benefit to waiting until he actually experienced pain from the cancer before beginning treatment?

Most studies that have looked at this question, however, concluded that starting hormone therapy early on, right after discovery of metastases, achieved better outcomes, even in men whose disease had spread only to the lymph nodes. For example, one small but often-cited study, published in 1999 in the New England Journal of Medicine, found that 77% of men who had prostate cancer with lymph node metastases and chose to undergo hormone therapy were still alive and had no recurrent disease roughly seven years later, as compared with only 18% of men who decided to forgo hormone treatment until the cancer spread to bones or lungs. A more recent analysis by the same group of researchers found that these trends held up over time (see Table 1).

Table 1: Survival benefits of early treatment

An analysis of 98 men with prostate cancer that had spread to the lymph nodes, who were randomly assigned to receive immediate hormone therapy or to forgo it until the disease spread further to bones or lungs, found that early treatment saved lives.

Deaths from prostate cancer Immediate treatment group (47 men total) Delayed treatment group (51 men total)
Deaths within 5 years 2 (4% of total) 12 (24% of total)
Deaths within 10 years 6 (13% of total) 21 (41% of total)
Source: Lancet Oncology 2006;7:472–9. PMID: 16750497.

Other studies have shown that starting hormone therapy early on increases survival times, delays cancer progression, and results in better quality of life. However, in a review of four studies involving 2,167 men with metastatic prostate cancer, the Cochrane Collaboration (a prestigious international organization known for its independent analysis) concluded that early hormone therapy had offered only a small overall survival advantage over deferred treatment, and cautioned that more research on the issue needs to be done.

Although debate on this issue continues, in most cases I advise my patients with metastatic disease to begin hormone treatment early on. This is particularly important for someone with spine metastases, because a bone fracture or extension of the cancer into the spinal cord area could lead to impaired mobility and even paralysis. Fortunately, this is a rare event. (For more information about research in this area, see “Hormone therapy: Immediate versus delayed.”)

Hormone therapy: Immediate versus delayed

Medical Research Council Prostate Cancer Working Party Investigators Group. Immediate Versus Deferred Treatment for Advanced Prostatic Cancer. British Journal of Urology 1997;79:235–46. PMID: 9052476.

Messing EM, Manola J, Sarosdy M, et al. Immediate Hormonal Therapy Compared with Observation after Radical Prostatectomy and Pelvic Lymphadenectomy in Men with Node-Positive Prostate Cancer. New England Journal of Medicine 1999;341:1781–8. PMID: 10588962.

Messing EM, Manola J, Yao J, et al. Immediate Versus Deferred Androgen Deprivation Treatment in Patients with Node-Positive Prostate Cancer after Radical Prostatectomy and Pelvic Lymphadenectomy. Lancet Oncology 2006;7:472–9. PMID: 16750497.

Nair B, Wilt T, MacDonald R, Rutks I. Early Versus Deferred Androgen Suppression in the Treatment of Advanced Prostatic Cancer. Cochrane Database of Systematic Reviews 2002;CD003506. PMID: 11869665.

Neoadjuvant and adjuvant hormone therapy for early-stage or regionally advanced disease

Hormone therapy is sometimes given in conjunction with a definitive prostate cancer treatment, such as radiation therapy, in order to improve health outcomes. When hormone therapy is given in advance of a primary treatment, it’s known as neoadjuvant therapy; when it’s given during or after a primary treatment, it’s known as adjuvant therapy.

Table 2: Boosting the effectiveness of radiation therapy

A randomized controlled study involving 206 men with early-stage prostate cancer evaluated whether adding six months of hormone therapy to external-beam radiation treatment would boost both overall survival and disease-free survival (meaning that the men did not suffer a relapse). The results are given below. The same research group found, in an earlier study, that the addition of hormone therapy was of most benefit to men who were considered at moderate or high risk, based on their clinical profile.

Five-year follow-up Radiation treatment alone Radiation treatment and hormone therapy
Percentage of men who survived 78% 88%
Percentage of men who avoided relapse 57% 82%
Source: Journal of the American Medical Association, 2004;292:821–7. PMID: 15315996.

Combined with radiation therapy. A number of studies have shown that men with early-stage prostate cancer are more likely to be cured when hormone therapy is given in conjunction with radiation therapy (see Table 2 above for the results of one study). Even when the disease is regionally advanced, meaning that it has progressed to tissues immediately surrounding the prostate gland, neoadjuvant hormone therapy reduces risk of progression and relapse (see “Evidence for combining hormone therapy and radiation treatment”).

Evidence for combining hormone therapy and radiation treatment

Bolla M, Collette L, Blank L, et al. Long-Term Results with Immediate Androgen Suppression and External Irradiation in Patients with Locally Advanced Prostate Cancer (an EORTC Study): A Phase III Randomised Trial. Lancet 2002;360:103–6. PMID: 12126818.

Bolla M, Gonzalez D, Warde P, et al. Improved Survival in Patients with Locally Advanced Prostate Cancer Treated with Radiotherapy and Goserelin. New England Journal of Medicine 1997;337:295–300. PMID: 9233866.

D’Amico AV, Schultz D, Loffredo M, et al. Biochemical Outcome Following External Beam Radiation Therapy With or Without Androgen Suppression Therapy for Clinically Localized Prostate Cancer. Journal of the American Medical Association 2000;284:1280–3. PMID: 10979115.

D’Amico AV, Manola J, Loffredo M, et al. Six-Month Androgen Suppression Plus Radiation Therapy Versus Radiation Therapy Alone for Patients with Clinically Localized Prostate Cancer: A Randomized Controlled Trial. Journal of the American Medical Association 2004;292:821–7. PMID: 15315996.

Denham JW, Steigler A, Lamb DS, et al. Short-Term Androgen Deprivation and Radiotherapy for Locally Advanced Prostate Cancer: Results from the Trans-Tasman Radiation Oncology Group 96.01 Randomised Controlled Trial. Lancet Oncology 2005;6:841–50. PMID: 16257791.

Nesslinger NJ, Sahota RA, Stone B, et al. Standard Treatments Induce Antigen-Specific Immune Responses in Prostate Cancer. Clinical Cancer Research 2007;13:1493–502. PMID: 17332294.

Zietman AL, Nakfoor BM, Prince EA, Gerweck LE. The Effect of Androgen Deprivation and Radiation Therapy on an Androgen-Sensitive Murine Tumor: An In Vitro and In Vivo Study. The Cancer Journal from Scientific American 1997;3:31–6. PMID: 9072305.

Although we don’t understand this phenomenon completely, animal studies suggest that a dose of radiation is more effective at killing cancer cells when given in the setting of androgen deprivation. One leading theory about why this occurs is that the combination of radiation therapy and hormone therapy somehow activates the immune system, so that immune system cells attack and kill cancer cells.

Hormone therapy may also be used for anywhere from three to six months prior to brachytherapy when a man’s prostate gland is large, usually defined as bigger than 50 grams. In this situation, neoadjuvant hormone therapy is used to shrink the prostate gland to enable better implantation of radioactive seeds so that the right dose of radiation can be administered.

Combined with radical prostatectomy. The results of combining hormone therapy and surgery have been mixed. On the one hand, neoadjuvant hormone therapy is effective at “down-staging” the disease before surgery by shrinking the primary tumor and eradicating micrometastases. Short-term studies were encouraging, showing that neoadjuvant hormone therapy reduced the risk of finding a positive margin in the excised tissue. On the other hand, long-term studies indicate that neoadjuvant hormone therapy does not extend time to biochemical recurrence or improve survival. (For examples of studies, see “Evidence about hormone therapy and prostatectomy.”)

Evidence about hormone therapy and prostatectomy

Gleave ME, La Bianca S, Goldenberg SL. Neoadjuvant Hormonal Therapy Prior to Radical Prostatectomy: Promises and Pitfalls. Prostate Cancer and Prostatic Diseases 2000;3:136–44. PMID: 12497089.

Hurtado-Coll A, Goldenberg SL, Klotz L, Gleave ME. Preoperative Neoadjuvant Androgen Withdrawal Therapy in Prostate Cancer: The Canadian Experience. Urology 2002;60:45–51. PMID: 12231047.

Kumar S, Shelley M, Harrison C, et al. Neo-adjuvant and Adjuvant Hormone Therapy for Localized and Locally Advanced Prostate Cancer. Cochrane Database of Systematic Reviews 2006;CD006019. PMID: 17054269.

Soloway MS, Sharifi R, Wajsman Z, et al. Randomized Prospective Study Comparing Radical Prostatectomy Alone Versus Radical Prostatectomy Preceded by Androgen Blockade in Clinical Stage B2 Prostate Cancer. The Lupron Depot Neoadjuvant Prostate Cancer Study. Journal of Urology 1995;154:424–8. PMID: 7541859.

Secondary treatment following relapse

Hormone therapy may also be used as a secondary or “salvage” treatment when PSA levels rise following initial prostate cancer treatment, indicating the cancer has returned. This situation is known as biochemical recurrence. The salient points to keep in mind are that hormone therapy is most often used as a salvage treatment when PSA doubling time is less than six months, indicating that the cancer is aggressive or may have already metastasized.

Options in hormone therapy

Testosterone levels in the body can be reduced either surgically or with drugs. The surgical option is castration, achieved by removing the testicles during a bilateral orchiectomy. Once the only option, it has since been supplanted by drugs that lower testosterone levels to amounts achieved by surgery.

For men, normal testosterone levels range from 300 to 1,000 ng/dl. The FDA requires that any new drug used in hormone therapy for prostate cancer lower testosterone levels to 50 ng/dl or less. In my practice, I usually try to lower levels even further, to 20 ng/dl.

Orchiectomy

Because more than 90% of androgens are produced in the testicles, bilateral orchiectomy significantly reduces testosterone levels in the body. The operation can be done on an outpatient basis. The surgeon opens the scrotum, and then removes the testicles, while preserving blood vessels and nerves. If a man is concerned about how his genitals will look after the operation, it is possible to have the surgeon insert saline implants into the scrotum, which will look and feel like testicles. Often, though, the spermatic cord is still present as well as some surrounding testicular structures, thus preventing the appearance of an “empty scrotum.”

Although the operation is relatively simple, many men find it psychologically devastating to lose their testicles — and for this reason alone decide against it. Another factor to consider is that, unlike medication options, orchiectomy is permanent. Some men continue to choose this option, however, because it remains the most efficient way to reduce testosterone levels, and it eliminates expenditures on medications and multiple visits for monitoring side effects that would be needed to achieve the same results. The option of orchiectomy is also sometimes recommended for elderly men who cannot readily visit a doctor for an injected medication, or who cannot risk the cardiovascular side effects of diethylstilbestrol (DES).

Figure 1: How hormone therapy affects the androgen cascade

The male sex hormones are known as androgens. Probably the best known hormone in this family is testosterone. Most androgens are produced in the testicles.

Androgens fuel the growth of prostate cells, including prostate cancer cells. Hormone therapy — also known as androgen-deprivation therapy — seeks to cut off the fuel supply. But different therapies work in different ways.

How hormone therapy affects the androgen cascade

A. The hypothalamus releases pulses of LHRH, which signals the pituitary gland to release the hormones FSH and LH.

B. LH travels through the bloodstream. When it reaches the testicles, it binds to specialized cells that secrete testosterone into the bloodstream.

C. In the prostate, the enzyme 5-alpha-reductase converts testosterone and other types of androgens into dihydrotestosterone (DHT), which stimulates the growth of prostate cells — and fuels the growth of cancer, if it is present.

Centrally acting agents

LHRH agonists flood the pituitary gland with messages to crank out LH. This causes a temporary surge of testosterone until receptors in the pituitary are overloaded. Then testosterone levels drop sharply.

The GnRH antagonist jams receptors in the pituitary gland so that it cannot respond to the pulses of LHRH sent by the hypothalamus. This prevents the LH signal from being sent — and no testosterone is made in the testicles.

DES inhibits secretion of LHRH from the hypothalamus.

Peripherally acting therapies

Orchiectomy removes the testicles, preventing testosterone production.

Anti-androgens block the interaction of DHT with the androgen receptor located in the prostate cancer cell. Stimulation of this receptor allows cells to grow. By blocking this stimulation, anti-androgens prevent prostate cancer cell growth.

LHRH agonists

Luteinizing hormone-releasing hormone (LHRH) is secreted by the hypothalamus, sending the first chemical signal essential for testosterone production (see Figure 1 above). LHRH agonists are among the most popular choices for hormone therapy in prostate cancer. These drugs work centrally, on the brain. (Because LHRH is sometimes called GnRH, or gonadotropin-releasing hormone, these medications are sometimes referred to as GnRH agonists.)

LHRH agonists are listed in Table 3 below. Because these medications are peptides, which would be broken down in the digestive system if taken by mouth, they cannot be given in pill form. Instead, LHRH agonists are injected into a muscle or fat tissue under the skin. The first LHRH agonists were self-injected on a daily basis by patients, much like insulin. But today “depot” formulations are available, which can be implanted under the skin to provide extended release of the medication. Such depot formulations can be given anywhere from once every four weeks to once a year.

LHRH agonists are popular because they don’t cause as many cardiovascular problems and other side effects as DES does. Even so, research indicates that using these medications can increase total cholesterol and triglyceride levels, as well as blood sugar levels and risk of diabetes, all of which can increase risk of having a heart attack (see “Cardiovascular risk,” below). To ensure that you can take these drugs safely, your doctor will measure your blood sugar and cholesterol levels, and may recommend an exercise stress test to determine your overall heart health.

Cardiovascular risk

D’Amico AV, Denham JW, Crook J, et al. Influence of Androgen Suppression Therapy for Prostate Cancer on the Frequency and Timing of Fatal Myocardial Infarctions. Journal of Clinical Oncology 2007;25:2420–5. PMID: 17557956.

Keating NL, O’Malley AJ, Smith MR. Diabetes and Cardiovascular Disease During Androgen Deprivation Therapy for Prostate Cancer. Journal of Clinical Oncology 2006;24:4448–56. PMID: 16983113.

Yannucci J, Manola J, Garnick MF, et al. The Effect of Androgen Deprivation Therapy on Fasting Serum Lipid and Glucose Parameters. Journal of Urology 2006;176:520–5. PMID: 16813881.

LHRH agonists also cost more than DES and require more frequent physician visits. More significantly, LHRH agonists cause a temporary surge in testosterone, generally lasting about three weeks to a month, which fuels prostate cancer growth. Although the cancer will regress once the surge ends and testosterone levels plummet, LHRH agonists are usually given in conjunction with anti-androgens — especially in men whose disease has metastasized to the spine, to prevent paralysis.

The testosterone surge is caused by the way these drugs act on LHRH receptors. As explained in Figure 1, the LHRH receptor normally receives only pulsating hits of LHRH. But the synthetic version of this hormone used in drug formulations remains “plugged in” to the receptor, so that it cannot turn off. It’s like leaving the toaster in the “on” position permanently: Initially you generate a lot of heat, but eventually you burn out the coils. Similarly, by taking LHRH agonists, men rev up the testosterone production system and eventually wear it out. (This temporary surge is actually valued by fertility experts, who use these drugs today for in vitro fertilization.)

GnRH antagonist

A new type of drug, abarelix (Plenaxis), received FDA approval in 2003, but for commercial reasons is currently not being promoted or available to new patients in the United States. However, the drug recently received regulatory approval in Germany, so that it may be available in Europe by the end of 2007.

Abarelix is a GnRH antagonist, which targets receptors in the pituitary gland and shuts them off without the obligatory initial stimulation characteristic of agonists. As such, it avoids triggering the testosterone surge created by LHRH agonists. (For more information about this medication, see “Research on abarelix.”)

Research on abarelix

Garnick MB, Pratt C, Campion M, Shipley J. The Effect of Hormonal Therapy for Prostate Cancer on the Electrocardiographic QT Interval: Phase 3 Results Following Treatment with Leuprolide and Goserelin, Alone or with Bicalutamide, and the GnRH Agonist Abarelix. Journal of Clinical Oncology 2004;22:4578 (abstract). PMID not available.

Koch M, Steidle C, Brosman S, et al. An Open-Label Study of Abarelix in Men with Symptomatic Prostate Cancer at Risk of Treatment with LHRH Agonists. Urology 2003;62:877–82. PMID: 14624912.

McLeod D, Zinner N, Tomera K, et al. A Phase 3, Multicenter, Open-Label, Randomized Study of Abarelix Versus Leuprolide Acetate in Men with Prostate Cancer. Urology 2001;58:756–61. PMID: 11711355.

Trachtenberg J, Gittleman M, Steidle C, et al. A Phase 3, Multicenter, Open Label, Randomized Study of Abarelix Versus Leuprolide Plus Daily Antiandrogen in Men with Prostate Cancer. Journal of Urology 2002;167:1670–4. PMID: 11912385.

This medication is injected into the buttocks muscle every two weeks for the first month, then afterward once every four weeks. Because there is a small chance that men receiving abarelix may experience an allergic reaction, causing low blood pressure and fainting, patients need to remain in the physician’s office for 30 minutes after the injection to ensure that such a reaction does not occur, or if it does, can be treated promptly.

Anti-androgens

Orchiectomy, DES, LHRH agonists, and the GnRH antagonist all work by shutting down production of testosterone in the testes. But about 5% to 10% of male hormones are produced in the adrenal glands. These androgens, which are closely related to testosterone, can also be converted to DHT and promote prostate cancer growth.

Because anti-androgens target receptors at the cellular level, rather than in the brain, they are classified as peripherally acting medications. This class includes flutamide (Eulexin), bicalutamide (Casodex), and nilutamide (Nilandron). The drug most often used is bicalutamide, which is given once a day and is less likely than the others to cause diarrhea.

Anti-androgens are often given in conjunction with LHRH agonists in order to counter the effects of the testosterone surge described earlier. But this use is controversial (see “Combined androgen blockade: Pro and con” below). Anti-androgens may also be prescribed if an orchiectomy or LHRH agonist is unable to keep testosterone levels at sufficiently low levels.

Estrogen

Diethylstilbestrol was the first type of drug used in hormone therapy for prostate cancer, and it remains in very limited use today — albeit with dosing changes, and not as a first choice. DES is a synthetic form of the female hormone estrogen. It is effective at lowering testosterone levels because it inhibits secretion of LHRH from the hypothalamus (see Figure 1).

Unfortunately, at moderate to high doses, such as 5 mg per day, DES causes significant cardiovascular problems and raises the risk of having a heart attack. To reduce this risk, physicians may try to reduce the dose to 1 mg per day, but this causes another problem: At this dose, testosterone levels often begin rising after 6 to 12 months of treatment. Today, DES is usually prescribed at 3 mg per day.

This medication is prescribed to men who value the convenience of taking an inexpensive drug once a day. Some physicians recommend taking a baby aspirin once a day to reduce risk of cardiovascular problems, but no studies have been conducted to provide evidence that this works. On the other hand, men do have options for dealing with another common side effect of DES, gynecomastia.

Table 3: Hormone therapy medications

Drug name by category Mechanism of action Side effects
LHRH agonists

leuprolide (Lupron)

goserelin (Zoladex)

triptorelin (Trelstar)

Act through the hypothalamus to indirectly inhibit LH release from the pituitary gland Hot flashes, impotence, decreased libido, fatigue, weight gain, anemia, osteoporosis; may increase risks of diabetes and heart disease
GnRH antagonist

abarelix (Plenaxis)

Targets LHRH receptors in the pituitary gland directly, to prevent LH release Hot flashes, sleep disturbances, small chance that a serious allergic reaction may occur
Anti-androgens

flutamide (Eulexin)

bicalutamide (Casodex)

nilutamide (Nilandron)

Target androgen receptors in the prostate gland, to prevent testosterone from being used by the prostate Hot flashes, impotence, decreased libido, breast tenderness and swelling, nausea, diarrhea, abnormalities of liver blood tests, and rarely, liver failure
Estrogen

diethylstilbestrol (DES, Stilphostrol)

Inhibits secretion of LHRH from the hypothalamus Hot flashes, nausea, breast swelling and tenderness, blood clots, and (at moderate to high doses) increased risk of heart attack

Controversies in hormone therapy

The use of hormone therapy requires as much art as science. Physicians do not always agree about when it is best to start treatment, whether it needs to be continuous or can be stopped and started up again periodically, and whether monotherapy or combination therapy is best. Here are the salient issues, what the studies say — and what I believe and follow in my own practice.

Initiation of therapy

We’ve already covered the longstanding debate about whether to initiate hormone therapy early or late after discovery of metastases. As the use of hormone therapy has expanded to other situations, questions about when to initiate therapy may also come up.

For use as neoadjuvant and adjuvant therapy. Your doctor may recommend hormone therapy before, during, and after radiation treatment. Few guidelines exist about exactly when to initiate hormone therapy and how long to continue it. Options abound, and the studies cannot cover every situation. You might have

  • two months of hormone therapy, followed by two months of radiation treatment combined with hormone therapy, for a total of four months
  • two months of hormone therapy, two months of hormone therapy and radiation treatment, followed by two months of hormone therapy, for a total of six months
  • concomitant radiation treatment and hormone therapy for two months, then hormone therapy for a total of three years.

This is an area where the art and science of medicine come into play. I select any patient with a Gleason component of 4, or palpable disease upon physical examination, who is a candidate for radiation treatment. I prescribe hormone therapy until the PSA reaches its lowest point (nadir), and that nadir is maintained for a month. It usually takes two to four months to reach nadir. Then the patient undergoes radiation treatment, while continuing hormone therapy. How long hormone therapy continues after radiation treatment ends depends on the man’s risk profile. I treat some men for a total duration of 6 months, while others may be treated for 9 months, a year, or 18 months.

For rising PSA. When PSA rises after initial treatment and the doubling time is less than six months, your doctor will likely recommend a full course of hormone therapy, which can delay progression of metastases to the bones. If PSA doubling time indicates the cancer is not aggressive, however, and you want to remain sexually active and avoid other side effects, then delaying hormone therapy while monitoring PSA may be the way to go.

Intermittent or continuous therapy

Once prescribed, hormone therapy used to continue for life, but scientists are now reevaluating that strategy and investigating whether hormone therapy can be taken intermittently, with so-called holidays from treatment. The thinking is that this may not only help restore quality of life — as, for example, returning libido and sexual health — but also delay the hormone resistance that eventually develops in men taking hormone therapy.

Clinical trials evaluating whether intermittent therapy is as effective or more effective than continuous therapy are now under way, so it is too early to say for sure.

Combined androgen blockade

Combined androgen blockade — also known as maximum androgen blockade or total androgen blockade — involves the concomitant use of a drug that acts centrally on the brain (an LHRH agonist or GnRH antagonist) and another that acts peripherally at the prostate cell level (an anti-androgen). In that way, you block all the activity of the androgens — not only production of testosterone, but also its action in the prostate itself. Theoretically, this should make hormone therapy even more effective. But combined androgen blockade is controversial.

One large controlled study, published in the New England Journal of Medicine, reported that combined androgen blockade (in this case the LHRH agonist leuprolide combined with the anti-androgen flutamide) offered roughly a 25% survival advantage over monotherapy (leuprolide alone). But a larger follow-up study, which involved surgery (instead of leuprolide), did not find any survival advantage with the addition of the anti-androgen. This study — which itself has generated some controversy — compared bilateral orchiectomy alone with orchiectomy combined with flutamide. (For more information about these studies, see “Combined androgen blockade: Pro and con.”)

Combined androgen blockade: Pro and con

Pro:

Crawford ED, Eisenberger MA, McLeod DG, et al. A Controlled Trial of Leuprolide With and Without Flutamide in Prostatic Carcinoma. New England Journal of Medicine 1989;321:419–24. PMID: 2503724.

Con:

Eisenberger MA, Blumenstein BA, Crawford ED, et al. Bilateral Orchiectomy With or Without Flutamide for Metastatic Prostate Cancer. New England Journal of Medicine 1998;339:1036–42. PMID: 9761805.

Two large meta-analyses that reviewed many studies comparing combined androgen blockade to monotherapy (using either surgery alone or LHRH agonists alone) concluded that the combination offered only a small survival advantage — and even that finding was inconsistent between the two analyses. One analysis, which reviewed 27 randomized studies involving 8,275 men, estimated that combined androgen blockade improved five-year survival by only 2% to 3%, at most. (For more information, see “Analyzing the studies,” below.) However, an advantage of “only” 2% to 3%, when applied to thousands of men undergoing treatment, translates into hundreds of lives extended — obviously an important benefit to the men who gain months and even years of life as a result. That is why I use combined therapy for all of my patients who undergo hormone treatments.

Analyzing the studies

Prostate Cancer Trialists’ Collaborative Group. Maximum Androgen Blockade in Advanced Prostate Cancer: An Overview of the Randomized Trials. Lancet 2000;355:1491–8. PMID: 10801170.

Samson DJ, Seidenfeld J, Schmitt B, et al. Systematic Review and Meta-Analysis of Monotherapy Compared with Combined Androgen Blockade for Patients with Advanced Prostate Carcinoma. Cancer 2002;95:361–76. PMID: 12124837.

Most doctors prescribe an anti-androgen a little before LHRH agonist treatment begins and then continue it for another month afterwards. In that way, anti-androgens counter the initial testosterone surge, but then are stopped when the surge is no longer a problem. What many physicians do not know is that actual levels of testosterone during the first month of combined androgen blockade are no different whether the anti-androgen is used or not. The potential benefit of the anti-androgen is to block effects of the circulating testosterone at the prostate cancer cell level.

What I recommend. Although it goes against conventional wisdom, I’m a total believer in combined androgen blockade. This is based upon both my reading of the key studies and my experience in treating patients. Take, for example, the 1989 study published in the New England Journal of Medicine (see “Combined androgen blockade: Pro,” above). Combining leuprolide with flutamide gave men with the most advanced prostate cancer another seven months to live, on average; the advantage was nearly two years for patients with less advanced metastatic disease. A potential seven-month or two-year survival edge may not seem overwhelming to a researcher, but it can be highly significant to the man affected and his family! It is also the reason why I spent a large portion of my professional life developing a GnRH antagonist that can act without the requirement for an anti-androgen.

So I tend to use anti-androgens extensively. I rarely, if ever, put a patient on LHRH monotherapy. But I don’t use combined androgen blockade for extended periods of time, because that causes another problem. If you block the DHT androgen receptor for too long with anti-androgens, something known as anti-androgen withdrawal syndrome occurs. This is a paradoxical situation in which the anti-androgen acts as an agonist — stimulating the receptors — rather than as an antagonist that blocks them. PSA levels rise, and hormone therapy stops working.

Fortunately, options still exist when anti-androgen withdrawal syndrome occurs. The first thing I do is discontinue the anti-androgen medication. The receptors are no longer stimulated, and about 25% to 30% of people will respond to the other leg of hormone therapy, LHRH agonists.

Looking ahead

Hormone therapy, long the cornerstone of treatment for metastatic prostate cancer, can also improve effectiveness of radiation therapy and provide another option for men whose rising PSA indicates a cancer relapse. As we look ahead to the future, several challenges remain in improving hormone therapy. First, we must determine how to better fine-tune the timing and duration of hormone therapy for patients, to provide optimal results. Second, we must find ways to overcome androgen resistance, so that lives can be extended even further. Finally, it’s important to find ways to reduce or at least counter side effects of hormone therapy, to lessen the impact on patients’ quality of life.

Originally published July 1, 2007; last reviewed March 22, 2011.

Comments:

  1. AlanK61

    At age 74, PSA of 7, continued to slowly rise, biopsy revealed 7 of 12 cores had some cancer. Started ADT, 6 months, followed by brachytherapy and radiation. 3 months later PSA zero, 6 months follow up, PSA zero.

    I continued to have negative impact from ADT, swelling of breasts, belly fat, even though my weight is same. Hot flashes still occur and my libido is slowly returning. I should have insisted for a shorter 4 month ADT to reduce these impacts. For anyone considering brachytherapy, use the shortest ADT course!

  2. Vanesa

    My Husbands biopsy gave him a gleason score of 9. That was 2 years ago and since having the Hormone injection he has lived a life of pure and utter hell. The side effects were so severe he was bed ridden 6 weeks after the injection. Weakness, fatigue, sweating, heart palpitations and breathlessness have been a daily occurence. Then came prostatitis. He has had it for over a year and no meds have helped him. Then came the heart failure. He collapsed 6 months ago and has lost over 20 kgs in less than 6 months. They put him on morphine for pain as the cancer has gone to his bones and the morphine blocks him causing him more pain. No more he said and he signed a letter asking the Hospital to not revive him again. This in just over 2 years. We are one of the unlucky ones. I spend hours with him next to his bed talking and just loving him. He is so pale and yellow now with dark rings under his eyes. We blame the injection. We made that call now we must live with those decisions. He is only 66. My poor man.

  3. Paul

    Seems to me the outcome of all treatments are simular so it’s a no brainier take the one that you get little pain avoid being cut

    In a perfect nhs world we would have proton machines that limit internal damage
    Two are being built in Manchester and London will not be available for Prostate cancer for ten years?

    I intend to grab as much QOL as I can then move to the best room in my house buy an expensive double bed fit a quality shower and toilet there fit a large champagne cooler and restart smoking cigars then thank my lucky stars for every pain free day
    I’m 68 with a beautiful girlfriend decades younger than me .

    So stop moaning get on with it

  4. Ronald Good

    My biopsy in July gave me a Gleason score of 9 on 15 of 16 samples, and they were mostly 5+4. So my urologist was ready to get me on hormone therapy and radiation. I wanted first to get surgery, and by persisting found a great surgeon at UCSF. After reading extensively, I decided that hormone therapy is truely horrible. Why invite heart disease and anemia and dementia and osteoporosis and diabetes and absolute misery from fatigue into your life? This “cure” is absolutely worse than the cancer. All the “positive” statistics you see about hormone therapy leave out the crucial test of success: mortality from all causes. Typically they just omit other causes of death except cancer in their stats, figuring that you would have died of these other causes anyway. NOT so. Hormone therapy is proven to cause significant impairment of cognitve functions. You get run over by a bus BECAUSE you have impaired functioning, slowed reaction time, poor judgement. You died because of hormone therapy. The news is now out about another very effective treatment that does inhibit metastatic prostate cancer and does extend life by more than hormone therapy: Coffee. Some studies say 3 cups, most say 5 cups of coffee a day will reduce and delay metastatic disease at least as well as hormone therapy and coffee is actually good for the heart, improves muscle tone, lowers lipids, reduces the likelihood of diabetes, dementia, liver disease, kidney disease. Virtually everything that hormone therapy does to ruin your life, coffee will make better. It generally makes you feel more energetic, reduces depression and suicidal thoughts. I am putting myself on ICT, Increased Coffee Therapy. Since I started, I am bicycling and exercising without having to force myself, I laugh more and play more and love life. Hormone therapy is torture by comparison.

  5. Mike Braun

    I was diagnosed with Gleason 3+4, 6 of 12 cores. Cancer contained to the prostate. Got Lupron shot and 9 weeks of radiation Oct-Dec 2016.
    Also started at that time taking one 50mg bicalutimide daily, still taking them. Have had three tests since, last one in October, ALL have been zero detectibility. Of course, side-effects of breast tenderness (started late last year), NO libido,I can still produce orgasm, but little to no erection. Some fatigue (of course, at 63, gong thru divorce and taking are full time of a 12 year old and an 18-year-old will tire you out). Just wondering if taking a “vacation” from bicalutimide might be indicated.

  6. Arthur Helbig

    Dear Doctor Garnick,

    I have early stage prostate cancer. My MP-MRI’s and other tests indicate containment. I do not want to risk the side-effects of radiation and radical surgery. I am 67 and in excellent health otherwise. I live in the US where I can’t find any docs to help me pursue a plan of just hormone therapy. I do not want to pursue chemical castration. Instead, I want an orchiectomy and to take estrogen.to mitigate the remaining testosterone. and would do active surveillance using regular PSA’s, MRI’s, etc.

    I understand the risks of this plan and am fully willing to take them. I am willing to travel anywhere to do this.

    If you could please advise me on where I can find a physician to help me implement this plan, I would be so very grateful. I need to do this ASAP to stop the cancer while it’s still contained.

    Thank you for your time.

    Sincerely,
    Arthur Helbig
    arthelbig@gmail.com
    (USA)443-878-3642

  7. Allan B. Greene

    12-14-2017: Dear Dr. Garnick: I am a 71-year-old man and I am currently under treatment for prostate cancer with a urologist. I’ve undergone a cystoscopy, flow tests, a biopsy, PSA tests which pretty consistently showed a high PSA (18 in one case, 18.6 in a second, 14 in another). My physician prescribed a bone scan, which I also underwent. So far, there’s no evidence of metastasis of my prostate carcinoma, my tumor. Last Thursday, 12-07-2017, I underwent a bone scan to check if there was bony metastasis and there was none. My physician said, after the completion of the bone scan, I should go on bicalutamide (I can’t afford the brand name, Casodex, so had to go on the generic I got prescribed for me and got filled at a Walmart pharmacy). I started on bicalutamide 50 mg. once per day after my bone scan on 12-07-2017. On Tuesday, 12-12-2017, I went to my physician, and after he and I talked and he knew I’d been on the bicalutamide 6 days, he said, we’ll take a PSA. A PSA was taken. Today, I was phoned and told my PSA was up, 20.4. But I was told to continue it and on this coming Monday, 12-18-2017, I’m to get a shot of Lupron. I was told there should be dramatic improvements in my PSA after the Lupron. The person who phoned me back today from my physician’s office was one of his nurses. I’m wondering if I should lay off the bicalutamide and just wait for the Lupron shot. They’d said not to, but I’m not sure. I’d been told by him when he told me to get the PSA this past Tuesday, 12-12-2017, that my PSA “would” go down. I said, what if it doesn’t. He said, it would. But, of course, it has not. It went up. I’m trying to reach them back to see if I should stop the bicalutamide, for the nurse who phoned me from his office said, no, stay on it, and it would eventually work. She also said that the shot of the Lupron I’m going to get Monday would result in a big improvement, as I earlier indicated. My doctor had also thought taking the bicalutamide plus getting the shot would be a double whammy against my cancer. But my impression is that if bicalutamide in some circumstances can actually make cancer cells divide more, making the cancer grow, rather than having the opposite effect, perhaps I should stop the bicalutamide till I get the Lupron shot. I realize I’m not under your care, but was wondering your thoughts on this matter. Thank you for any advice you might give me. Best wishes, Allan B. Greene

  8. Alan K

    Age: 75
    Risk Group: T2c
    PSA: 8 at start of therapy
    Gleason distribution of 12 cores: 7 had cancer, both lobes, no lumps, normal size prostate. ( 4 were 6, 3 were 7 -(4+3))
    Treatment: ADT + Seeds + EBRT
    Started Treatment 01/08/2017
    Completed Treatment: 06/24/2017
    Follow Up tests: 08/09/2017- Results- Excellent

    When my Urologist and Oncologist suggested ADT during my PCa treatment I opted for the fewest months known to provide the best results. The problem was that very few research studies could confirm which length of time was the most favorable. Newer study results hinted that 4 months was all that was needed, but the data was too new to be definitive, so I opted for 6 months. My treatment is completed, Undetectable, Testosterone is below normal. Side effects of the Firmagon are still with me, 2 months after it was “expired”. I also had minor radiation proctitus resulting in occassional diarhea and constipation and urgency of bowel movements. I had NO urinary problems and I never missed a day of work, nor had any loss of energy. My libido is returning, but the ability to maintain an erection is limited. I would strongly recommend the SHORTER 4 months of ADT. All the recent data in 2017 points to a shorter time providing the same results for those on EBRT or Seeds.

    Based on my success with this approach, I would recommend ADT with radiation.

  9. Tiffany formally Tim

    44 year old male diagnosed with prostate cancer in 2014. Gleason scale 9+, PSA 77. Given Lupron shots every 3 months for 3 years along with daily Casodex. Radiation treatment = 44 high beam intensity.
    Cancer as of 5/2017 = NED (No evidence of Disease).
    Unfortunately, the testosterone block has feminized me to the point that I have very little body and facial hair, lost all “male” muscle tone and my testicles shrank to nothing. My personality has become non aggressive (submissive), my voice is noticeably higher and I no longer even remotely think about sex as a man. It was like a switch was thrown. I’ve grown breasts to the point that I wear a C cup bra and wear woman’s clothes due to my hips, butt and boobs. My skin is soft and I easily pass for a woman now that my hair has grown out. I actually look much younger than my wife.
    The memory loss and hot flashes caused me to no longer be able to capably run my business. In fact, I was forced to trade places with my wife, who took over as the Director. I’m now an executive assistant (Secretary), as I struggle to remember things like I used to. Again, it’s like a switch went off. Bottom line is I’m now a bimbo who no longer even remotely resembles my wife’s husband of 18 years. But I’m Cancer free.
    The Doctors have indicated that this is an extremely rare and isolated case but attempting to live as a male was becoming increasingly difficult. Counselling and therapy have addressed the depression associated with my changes as well as helped my wife and I deal with the adjustment to both my lifestyle and our relationship. On our recent anniversary, my wife gave me a diamond engagement ring (identical to hers), that I wear now with my wedding band. It has helped alleviate uncomfortable situations with men.
    With the hormone blocks expecting to end in August, I have some decisions to make. I am no where near the same person I was both mentally, physically and emotionally, who took that first testosterone block shot and pill almost three short years ago.

  10. Jim

    Men beware!

    Read the sad truth about prostate cancer testing and treatment.
    Prostate cancer lies, exaggerations, deception and elder abuse.
    A prostate cancer survival guide by a patient and victim.
    Men, avoid the over diagnosis and unnecessary treatment of prostate cancer.
    Read about prostate cancer patient exploitation, testing and treatment dangers.

    If you don’t want to read this entire document, just read the bold print. One day your life or your quality of life may depend on it.

    Revised April 26, 2017

    In my opinion:
    Read the hard facts about prostate cancer testing and treatment that no one will tell you about, even after it’s too late. This is information all men over 50 should have. Also, anyone concerned about cancer in general, clinical trials, medical mistakes, exploitation, elder abuse, HIPAA laws or privacy issues should read this document. Prostate cancer patients are often elderly, over treated, misinformed and often exploited for profits by predatory doctors. The testing, treatment and well documented excessive over treatment for profit of prostate cancer often results in devastating and unnecessary side effects and sometimes death. At times profit vs. QOL (quality of life).

    Per some studies:
    1. Studies have verified more deaths caused from prostate cancer testing and treatment then from prostate cancer itself.
    2. Extensively documented unnecessary testing and treatment of prostate cancer for profit or poor judgment by some doctors in the USA.
    3. Medical mistakes are the third cause of deaths in the USA (over 251,000 deaths a year, over one million deaths in 4 years) more then suicide, firearms and motor vehicle accidents combined.
    4. 1 man in 6 will be diagnosed with prostate cancer in his life.
    5. About 233,000 new cases per year of prostate cancer.
    6. About 1 million dangers prostate blind biopsy’s performed per year in the USA.
    7. 6.9% hospitalization within 30 days from a biopsy complication.
    8. About 1.3 to 3.5 deaths per 1,000 from prostate blind biopsies.
    9. .2% to 1.2% deaths as a result of prostate cancer surgery.
    10. 60% had a prescription filled for an infection after a Biopsy.
    11. Black men are at an increased risk of prostate cancer.
    12. Prostate cancer patients are at an increased risk for fatigue, depression, suicide and heart attacks.
    13. Depression in prostate cancer patients is about 27% at 5 years, for advanced prostate cancer patient’s depression is even higher.

    Excuse the generally accurate humor and sarcasm. Its intent is to entertain and educate while reading this possibly laborious text.

    Prostate cancer patients are often elderly and exploited for profit, the treatments offered has horrible side effects, and newer treatment options are either unavailable or not offered to patients or available outside the USA. Prostate cancer is often slow growing and of low risk and can just be monitored. Often no treatment is the best treatment. Over testing and treatment has been verified by numerous experts, studies and investigations, documentation, etc.

    The medical field is now alluding to the fact that prostate cancer testing and treatment may be do more harm then good. The U.S. Advisory Panel is now recommending for prostate cancer PSA testing and screening: “letting men decide for themselves after talking with their doctors”. However this may not protect men from predatory doctors exploiting them. This may only shift the accountability to the victims, patients are not doctors. Patients usually follow a doctor’s recommendation. Do you think any regulatory agency will stop the exploitation of elderly men with a high PSA or prostate cancer or approve new treatments at the risk of financially bankrupting thousands of treatment facilities and jeopardizing thousands more jobs? Do you think any regulatory agency will set guidelines for testing and treatment at the risk of upsetting the doctors who are over treating?

    If a surgeon is financially responsible for a building lease, a large staff or an oncologist is also responsible for a lease on multimillions of dollars in radiation treatment equipment, do you think they would be more or less honest about the benefits and hazards of treatment? Do you think the profit margin would compromise some doctor’s ethics? Typically, what is the purpose in over testing and treating a cancer that often will not spread and the testing and treatment frequently causes lower QOL (quality of life), ED, incontinence, depression, fatigue, suicide, etc if it was not extremely profitable.

    A 12, 18 or 24 core blind biopsy, holey prostate! Prostate blind biopsies are dangerous. Men with a high PSA tests result are often sent to an urologist for a blind biopsy. Men should be told about other options: Percent free PSA test, 4Kscore test, PCA3 urine test or a MRI test before receiving a blind biopsy. These tests can often or always eliminate the need for a more risky and invasive blind biopsy. Insertion of 12, 18 or 24 large holes (most of the time) through the rectum into a gland the size of a walnut, a blind Biopsy can result in (per studies) prostate infections, a risk of permanent or temporary erectile dysfunction, urinary problems, hospitalization from infections and sometimes even death from sepsis (About 1.3 to 3.5 deaths per 1,000 from blind biopsies). There is also controversy that a biopsy may or may not spread cancer because of needle tracking. A blind biopsy can also increase PSA reading for several weeks or months, further frightening men into an unnecessary treatment. Blind biopsies are almost never performed on other organs. One very prestigious hospital biopsy information states “Notice that your semen has a red or rust-colored tint caused by a small amount of blood in your semen”. Another large prestigious hospital states “Blood, either red or reddish brown, may also be in your ejaculate.” These statements are often an extreme exaggeration (mostly lies). Very often after a biopsy a man’s semen will turn into a jet black goo. This could be an unpleasant surprise for a man and especially for his unsuspecting partner. However if a biopsy is performed before Halloween or April Fools’ day this may be of some benefit to a few patients. If some very prestigious hospitals are not factual about the color of semen, what other information is not being disclosed or misrepresented?

    Bone scan scam: Prostate cancer patients are often sent for a bone scan. A bone scan has about a 13% chance of having a false positive and only 3 men in 1,000 have bone cancer who have a bone scan. Bone scans may often be unnecessary in lower risk prostate cancer patients.

    Low risk cancer patients or patients with advanced age are often sent for aggressive treatment by some doctors when monitoring is usually a better option. An extreme example of overtreatment is one SBRT radiation clinical trial. Prostate cancer patients (victims) where intentionally treaded (fried) with a huge dose (50Gy total, 5 fractions) of radiation resulting in disastrous long term side effect for some of these men. A large percentage of prostate cancer patients in this clinical trial had low risk prostate cancer and may have not required any treatment at all.

    Clinical trials may or may not be hazardous to patients. The goal of a clinical trial is to gather information; the intent is not necessarily to help or cure patients. In a clinical trial, if someone is given a treatment that will harm them (as in the above example) or given a placebo in place of treatment or needed treatment is withheld, the patient may be deceived or harmed. Investigate before you participate in any clinical trial. Often drug company’s get your information from medical databases and pharmacy information to lure people into clinical trials, soliciting people with letters and postcards in the mail. This is often a HIPAA violation. If you call about a clinical trial your phone conversation will probably be recorded “for quality purposes” including your medical and personal information. You will not be told if you are getting a drug or a placebo.

    Your privacy and confidentiality may be just an illusion: You may have little privacy and confidentiality! Under the HIPAA law all access to your records is allegedly by a “Need to know” basis only, this is another exaggeration. Prostate cancer patients are asked to fill out a series of EPIC questionnaires and other standard questioners. The EPIC questionnaire asks several intimate details about patient’s sex life, urinary and bowl function. By a prostate cancer patient completing an EPIC questionnaire may be able to assist his doctor, nurse, office workers or database track his progress or decline. By refusing to fill out these questioners and supplying other unnecessary information one can help insure his privacy, dignity and insure he do not unknowingly become part of a study or clinical trial or other collective survey or have his information forwarded to multiple databases. He may be told these questioners and records are “strictly confidential” (as stated in some EPIC questionnaires); this statement is misleading. Most of the time a patient has no idea who has access to medical records or why the records are being looked at. Who has access to your medical records? Probably everyone that works in a medical office or building has access to the records, except you (often you the patient may have limited or no access). Access may include/however not limited to non-medical employees, office workers, bookkeepers, janitors, insurance companies, temporary high school or college interns, volunteers, etc. This may also include other medical facilities, programmers, hackers, researchers, etc. Very often records are placed on a Health Information Exchange (HIE) or server, dozens, sometimes even hundreds or thousands of people may have access to medical records. Some major databases like SEER are linked to Medicare records to determine “the final outcome” for researchers, studies, drug companies-often for clinical trials offers, etc. SEER is an appropriate name for this database! Your drug prescription history can also be tracked by insurance companies and others. Records may be packaged with others and offered for sale, this does often happen. Your medical records can be downloaded to multiple servers all over the world to countries that do not have any regulations for privacy. If a doctor, patient or insurance company is involved in a criminal or civil case, medical records may become public court or law enforcement records. Your records can be acquired by insurance companies if you apply for disability. If a patient has radiotherapy he may have a photo taken before treatment to verify identity. All patients should get a copy and read any confidentiality disclosures statements (HIPAA statements). Patients can also become the victims of financial or medical Identity theft. Under the HIPAA laws you are entitled to a copy of all your medical records, however if you try to obtain a copy of extensive records as in a hospital stay you may be met with resistance. I recently went to a new optometrist for glasses and I was given a form that asked details about my heritage, including my mother’s maiden name and a form for my complete medical history. Your records can also be accessed by anyone (trainees, volunteers, students, interns, minors and adolescent people as young as 16 years of age, etc) “for training purposes” or any other reason, all without your consent. This gives kids a chance to play doctor and nurse in a real doctor’s office with real patients. A list of what a high school intern is allowed to do to patients: “learning simple medical procedures, watching surgeries, shadowing doctors (including seeing patients, possibly you), working in hospitals, interacting with patients, and more.” They can also read all records about your prostate problems, your wife’s hemorrhoids and your daughters yeast infections or any files for any patient, all within the HIPAA guidelines. These people do not have to be employed by the facility or have a background check. My family doctors office has summer time high school interns with full access to all records. One high school intern signed me in, took my temperature, weight, blood pressure and logged it in my chart. Would you like to have a high school or college student that possibly lives in your neighborhood or attends school with your children read over your extensive family member’s medical records and personal information? How much curiosity or self control does a high school or college student have? I also went to a hearing aid center in a department store to get a free hearing test and was given forms inquiring about personal information and my complete medical history. This is information I do not want filed in a department store. All patients should avoid supplying unnecessary information whenever possible. Supply relevant information only when filling out forms. In the USA identity theft is very common, growing problem and is often financial devastating. Medical forms can be a good source of information for thieves. Recently my friend with arthritis in her hips received a letter offering a clinical trial for a new medication; coincidently looking for patients with hip and knee arthritis. How did this company determine she and not her husband or other family member was a prime candidate for this new drug study without violating any HIPAA privacy laws? Numerous exceptions (loopholes) appear within the HIPAA laws regarding you privacy. Even without HIPAA privacy law violations, records can be accessed by multiple people and appear in multiple databases. Sometimes medical phone calls are recorded “for quality purposes”. Calls about a clinical trial, calls to a large clinic toll free number and calls to insurance companies may be recorded. These conversations can include confidential or medical information. Some of the Obamacare goals sought after everyone’s medical records on servers so they could be accessed by any medical facility or doctor. HIPAA laws are deficient and often will not protect your privacy. Your privacy and confidentiality is not that secure. I believe the medical field has little regard for our privacy, especially if it is in conflict with training, research, studies, profit or other objectives. If you’re a public figure, celebrity, rich or famous you may be subject to numerous people wanting to see your medical records. Also if you are known to or an acquaintance of anyone with access to your records (neighbor, co-workers spouse, etc) they would possibly want to get a look at your medical records. You are naive if you believe otherwise or that your records are secure. The same also applies to pharmacy workers and your prescriptions.

    A patient’s dignity: Prostate cancer testing and treatment is often degrading and demoralizing. EPIC questionnaires can be counterproductive impact a patient’s dignity, privacy, confidentiality, and self image. EPIC questionnaires probably have an increased potential and greater impact on patients for privacy violations because of its format, nature and personal content (potential for HIPAA privacy law violations). Patients may mistakenly believe the EPIC questionnaire is a requirement to be filled out. Also the term “strictly confidential” can be misleading and ambiguous. One blogger patient posted he filled out and turned in his “strictly confidential” EPIC questioners only to have every female office staff member read it and ogle him. Resulting in him not filling out any more EPIC forms or any other forms and he stated that he became very uncomfortable and evasive with the entire office staff. The drawbacks of this form seem to outweigh any potential benefit for some patients. Medical tests and procedures can be degrading and embarrassing for both men and women. Many women prefer or will only see female doctors or gynecologists, about 50% to 70%. Over half of men prefer a male doctor. (Per some respected doctors: Men stay away from medical care in large numbers because of privacy and dignity. Many men still avoid medical care because of embarrassment. Honest answers will often not be given if asked by a female doctor or nurse.) What percent of old men will feel comfortable consulting a female doctor, nurse or office worker about his prostate problems, ED, etc or would want an invasive test or procedure performed by a female?

    The most common treatment options for men with prostate cancer are radiation, Brachytherapy, surgery, cryotherapy and hormones (ADT). Sometimes chemotherapy, immunotherapy and castration (orchiectomy) are used. A combination of treatments is often used. Most or all of these treatments have long term or short term side effects. Often men are not told about all of the true risks and side effects or they are downplayed for both a blind biopsy and treatments.

    LDR Brachytherapy is permanent radioactive seed implant. This treatment procedure implants about 50 to 100 radioactive seeds in the prostate, sometimes resulting in urinary problems. The patient will literally become radioactive for months and up to 2 years. The patient may set off radiation alarm and also possibly metal detectors at airports. He will also be required to use a condom, have no close contact with pregnant women, infants, children and young animals or pets for months or longer. Occasionally he may even eject radioactive seeds during sexual activity or urination. The patient will become like a walking Chernobyl, having radioactive scrap metal and emit radiation from his crotch. He will also be required to carry a card in his wallet stating he is radioactive. The videos of this procedure seem to be disturbing and bizarre. A catheter will also be required for a short time. However allegedly LDR Brachytherapy seems to have less sexual side effects than some of the other treatments available.

    Men are sometimes prescribed hormone therapy (ADT therapy), AKA chemical castration as an additional or only treatment. Hormone (ADT) therapy is sometimes over prescribed for profit, per some studies. Hormone therapy is often very expensive (may be profitable for doctors if provided at the doctors office and not a pharmacy) and can have horrible, strange and devastating side effects, feminization, fatigue, weight gain, depression, etc. His penis could shrink and his testicles can completely disappear, he may grow breasts. This treatment can have so many mind and body altering side effects that doctors will often not inform patients about all of them. Men are sometimes castrated (orchiectomy) as a cancer treatment to reduce testosterone. Studies (Medicare and financial) have documented doctors do over prescribe ADT therapy for profit (depending on Insurance payout rates/profit margin). When insurance payment reimbursement for ADT decreased so did the number of patients being prescribed ADT therapy! Per Wikipedia: “in patients with localized prostate cancer, confined to the prostate, ADT has demonstrated no survival advantage, and significant harm, such as impotence, diabetes and bone loss. Even so, 80% of American doctors provide ADT to patients with localized prostate cancer.” Overtreatment with ADT is extremely profitable, unfortunate and avoidable.

    Nerve sparing Robotic-assisted DaVinci surgery is touted as being a better treatment and having fewer side effects, this is usually an exaggeration. The nerves can not always be spared. Robotic surgery can result in a faster initial recovery. Long term risk of incontinence, fatigue, ED, etc is about the same as conventional surgery. Patients undergoing surgery are at a very small risk of developing post traumatic stress disorder (PTSD) and about a 25% chance of long term or permanent fatigue. Also .2% to 1.2% risk of deaths as a result of prostate cancer surgery or medical mistakes. Patients can have unrealistic expectations about the results and regret the surgery treatment option. The ED rates and other side effects are often understated to patients.

    Patients should not be naive: Medical mistakes are the third cause of deaths in the USA (over one million deaths in 4 years). Medical mistakes cause more deaths then suicide, firearms and motor vehicle accidents combined. Countless other patients have been harmed by medical mistakes. If you are having surgery, brachytherapy, a biopsy or a procedure take precautions if possible. Have someone qualified or knowledgeable monitor you and your medications, etc. Doctors, nurses and technicians can be profit motivated, use obsolete procedures, be lazy, incompetent, make mistakes and be apathetic or rushed. Occasionally harm can be done or not prevented with intent. Drug abuse is often a problem with some medical workers because of easy access. Doctor’s offices and clinics can see many patients in a relatively short amount of time. This may be a disadvantage to patients, empathy and quality of care can sometimes be compromised. Sometimes a nurse, medical assistant or an office staff member may be the person that overseeing much of a patient’s cares. I personally know of at least 5 medical staff that I would consider incompetent, abusive, mentally disturbed or drug abusers that work in doctors offices and hospitals and I now understand why medical mistakes are the third leading cause of deaths in the USA. TV and sometimes the public seem to idolizes doctors, nurses and caregivers, however health care workers seem to have the same amount of abusive or incompetent workers as other occupations. I have also had excellent doctors and nurses. however this may not protect you from the bad ones. What are the main reasons nurses get fired: 1. Prescription drug abuse (because of easy access to drugs). 2. Too many mistakes. 3. Code of conduct and privacy violations. 3. Bad attitude. 4. No proper licenses 5. Abuse of patients. Patients should be aware that sometimes QOL (quality of life) may be secondary or an absent goal in treatment. Sometimes overtreatment for profit or to prevent an unlikely death or metastization from low risk cancer may be the primary or the only goals of cancer treatment.

    A blind biopsy or treatments are often worse then the disease: Resulting in Chronic/permanent fatigue, incontinence, depression, sexual dysfunction and sometimes death. Hormone therapy may have an extensive list of side effects that can be devastating for men. Biopsies and treatment are degrading, stressful and often unnecessary. Many men may not be prepared or have unrealistic expectations about the outcome, physical and psychological impact of testing and treatment.

    The risk of long term chronic and permanent fatigue (that can result in depression) is almost always understated if mentioned at all to many patients. Per some studies and depending on your treatment; the risk of long term or permanent fatigue is about 25% to 60%. Radiation with Hormone therapy has a high risk of fatigue. Long term fatigue also increases the risk of clinical depression and suicide.

    The prostate may have unknown or undocumented functions. The removal or destruction of the prostate often results in chronic fatigue, loss of libido and depression that often can not be accounted for.

    In my opinion: Castration, ADT hormone therapy (chemical castration), LDR Brachytherapy (radiation seed implant), radiotherapy, surgery and blind biopsies are often psychically and emotionally brutal, traumatic and disturbing. These types of treatments are primitive and almost beyond belief in today’s world of advanced technology. Newer treatments like, HIFU, hyperthermia, Boron Neutron capture therapy, focal Ablation (only treating the cancer and not the entire prostate) and orphan drugs should be approved and used when appropriate. Biopsies should be limited to selective MRI guided samples only; blind biopsies should seldom or never be performed.

    Approved advances in prostate cancer treatment mostly consisting of newer more accurate radiation treatments, robotic surgery and new drugs. These advances sound like greater strides have been made. However most of these approved advances are of limited benefit to prostate cancer patients and still have about the same amount of long term side effects. Compared to other technologies, computers, communications, electronics, aviation, etc, cancer treatment approved advances have been dismal. QOL (quality of life) issues have not been adequately addressed. Profit sometimes outweighs QOL.

    Prostate Radiotherapy (EBRT-external beam radiation therapy) for cancer treatment. New technology consists of: IMRT, SBRT, IGRT, VMAT, TrueBeam, Cyberknife, etc. This newer, faster, more accurate and easer to setup radiation equipment is of much benefit for doctors, staff and a good selling point to patient’s. However as far as reducing long term side effects, only small gains have been made with the newer radiotherapy equipment. A patient should be skeptical if exaggerated claims are made about reduced long term side effects, especially fatigue and ED rates. About 25% of radiotherapy patients can expect an alarming temporary “bounce” (spike) in the PSA value after treatment. Patients should inquire as to the treatment plan: Gy dose and fractions, margins, testicular dose, constraints and age of radiotherapy equipment to insure excessive radiation exposure treatment is not given that can result in additional side effects. Patients should be aware that pelvic shaving, permanent tattoo markers, fiducial marker (small seeds) are sometimes placed in the prostate, MRI, CT scan, photographs, catheters and other procedures may or may not a be required. Radiotherapy can also occasionally result in secondary cancers and damage to “organs at risk” (organs close to the prostate). Radiation has high probability of sexual dysfunction and fatigue. ED rates estimated at 35% to 75% or higher, 93% at 15 years. Sometimes radiation can also cause bowel and urinary problems. A 5 day SBRT radiation treatment is now commonly available with about the same results and side effects as a 9 week radiation treatment. A doctor with a multimillion dollar lease and maintenance agreement on radiotherapy, CT scan and MRI equipment and a large staff may or may not be influenced by his or her financial obligations when deciding to recommend over testing and treatment.

    Often prostate radiotherapy (EBRT) can result in a 5% to 30% temporary or permanent drop in testosterone levels, excluding hormone therapy. This drop is determined by the testicular radiation dose (treatment equipment and planning). A below normal drop in testosterone can result in increased fatigue, depression, sexual dysfunction and other symptoms.

    It seems all of the best treatments for prostate cancer have not been approved and most are only available outside the USA. Treatment options outside the country or under development are HIFU, Laser, Hyperthermia, Boron Neutron capture therapy and orphan drugs, just to name some. Focal Laser Ablation is a good option with fewer side effects however it is not widely available in the USA and sometimes not practical.

    Any cancer patient (man or woman) who are being offered chemotherapy should be particularly cautious. Chemotherapy can be extremely toxic and sometimes deadly. Without genomic testing or proof of the effectiveness of the specific drug being used on the exact cancer type being treated, chemotherapy can often be more toxic to the patient then to the cancer. Chemotherapy may be extremely expensive, profitable for some doctors (if dispensed by the doctor and not by a third party) and can be misused or overused, sometimes for profit. A doctor may purchase a quantity of chemo drugs for $10,000 and charge a patient (insurance) $20,000. What is the motive for some doctors to perform Genomic testing and giving a patient a different and more effective treatment at an unknown profit versus a guaranteed $10,000 profit with a probable worthless and harmful treatment? This is a well documented and common practice.

    When a doctor, rich, famous or influential person becomes ill often the testing and treatment are more thorough, advanced and beneficial. If you are an average or uninformed patient you may be a prime candidate for predatory doctor offering prostate cancer testing and treatment.

    Often few good choices often exist for treatment. A prostate cancer patient treatment choice often ends up being the least worst choice or the choice with the side effects a patient thinks he can tolerate. Patients can sometimes be mislead about the expected side effects and results of the treatment being offered. The risk of chronic fatigue and depression is often never disclosed.

    Long term care consists of regular PSA testing for years. Long term care for side effects is often lacking or exploitive or ineffective. Often complaints of side effects are disregarded by nurses, doctors and sometimes referred out to other doctors. The patient is sometimes left to figure out what to do about his side effects with the resources available to him. Long term side effects often consist of fatigue, bowel or urinary problems, sexual dysfunction, depression and other symptoms. Patients with complaints of chronic fatigue are often told to exercise, get plenty of sleep, pace yours self and eat a healthy diet; this advice is of limited help for chronic fatigue. Often treatments for long term side effects are embarrassing, degrading, unavailable, nonexistent, costly, not effective, not offered or bothersome. Prostate cancer treatment often results in fatigue, depression, isolation and sometimes suicide. Billions of dollars are profited from ED drug and other ED products, catheters, pads and diapers, drugs for depression or pain or insomnia or incontinence, additional treatments and surgeries for side effects. Also treatments for the multiple and bizarre side effects from hormone ADT therapy (chemical castration) is sometimes required.

    Men, ageing and elder abuse: If any man lives long enough it is very likely he will have a prostate problem, low testosterones or some form of sexual dysfunction. In my opinion modern medicine often has been exploitive, abusive and has provided substandard care for older men in general due to all of the explanation given in this text. I believe much of the attitudes toward older Americans need improvement and they are sometimes viewed as being subhuman and exploitable by various groups and individuals. If documented cases of unnecessary surgery and radiotherapy or blind biopsies on children by doctors for profit were released, the vast majority of Americans would be outraged and this practice would quickly end. However for older men it dose not seems to be of great concern! As defined by some or all state laws, exploitation of elderly men by overprescribing treatment for profit is a crime or an offence of various guidelines and regulations. It is extremely unlikely any doctor will ever be prosecuted or have a medical license suspended for this common and extensively documented abuse or crime. One patient after recovering from a brain injury testified that he was repeatedly abused, slapped and hit, forced to drink boiling hot tea by multiple caregivers and sexually assaulted by one female caregiver. It is well documented that all forms abuse do occur to the aged and disabled in nursing homes and other facilities including, neglect, theft, starvation, torture, harassment, sexual assault, etc. I personally know of an elderly lady that is living in an expensive assisted living home that has had all of her possessions (radio, clothes, underwear, shoes) stolen and replaced by her family several times including the sheets off of her bed, even after the sheets where marked with her name using a larger permanent marker pen.

    Depression in prostate cancer patients is common, about 27% at 5 years (per some studies) and for advanced prostate cancer patient’s depression is even higher. Prostate cancer patients are at an increased risk of suicide.

    Almost all prostate cancer treatments usually result a high percentage of erectile dysfunction. Loss of libido estimated at about 45%. Excluding hormone therapy, lower libido is almost never disclosed as a treatment side effect and sometimes it is completely denied as a problem. Blind biopsies can sometimes or often cause temporary or permanent ED. Often claims of prompt effective treatment for ED or other side effects if they occur after treatment are often misleading. Statistics for ED percentages from treatment are usually quoted after treatment with Viagra, Muse or other ED treatments, therefore most statistics are very misleading. ED rated at 5 years may be as high as 50% to 80% or higher for most treatments. ED rated at 15 years may be as high as 90% or higher for most treatments. For cryotherapy, ED rates are extremely high. The cost for ED drugs like Levitra, Cialis, Viagra and Muse are deliberately kept very expensive by drug companies, about $10 to $45 per 1 pill. At these prices Lilly could consider including the bathtubs featured in its advertisements for Cialis. The cost of a 30 day supply of Cialis is usually well over $300 and the cost of an inexpensive bathtub is about $200. Many insurance companies will not pay for ED drugs or treatment. The patent for Viagra should have already expired in the USA. Less expensive generic drugs are usually unavailable in the US. Viagra should have already become available in a generic (in the USA) form for about $1 to $2 a pill. This is further exploitation by the drug companies of men in general. Men are also exploited by counterfeit mail order ED drug sales. ED drugs are not always effective and may have side effects. ED treatments can also be embarrassing, not offered, not practical, painful, expensive/not covered by insurance. Men will often not seek treatment because or these reasons.

    The numbers game (more exaggerations)-: A doctor (and literature) may state patients chances of ED is about 35% with EBRT radiotherapy (or some other treatment). A patient may think, 35% is not too bad and if I do get ED I can always take Viagra. What a doctor may not tell a patient is that the ED rate is 35% at 2 years for a patient under 65 years old and with an ED drug treatment option. For a patient at 3 years, over 65 and no ED drugs the ED rate may be about 75% or higher, after age 70 your chances of ED is about 85%. Obviously, a man is more likely to refuse treatment at a 75% ED rate verses a 35% ED rate. Some side effects may not be disclosed at all. If side effects (low libido, chronic fatigue, depression, increased suicide risk, etc) are not disclosed, no percentages will usually need to be quoted. Results are often worse for a surgery option, the main difference in ED results between surgery and radiotherapy is; with surgery ED will start out bad and may or may not get better with time, however with radiotherapy ED will get worse over time. With both treatments together or with ADT hormones also you’re in real trouble with ED percentages. Cure rates are often quoted at the 5 years mark for most treatments. 5 years is not a magic number, you can have a treatment failure before or after 5 years. A cure rate for a treatment at 5 years may be quoted at 85%; however the cure rate at 7 to 10 years may be only 70% and 50%. Always ask what is the “biochemical recurrence” (AKA rising PSA or treatment failure) rate for well beyond 5 years with your computer software simulation. Ask your urologist or radiation oncologist for a 10-year cure Rate. If the physician is unable to provide one, consider finding another doctor. Studies and clinical trials results, side effects percentage claims, etc can be biased. Watch out for terms like “age adjusted” or ambiguous or excluded facts as given in the above examples. I have read and have been given some extremely exaggerated claims (mostly lies) concerning cure rated, side effects, etc.

    In conclusion: Prostate cancer patients are sometimes elderly and exploited for profit (per documented studies). A blind biopsy is unsafe and newer test methods should be used. The treatments offered have horrible side effects. Some doctors are treating patients with low risk cancer or advanced age when monitoring is often a better option. Patience with low risk cancer or advanced age should often be offered “watchful waiting” or “active surveillance” instead of treatment. Aftercare for long term side effects is frequently ineffective, expensive, not offered, degrading or nonexistent. Prostate cancer patients are seldom told about chronic fatigue and the true risk of side effects are usually understated. Modern medicine often fails and victimizes prostate cancer patients.

    If a patient has intermediate or high risk prostate cancer and dose not have advanced age he may need treatment. He should have genomic testing and look into other advanced treatments if available and genomic testing. Also he should try and avoid hormone therapy if possible because of the multiple side effects especially if the cancer is organ confined. If laser or other advanced treatments are not available a 5 day SBRT radiation treatment may be considered (In my opinion, it could be the best of the bad choices). SBRT seems to be fast, least invasive or traumatic. ED and fatigue is still a high long term risk. Radiation with hormone therapy has a higher risk of ED and long term fatigue. However, I now believe often prostate cancer testing and treatment could be a mistake in most men.

    The short version of my story: I was referred to an urologist by my family doctor after a high PSA test. I will refer to the urologist as Doctor “A”; he used old testing technology (18 core blind biopsies), his nurse seemed to have a mental defect exhibiting arrogant, rude, strange and abusive behavior and was intent on inflicting psychological harm to me. Shortly after my Dr. “A” visits ended, his nurse was no longer employed at his office and no person in that office would refer to her employment or her existence. I now believe this nurse was high because of drug abuse being common among nurses (the easy access to drugs). I was diagnosed with prostate cancer by Dr. “A”. I refused his surgery and hormone therapy recommendation because of the eminent side effects and his unprofessional nurse behavior, so Dr. “A” referred me to Dr. “T”. Dr. “T” was outside of my insurance network; however his office manager stated she was willing to work with my insurance, offered me a doctor consultation and would accept any insurance payment as a full payment. When I arrived in his office the waiting room was empty. He also had a large staff. Dr. “T” used older conventional technology, offered me overtreatment, hormone therapy, unnecessary procedures and testes. One week after my consultation with Dr. “T” I received an $850 bill for the consultation, in conflict with what was agreed upon with his office manager. After a recommendation from a friend, I called Clinic “O” and met with the nurse. She offered me conventional treatments with a verbal guarantee of “no long term side effects”. However this nurse could not answer any of my basic questions, lacked any credibility and sounded like a used car salesmen. Most of these office visits caused me multiple problems with offices workers processing paperwork for tests, insurance forms and billing, etc. Two of these doctors offered me an unnecessary bone scan. Two of these doctors recommended unnecessary hormone therapy (ADT Therapy) for my organ confined cancer. After I absolutely and utterly refused hormone therapy, both doctors admitted it probably would not help me in my final outcome because of the computer estimate run on me with my PSA, biopsy report, etc. Having no advance treatments (laser, etc) available to me at that time, I decided on SBRT treatment with Dr. “K”, he could answer my questions and had new equipment. Before my treatment could start I was referred to “W” lab for an MRI. “W” lab had a trainee assisting and it took over 2 hours to complete my MRI. 2 days later after receiving a copy of my MRI report, I examined the MRI report; it had my name and some other patient history information. I wasted 2 more days verifying it was the correct MRI of me and not some other prostate patient MRI before my treatment could start. I did receive treatment from Dr. “K”. I did have a relatively fast and completely noninvasive treatment (SBRT), resulting in months of fatigue, a large PSA bounce 18 mothers later and some other short term side effects. At this time I am doing okay, however I’m not sure what the future will bring? I also no longer trust modern medicine, doctors, nurses, etc. Modern medicine seems to be more of a gamble then a science. I have wasted hundreds of hours and thousands of dollars. I feel modern medicine has abused and failed me due to the lack of guidelines and regulation, still approved obsolete technology, better unapproved treatments, exploitation, greed, apathy and incompetence. Hindsight is 20/20. I was never offered Genomic testing. I also believe I should have had no PSA testing or treatment. If I could do it over again, I would also consider no PSA testing and treatment or traveling for advanced treatments from a competent provider if practical and available. I believe if I did take the two doctors recommendations and received unnecessary hormone therapy in addition to the radiotherapy my quality of life (QOL) would have been severely impacted for years or permanently and could possibly have resulting in my early death. I did seem to have a lot of bad luck in picking providers or is this just the new standard in medical care?

    “Do no harm”, unless you can make a lot of money and get away with it: I was harmed physically and verbally by Dr. “A” 18 core blind biopsy and verbally abused by his nurse. I was potentially exploited and financially harmed ($850) by Dr. “T” and offered unnecessary testing and overtreatment. Clinic “O” nurse attempted to misinform and deceive me about the treatment outcome of “no long term side effects”. I was harmed by “W” lab by mistakes and incompetence. I did also have numerous other billing and paperwork problems probably due to mistakes and apathy. A few of the office staff were incapable of completing some very simple tasks like filling out lab work request or insurance forms. At least 40% (probably substantially more, 40% to 60%) of the health care workers I came into contact with did or attempted to do some form of harm to me or provide substandard care: attempted excessive testing and treatment, mistakes, billing overcharges, blind biopsy, false statements, deception, misinformation, apathy and abusive behavior¬¬¬, as explained in this text. I have also observed several medical facilities do not require workers to wear name tags and when asked for a name most will give a first name only; this may also be a factor in health care workers not acting in an ethical manner. It seems that this prostate cancer nightmare maze was intended for maximum physical, psychological, financial harm and to be of questionable benefit. My prostate cancer experience has been one of the worst events that has happened to me in my lifetime and I specifically blame modern medicine for not protecting patients from predatory doctors, substandard technology and a lack of regulations that would protect patients.

    My treatment choice: In my opinion, I feel LDR Brachytherapy and hormone therapy (AKA chemical castration) seemed to be completely degrading, disturbing and bizarre. Hormone therapy would not have been an effective treatment for me. Surgery and Brachytherapy are to invasive. Surgery has an imminent danger of incontinence and ED. A 9 week EBRT radiotherapy was just to long and laborious. Because castration (orchiectomy), ADT hormone therapy (chemical castration), LDR Brachytherapy and blind biopsies are what I consider Frankenstein medicine (strange, bizarre, brutal, twisted, degrading or a perverted nightmare) I would avoid all of them. Unfortunately, I was deceived and misguided into having a blind biopsy. I do not believe other conventional treatments like radiotherapy are good or great choices either, just not as bad and acceptable at that time for me. The choice I made was a 5 day SBRT radiotherapy. A 5 day SBRT also has numerous drawbacks and side effects, about the same as a 9 week EBRT radiotherapy. I also had no advanced treatment options available to me. As I have stated above, If I could do it over again I would also consider either no PSA testing and treatment or traveling for advanced treatments from a competent provider if practical and available. I am now sure I made the wrong choice by receiving a conventional treatment. With prostate cancer, the testing or treatment is often worse then the disease. I am not implying anyone should make the same choices as I did. I am only giving the motives for my decisions. I was also the victim of profit motivated and substandard providers. 3 years later I now believe my prostate cancer testing and treatment accelerated my ageing (through the stress, testing, treatments and physically from the radiation). Per the new SBRT studies and my 4+3 Gleason score, I now have about a 50% chance of a treatment failure in 8 to 10 years. My previous long term cure rate was originally quoted at 85% before my treatment started. I am now sure prostate cancer testing and treatment is all smoke and mirrors. When asked: “How did you live so long?” A 99 year old woman stated “stay away from doctors and don’t take anything they prescribe for you”. With some exceptions I now believe this to be mostly true.

    Always protect yourself: It should not be up to a patient to protect himself or herself from harm from doctors, however the new standard in medical care now seems to be substandard. Do not let the sterile, friendly and professional environment of a doctor’s office detour you from protecting yourself from overtreatment or any unnecessary life changing tests and treatments. If you are concerned about misuse or privacy issues, refuse to fill out EPIC questioners and limit the information given to relevant information only. If you have a high PSA or prostate cancer, educate yourself. A patient should be extremely skeptical if exaggerated claims are made about minimal long term side effects from conventional treatments or blind biopsies. Bring someone educated or astute with you to your consultations and appointments. Insist on Genomic testing if you have prostate cancer. Avoid doctors that are mostly profit motivated. Do not submit to a prostate blind biopsy if other options are available. Get a second or third opinion if you are being offered treatment with low risk prostate cancer. Learn about all your treatment options, testing and side effects. Verify everything you are told. Under the HIPAA law you are entitle to a copy of all your medical records and bills. Always ask the name of the person assisting you. If they refuse the request for a name leave immediately (you may or may not be in extreme danger). Be very cautious if you are ever refused a copy of your records; demand a copy of your records and a reason for any denial and seek other advice. Get a copy and keep a file of your test results, biopsy report-Gleason score, PSA, MRI report, treatment plan, bills, insurance payouts, etc. Carefully monitor your PSA. Expect a temporary increase (for weeks or months) in PSA after some procedures. Verify the accuracy of paperwork. If treatment is necessary talk to your doctor in advance about side effect management, chronic fatigue, ED, etc. Doctors that provide treatments often have computer software to predict the outcome using test results and different treatment options. Ask to see your computer predicted cure rate outcome with your treatment options if available. This may give you some insight to your options, cure rate and also to avoid overtreatment. Always ask what is the “biochemical recurrence” (AKA rising PSA or treatment failure) rate for well beyond 5 years. For help contact a good prostate cancer support group without a conflict of interest. A wise man once told me “you need to learn to think like your doctors and nurses (or other providers)”. What are the motives of your providers, place them in order that you observe at your doctors office: to profit, to cure, to get high on the backroom drug supply, to do less work, to take an extra long lunch or get off work early, to help people, to cover up their incompetents, etc? This exercise may give you some insight into the care you may receive.

    A medical holocaust: Multiple studies have verified more deaths caused from prostate cancer testing and treatment then from prostate cancer itself. Medical mistakes are the third leading cause of deaths in the USA (over 251,000 deaths a year, over one million deaths in 4 years) more then suicide, firearms and motor vehicle accidents combined. These statistics do not include people that have had there lives destroyed by modern medicine or a reduction in QOL (quality of life).

    Strict guidelines for prostate cancer testing and treatment need to be created and enforced because of the extensive and documented abuses of prostate cancer patients: 1. Blind biopsies should be banned. 2. Strict standards and gridlines for testing and treatment need to be created. 3. Full mandatory industry standard disclosure forms need to be created for tests and treatment to include realistic risk factor disclosure. 4. Newer testing and treatments need to be created and approved. 5. Dignity, privacy and confidentiality need to be standardized and enforced in addition to the HIPAA laws. 6. Aftercare needs to be available, standardized and regulated. 7. The cost for drugs needs to be regulated to end financial exploitation by drug companies. 8. Medical workers should be identifiable and be required to wear name tags with first, last names and job title. 9. A new standard “Ethical Code of Conduct” needs to be created and enforced to end patient exploitation and abuse. 10. Genomic or genetic testing should be required before any patient is sent for treatment, to avoid overtreatment and insure the correct treatment. 11. A standardized education book or PDF document needs to be created and distributed to all high PSA and prostate cancer patients.

    It is unlikely any of the above recommendations will be implemented unless prostate cancer affected a larger percent of the population or enough prominent people are affected. Prostate cancer patients must protect themselves as the only alternative!

    Clarification: The above text may probably anger and upset some people for various reasons. The intent of this document is not to imply all doctors are dishonest or to condemn all medical providers. The intent is to educate men and prostate cancer patients of the consequences and dangers that may await them so they can take appropriate action and to inform patients of real world, typical or worst case scenarios. I have also tried to include most scenarios a prostate cancer patient should be cautious of. Would some health care providers harm a patient for profit or by accident or some other reason? Yes, absolutely! We just don’t know who or what percent would. Shockingly, for me it was will over 40% (probably 50% to 60%) that intended to do me some form of harm or provided substandard care as explained in my story. . I have also had excellent doctors and nurses, however this may not protect you from the bad ones. Are some other doctors and nurses exceptional? Yes! Differences in opinion, variations in semantics do not invalidate this document or its intent. The information in this document is a sum of my experience, other patient’s experiences and hundreds of videos, documents, books, conversations, clinical trial, blogs, studies, articles, etc.

    Disclaimer: I have no conflict of interest. I do not represent any support group or other organizations. I am not a doctor. I do not prevent, treat, diagnose, cure or advise on medical matters. The information above is for educational purposes only. If you need treatment or medical advice, consult a competent and trustworthy medical doctor.

    Anyone may copy, email or distribute this document without changing or modifying it.

    I have been extensively criticized by some for creating this document and its blunt content. In order to insure my privacy and avoid any potential reprisals, further abuse or exploitation, I will remain Anonymous.

    • Dave Howell

      Great work in your article. Bless you for telling the truth. Had I known before I went through surgery what life would be like now I would have taken my chances on not having treatment. Even at 58 years old I would have rather had a few quality years than the post surgery results of incontinance ED and depression for the past 2 years. Again thanks

  11. My husband was dx with a highly aggressive prostate tumor in his 50’s. The tumor had a Gleason Score of 8, and the cells were highly undefererentiated, thus they did not PSA to any great degree. Surgery was ruled out because the cancer had broken through capsule, and invaded part of bladder and urethra. He was started on Lupron and Casodex followed up by 42 treatments of external beam radiation. He tolerated everything very well. We would go once a year to Sloan-Kettering for blood work, DRE. Once a year we would see his radiologist for DRE and review. Every four months we would go for his blood work and Lupron shot, and every other visit we would meet with his oncologist. My husband would have bone density testing done every two years. Our life was going along well; my husband is 16 years out from his initial diagnosis. Then we noticed subtle changes at the medical center: personnel changes; staff no longer there. Finally, our oncologist, with whom we have a great relationship, told us he was now only seeing breast cancer patients. So he recommended another doctor who supposedly was a prostate specialist. We met with the new Dr. who told us my husband should be off the Lupron. No collaboration— no personality—no rapport with us. Our regular oncologist said if another expert would say some patients, if they choose to, could stay on Lupron for their life, which we were told would/should be the case with my husband, he would support our desire to stay on Lupron. We are very anxious now because, after all these years, this new guy wants to upset our path of survival. Please tell us what we can do, and your opinion.

  12. mike heit

    m 71, gleason score 8-10, psa tests are 14 and 16, mri indicates cancer confined to prostrate but bone scan/psa results not in yet. Treated with hormone therapy last week.

    I am a very fit cyclist and recorded my cardo/weight lifting benchmarks just prior to injections to see if my fitness changes as my treatments go thought the course- be it surgery or radiation.

    Mike Heit, victoria bc dec. 31/2016

    mike@mikeheit.com

  13. Roger Flaherty

    Correction lupron shots
    Roger

  14. Roger Flaherty

    Can I take pawpaw herb with Lipton shots

  15. Kelly

    I am 54 years old and had my prostate removed in late December 2016. PSA was 200 and went up to 300 within a short time. Followed up the surgery I had 40 separate days of radiation to make sure they got everything. Additionally, I received Lupron shot before surgery and six months later. I am tired of legs and joints and tendons aching. Also, the hot flashes are awful. Are these Lupron side effects going the end when I stop doing Lupron? Current PSA is below .01 which is good. So I am questioning the value of continuing Lupron given the side effects, especially since the cancer seems to become resistant to Lupron. What else could I take that will not have the side effects? I appreciate any thoughts people might have.

  16. Roger

    I had prostate removed in 2004. Recurrence in late 2005 resulting in 37 radiation treatments. Remission. Recurrence in 2010, PSA tripling and ct scan showed 14 nodules in lungs. Started Lupron and knocked PSA down rapidly. Most recent CT scan shows only 4 stable nodules in lungs and currently PSA of less than .01. Get my Lupron injection every 3 months and I find great peace in prayer. I think it works really well with my treatment. God Bless you all!

  17. ghazaleh

    Hi,
    I am ghazaleh to write this message to you about my father problem. Actually my father has prostate cancer which me metastasize to his bones and his lymph. He had prostate cancer from 15 years ago, and he had two time surgery. In the last surgery which was about 6 years ago his Dr was cleaned all his Testicle.After that his cancer metastasis to his bones but his dr controlled this by Zometa injection. From 2 years ago he used Flonatax tablet every day and was injected Diferelin every 3 mounts and his PSA was about 6 and sometimes was 5. Unfortunately, 5 mounts ago his PSA was about 7 and the next mounts became 8. I talked with his Dr and he told me its better to take him for PET Skan. after this we found that his cancer metastatic to his lymph. In this time his dr recommended some injection which name is Decapeptid flutamide. For 5 mounts my father used this injection and after that his PSA result was 20. His Dr told us this treatment is not useful for my father and for one month he should not use anything and after that your father should be go for Chemotherapy. But I want to know is it another better treatment for my father now? If there is, I really would like to take my father to your clinic for his treatment.

    Thank you for your attention.
    Ghazaleh

  18. Sangita Banga

    My father (age 72) was diagnosed with advanced prostate cancer in November 2014 with Gleason number 8 and PSA around 95. His bone scan showed the metastasis to bones, ribs and pelvic. He was treated immediately for hie testicle removal and was put on few drugs and one injection to be given once a month. Till june 2016 his PSA was under control but is increasing now and has increased from 1.8 to 8 in last 4 months. What is the further course of treatment in this case. please suggest. Kindly send suggestions on my mail.

  19. Neelesh

    Hi my grandfather was diagnosed of prostate cancer 10 years backin year 2005 and doctors decided to remove testes. Psa came to normal range gradually when it increased he was suggested to take calutide 50 which kept it in control. However,now after 10 years of the surgery calutide 50 failed to control the psa. He was asked to start Honvan. But honvan is also not able to reduce the PSA. Currently his psa has reached 63 with regional lymphnodal spread and retroperitonel lymphnodal metastases. He also has an enlarged prostate. Please suggest what options do we have?

  20. Abed Jaatoul. Canadian live in beyrout

    Your article is amazing help to patients that has been in 5 different story dr.clinics without receiving so many clear view of what to expect to make them aware……thank you …I am Gleason 4-5 and running this road against cancer still not decided taking zoladex and casodex hoping …better days to come ….god bless you

  21. Robert Bethe

    I was diagnosed with prostate cancer in 2000 when I was 51 years old. My psa was 37.4 and had a gleason score of 7. I had surgery and it had spread to one lymph node. My psa started to rise after surgery so I was put on Lupron in Oct.2000. At that time I was told I had 2 to 5 years to live. That was 16 years ago and I am still on it. In 2008 my psa started to rise slowly and my last psa count was 1.7 4 months ago. In 2012 I had a ct scan and a bone scan and both were negative. Naturally I still worry every time I have a psa test. Do I still have to worry after all this time?

  22. Sohan Lal Bhatoa INDIA

    Dear friends,
    Before my retirement from Govt.service,I was diagnosed ca prostate, my psa was 7.5 at that time.During various tests at the Hospital,one report said I am at initial stage, the second report of the same hospital said I am at last stage. My treating Doctor was astonished to see the difference to which I reacted with a smiling face to my Doctor that I am least worried,you Doctor,please go for may surgical operation, lets it will be first stage or last stage of cancer,it will not effect my age,which is already decided by my SatguruGod, I am fully satisfied.The Death is not related only with this disease,there are so many other reasons set out by God other than a disease. I am not afraid of it,my Doctor was happy to see my faith in GodsWill.. So I was surgical operated and set on harmonal therapy with bicalutamide 150mg by my Doctor with my psa 0.123, but after one year when I noted my breast enlargement, without consulting my Doctor, I start using Bical 50mg only for 4 years without knowledge of my Doctor with the result gradually my psa increased due to my own mistake, again I started Bical 150 and my psa now stands to 0.691 variation bothside.My doctor also got suspicious about gradually increasing my psa, and he then prescribed psa checks after 3 months than 6 months. Lets see further developments Alls HIS WILL.So,I have suggestions to use prescribed dosages by the Doctor regularly rather decreasing it by own due to side effects,we are to bear these as per our past Karmas. THANKS.

  23. Tomas P Reyes

    I have been diagnosed with prostate cancer, stage 1 with a Gleason score of 8, psa of 10. I have no symptoms before my biopsy, but after the biopsy, I go to the bathroom to urinate more often, about 5-6x. My cat and whole body scan were negative.

    After going thru all the possible options, I note that the after side effects were so numerous that it makes sense to me to decide on “watchful waiting.” I am 79 years old, and I will take my chances to do nothing. I will just eliminate “bad foods” like dairy, sugar, red and processed/fast food, coffee; and eat more raw veggies and fruits, make my body more alkaline and develop stronger immune cells, less stress and just live my life to the fullest as long as I can. This, I believe, is the best weapon against cancer.

  24. sherry kotz

    My husband was diagnosed with stage4 prostate cancer. It spread to his pelvic bone. On hormone therapy for nearly a year. But in January of this year cancer doc decided to try chemo. BIG MISTAKE!! My husband got one round of chemo and ended up in ICU with severe brain swelling and nearly lost his life. Cancer doc couldn”t come up with any other explanation but bad reaction to chemo.Like 1 in a million. With that being said…It has been a down hill battle ever since. He now has an autoimmune disease called NMO.Again I in 100 thousand. You tell me what caused this. Doctors are saying they have no answer but don’t believe it was from the chemo.One day after administering chemo he nearly died. Before this he was living somewhat of a normal life.Now he can barely walk,falls,losing his vision,confused,depressed,headaches,brain biopsy that shows lessions that go along with the disease. Could go on. My heart is broken. Yet his psa is normal. At least one thing is good. Prayers to all of you. His case is not the norm.

  25. Richard Henderson

    I have had metastatic prostate cancer since in 2010, when my radiation/seed treatment in 2005 failed (after five years). Since 2010 I have used Lupron and Casodex very intermittently (two to six months at a time). This treatment immediately drives PSA and Testosterone to near zero. But I have suffered serious depression and anxiety since 2010. And I have tried at least ten of the traditional antidepressants with no help at all. My 24/7 hot flashing during Lupron periods are incidental compared to to the months of depression. I have discovered on my own that my only relief comes from hydrocodone, with careful doctor and wife supervision. I do not know what I would have done if I had not discovered the hydrocodone symptom relief.

    I am currently two months after a second 7.5 mg Lupron injection and and really suffering emotionally. With all my experience, I should know this but how long will the side effects of my last 7.5 mg Lupron last? I do not think they ever entirely go away but at some point (I hope very soon) my depression will become more manageable. What is the half life or side effect duration of Lupron when taken in one month (7.5 mg) injections?

    I might add, that hormone therapy remains very effective in immediately reducing my testosterone and PSA to an effective zero , but over the past six years, my PSA return rate has increased to where my PSA no doubles every month during months of no hormone treatment.

  26. Pierre Drouin

    My psa level was 4 in 2012, 5.6, in 2014 I got a positive biopsy that got infected. The antibiotics probably lowered the psa to 4.6 in 2015, some gleason 3+3, some 3+4.I still waited.

    In 2016 psa was up to 5,8 and another biopsy confirmed it was time for a treatment. Hormone therapy for 18 months,22 external beam radiation treatments and brachytherapy in one treatement.The doctor says theres a 15 year survival rate of 93%.

    I’m 63 and have cut dairy products,coffee,beer (most of the time) and I exercise 30 minutes a day and attend a laughter club.
    The hormone shots stop my libido so sex is of no interest(I have a different outlook)
    Watchful waiting was fine with me.

  27. Steve Vanne

    This is a superb article, thank you. I was a 58 year-old Stage 2B/Gleason 7 PC patient the first half of 2015 at a proton treatment center. The care was exceptional and, a year out of treatment, my prognosis is good and I am doing my part with nutrition and exercise. My treatment called for Lupron two months prior, the two months during proton treatment, and two months post-treatment. The proton treatment was painless and I had virtually no side-effects from this. The LHRH agonist, Lupron (leuprolide) triggered the following effects in me: 1) Total loss of libido and sexual function within the first month-persisting for several months post-treatment; 2) Shrinkage of testicles and penis; 3) Breast growth; 4) Brutal hot flashes (2-3 times per hour, 24/7), lasting for another four months post-treatment; 4) High liver reading (GGT spiked to double upper limit w/o alcohol intake–slowly recovered with aid of silymarin (milk thistle); 5) Cholesterol spiked 50% under same diet and daily exercise–slowly normalized; 6) Onset of anemia with careful diet and daily exercise–slowly normalized; 7) Vision impairment (slowly normalized much later); 8) Sudden onset of fatigue–as if I suddenly could not stay awake driving one more mile; 9) Moderate joint pain; 10) Much slower beard growth and loss of body hair; 11) Poor sleep at night and general lethargy during the day; 12) Weight gain (+15 pounds) to a weight I have never in my life come close to, and which has been very hard to lose. Six months after the last Lupron shot timed-out my T tested at 290, the low end of normal. In short, the drug performs its primary intended function, but the side-effects are pervasive and long-lasting. This appears to be the case as well with women who take this in treatment for endometriosis. I would recommend that anyone taking this type of drug have lab work done every three months, including RBC, liver and cholesterol checks. Preferable, the patient should be under the care of a good endocrinologist.

  28. D. Chandler

    My husband has prostate cancer. He has been on hormone therapy for almost a year. He is 78 years old. His Gleason Score was 8 when started on the treatment. He was told that the cells may have spread. So far his only side effect has been hot flashes. He works every day and complains some about back aches. What can we expect as far as pain? Is there something else he can do?

  29. toni

    Thank you for sharing some of your extensive knowledge with us on prostate cancer. My dad has been on hormone therapy for a year and a half. His PSA has shot up to 2500. Dad has had 2 bouts of radiotherapy the second was not effective. My sisters and I are bracing ourselves for a possible downward spiral. As is my mom I’m sure. Please can you give me some insight into the most probable and realistic outcome at this late stage based on your experience with other patients at this stage? He will be meeting with his consultant tomorrow regarding pain management. Kind regards. Toni

  30. Doug Munch

    Good information…fyi course of treatment
    age 64
    Original 3.?
    Gleason Score 8…cancer on one side of prostate
    Robotic surgery
    PSA after.. non detect
    Clean pathology report
    PSA 6 month approach .1
    PSA 1 yr 1.8
    Initalized hormone treat 1month prior to salvage radiation
    Salvage radiation for 37 days in conjunction with Lupron(4month injection)
    PSA one month after radiation .1 expecting to decline
    PSA due again in three weeks…
    Continued Hormone therapy? hopefully not but will if necessary.
    Go Gators…University of Fla Meds..North Florida Regional Hospital
    PSA

  31. Suman Majumder

    I am 82 years old. Due to my high PSA Level(i.e. 67.3 ),as per an urologist ,i did a prostate biopsy just 11 days back from now,it revealed i have adenocarcinoma as histology type .Now my urologist suggests me to have “Bicalutamide” tabs thrice a day in continuous basis.I also started to take that from yesterday .
    Please let me know that after how may days should I go for my PSA Level test once again?
    Please help me…..
    Thanks
    Suman Majumder

  32. jacques b poirier

    Me again! a 73 year old confused person.
    I have prostate cancer that has metastasized to lymph nodes with PSA over 100, So my uro put me on twin hormonal treatment (Lupron+Casodex) No side effects to write home about. PSA fell to 2 ng – So I took a 2 month holiday and it shot back to 5.7. Reading on the topic, I learned for the first time that one should not have sex 3 days ahead of PSA reading. I was told one day…and in truth I had sex 2 days ahead of the shot. I know that these things are not mathematical, however I’d like a longer drug holiday. I miss my hormones when losing short-term memory, going blank while doing a large project like the current one (a refugee town for 20,000 people in Canada ). Mostly it screws up my authority when dealing with other engineers and architects. By fall, I don’t mind returning full-time on the juice. BTW, last time I checked my testosterone serum was 357, most probably why the uro wanted me back on Lupron. Just fishing for advice on all this but also to suggest to you fine people to look for a fix for memory loss and sudden weaknesses. I’m seventy three and I was racing with my bike not so long ago. Now I’m afraid to use it. It’s not the sex I miss when deep into Lupron, but my bike and street hockey on rollerblade in Baja.

  33. jacques b poirier

    Jacques Poirier,
    73 and getting ready for a second round of 4-mths Lupron Depot + biatulamide (Casodex) daily, this after a break of 2 months with nothing at all. So I prepared this with 3 weeks of Casodex that had many side effects. I was traveling abroad and the pills ran out 3 days ago. I will be back home for the injection Friday. A week without Casodex, can this still disable the Lupron testosterone boost? BTW, the last month of the double treatment were great with their absence of side effects. Why is it that Casodex alone is so problematic this time? Memory loss, extreme weakness episodes, balance etc…

  34. Don Anders

    I have prostate cancer cells in one small area on one side of the prostate. My PSA was 1.83. My Gleason was a 4 plus 3 only in this one small area. All cancer confined to the prostate gland. I took Zoladex prior to my 44 treatments with radiation and have had a total of 3 injections with the doctor wanting me to do 5 more. After radiation my PSA is .01. I want to stop the Zoladex because of the side effects that I am experiencing. Would like to continue PSA testing to monitor any possible cancer return.My question is can I safely forego any additional Zoladex? My age is 83.

  35. Sylvia

    This is very informative! Thank you.
    My husband is 72, had a full colectomy in 2008 and now has j-pouch; PSA was 7.1 in 11/15 and now it is 8.65. Gleason is 3+4 with 31% of the biopsies being positive but it has not spread. Weight of prostate is 41 grams. MRI reveals the tumor is on one side and wait and watch is off the table. Surgery is very challenging because of j-pouch and adhesions; he had 3 incidents of obstructions that resulted in surgery. They are considering Lupron to shrink the tumor so they can create more space between the prostate and the tumor.
    Your thoughts?

  36. Vincent

    Thank God Almighty that lead me to Dr Al-Jamali in Dubai, My brother lungs cancer has been cured by Dr Al-Jamali. My brother has been through chemo 3 times, but this time his condition was getting worse that I was afraid it will kill him. When a friend of mine directed me to Dr Al-Jamali at: (drjamaliremedycenter@gmail.com ) where I could buy the medication from, because the Dr Al-Jamali has help cured his own Brain tumor and he strongly recommend that he would helped me with my brother cancer and cure it completely, I never believed the story, but today, with thanks giving in my heart, My brother lungs cancer has been cured within the Dr Al-Jamali hemp oil and I want you all to join hands in appreciation of the great work that is been done by Dr Mahmood Al-Jamali , he is the man that saved the life of my brother with hemp oil, thanks to him. for all those who have problem relating to cancer and other diseases should contact him through his emai(drjamaliremedycenter@gmail.com) I’ll keep thanking him because his God sent to save my family that was at the stage of collapsing all because of my brother cancer, if you have cancer is time to save your life thanks everyone again bye.

  37. Christian

    I have a gleason 5+4 adenocarcinoma occupying 25% of the prostate. It is multilobular but encapsulated. The capsule is apparently not breached on MRI and biopsy. I am 59 and there is no node or bone spread from bone scan. The biopsy was done about a month ago.

    I am waiting for a radical prostatectomy using robotics in 4 weeks. I have been put on bicalutamide in the meantime.

    This sounds a reasonable treatment. Do you agree?

  38. Tammy

    l want.my hormones to return back. can male who use firmagon injection after treatment father child? how long will the drug effects and depression last as to father child. or what alternative drugs required

  39. J. Cao

    My relative has local advanced prostate CA, spread out to bladder G score was 9. He is on Lupron. Doctor said, he only can have 9 month Lupron therapy, stopped Casodex. What he should to do. Radiation therapy? restart Casodex or prolonged Lupron therapy?

  40. Vishwajit Akolkat

    I want to know that prostate ca with bone metastases which Inj we prefer (Inj Xgeva or Inj Zometa) Please reply me on my email id Thanks

  41. Joseph Hessllink

    63 year old, 210 pound man in October 14 diagnosed prostate cancer 43 met lymph nodes – spine put on lupron every 6 months psa down to 1. Went to MD Anderson Nov 15 one lymph node 1 cm x 1 cm = prostate size 3cm 3cm decreased from nerve bundle now have added casodex until ert radiation for regional control. It is my hopes that I can get off of the hormones. I have stopped most sugars / starches / carbs. my physical health is good want to get it over while my immune system is strong.

  42. mktgguy82

    What happens when Hormone Therapy stops in controlling the prostate cancer and it advances to soft tissues and other parts of body. How dangerous it becomes as Hormonal Therapy helped in controlling the same for almost four years, but now doctor has to start with Chemotherapy.

    How worse this situation is and how successful chemo is to kill the cancer cells in the case of metastases.

  43. don carter

    I just finised 9 weeks of radiation treatment for prostate cancer. I’m 66 years old. I also had hormone therapy and it caused terrible almost debiliting hot flahes. Had I known they would have been this bad, I would have opted out.

  44. P. K. BARHAI

    In continuation with my above comment could any body guess the survival time and rate in these cases?

    • Sarmistha Ray

      Hello Mr.Barhai,

      My dad has suffering same problem like you. Dr said to do hormone therapy. But I need to educate myself on this before I go for him hormone therapy. Could you please tell me your plan of treatment.

      Thanks

      Sarmistha Ray
      pH : 001-480-3887338

  45. P. K. BARHAI

    I had PSA of 48.6 on 22nd April, 2015 and Biopsy showed Adenocarcinoma of Prostate with possible metastasis in 4 sites. Orchiectomy was done on 11th May, 2015. I was given 50mg Bicalutamie twice. My PSA after 6 weeks was 1.7. Is right as many doctors say it should be less than 1? After 3 months it was 2.14 and after 4 months it was 3.51 and after 5 moths it is 4.54. I had my testosterone tested it 54. I am asked to increase the dose of Bicalutamide to 3 time with 50mg each time. Will it help?

    Could any body help how to go for my treatment? Likely affected sites are spinous process of right scapula, right side of body of D4 vertebra-likely degenerative osteophyte, right ala of sacrum, and left acetabulum. comment: possibility underlying sketetal matastases should be consisered.

    I have no other health problem other than some pain in the hips.
    Any comment may be sent to my email.

  46. Judy chetta

    my friend Leo, and I have been together for 7years, he is a cancer survivalist of nonhodgkins lymphoma went into remission for 2years, then it went to throat cancer and was on chemo for 6mo. And got rid of it, was good for 2 years , now he has prostate metastasis to spine, had medical cement into L12 for compound fractures. He has camcerous lesions, in 3&4 ribs, right clavicle. He has so much pain, it feels like everywhere sometimes, he is on Firmagon injections into belly fat area of stomach. The pain is really doing a number on him making him weak and tired. He feels best when laying down all the time. He suffers to much. He goes to Dr. Office once a mo. For shot of firmagon. He has severe hot flashes too. And cold sweats. Doesn’t eat much either. The Dr. Will not say how long he has to live. We try to make every day a good day if possible. And take one hour and one day at a time. I scheduled to drive to Issaquah Wa, to stay in a beautiful tree house of Pete Nelson and it is on the river view side. I know the car trip will be difficult, but we can rest a lot on the way. We need to focus on gods nature and enjoy what life has to give us.

  47. Joseph Binkley

    Ihad radiation for prostate cancer ,finish 13 month ago, also harmone shots ever 6 month for two years. My urology Dr wants to stop the shots. My psa is 00.1 do you agree I am 74 years old. Thanks.

  48. Huzaifa Younus

    Dear Doctor,

    My father was diagnosed with Satge 4 cancer last year which was spread to liver and lympnodes and even in lungs. when biposy done it read that he had carcinoma of undefrintiated endocrine. and doctor gave him Liposomal cisplatin three weeks, but no effect on the cancer. then i asked doctore to if we could perform PSA on the tissue sample to see if he has prostrate. and the result came positive. we started hormone therapy with Lectrum 7.5mg every two months. Dad received four injections and last month we did surgery and removed his testicals, now doctors has stopped hormone therapy. my dad is well now the cancer has shrinked well and his PSA has come dowe to 57 for 63. Now please can you tell me what will be the next line of treatment how will the remaining cancer will be treated.

    • Abubakar

      How is Ur father now ? from where U r getting treatment ??? His PSA now ??? if U can contact me on my whtsapp 0301 4539738 plzzz cntct I wanna talk
      ThnkU ….

  49. Jeff Knighton

    I was found to have prostate cancer over 2 years ago, with cells also in 3 lymph nodes. The prostate was removed, I underwent 52 radiation treatments, and I have now concluded 2 years of Lupron therapy. For over 18 months my PSA has varied between 0.0 and 0.13. After about six months of Lupron therapy, a scan showed no signs of cancer cells anywhere. Surprisingly, my Oncologist suggested “research” now believes a 3-year course of Lupron is supported in some cases. The suggestion was a shock, of course, and as weary and tired as my body is, and as frustrating as my short-term memory loss is, would your experience/research indicate another year of Lupron be appropriate in a case like mine? Thank you for your consideration.

    • Jen

      Look into raw apricot seeds take three a day do some research my husband is not going to continue with the hormone treatment anymore he is only 47 years old however quality of life is more important to him at this time so we have done some research and we are going this way check it out

  50. Vincent chellemi

    Dear dri had my prostate removed dec15 2014 before the operation all my cat bone scans negititive so I had the operation dr said operation complete success my psa before operation was 2 and my Gleason was 8 went for my 6 week check up he dshowed me my pathology everything benign and tumor encapsulated dr said great my psa came back 2 do not went wrong oncologist said some cell must have got out before operation I told her if that was true why would my pas only be 2 before operation the dr that did the operation won’t even talk to me for after he came to my room and said everything was great have a good life recieve a letter to see oncologist and her is where ism sick scared depressed so she you have cells that are circulating in your body sent me for ct and bone scan she said on my rib before operation the dr believed it was from a car accident I had last April and she said there are cells by c7 and some cells by hip it say possible mets do she put me on luperon andbicalutamide after one month my psa is now 0.23 she said great after one month I went back she gave me a three month shot of luperon and stay on bicalutmide till July dr try to help me I was told I was cured no iam incureable I asked about radiation she said you have no prostate I said how about the area that say me focal uptake she said no this is the treatment for you lets pray and hope your next psa is0.05 and stays there and the ,mets that are there are gone really don’t no what to do for I keep reading some rope go for radiation and Harmon theropy so iam really confused oh iam 63 with no other health problems before this except oh being hit by a car last April and surviing so when I told her I broke my ankle have screews broken framer and broken ribs see states what she see is mets but to another dr it would like post traumatic but now it reads increased sclerotic osseous chsnges an s1 corresponding to ill defined sclerosis and focal change left trochanter again reports say possible confused heart broken I need help are these tutors or cells for I just don’t no the dr is at Sloan Kettering so I asked her do some prle live ten years she said some people can live that long and some can live2 I walk around in a daze for on my pathology my lumped were clear margin clear I don’t no what stage iam in I want another dr opinion for if there is a way to slow this down I want to no gave you as much info as I could I pray I have years ahead have children to take care of please email me back love a dr with compaction be looking for you on my email vjsinger3@ aol. Com thank you God bless wish I had you for dr vincent

  51. sham sunder

    very much pleased to gain this higher level knowlege about cancer..want to know after injecting [ELIGARD]and takin oral dose of bicalutamide 50mg once in a day, …RESULS:: BOLOOD SUGAR SHOOTEDDD UP 290 FASTING AND 390 .PLEASE GUIDE me substitute of becalutamide, or sugar controlling drug…….in addition frequent urination is also a side effect………..well wisher shamsunder,B-549,RANJIT AVENUE,,P.O.AMRITSAR,

  52. Shelley

    Dear Dr. Garnick,

    Thank you for such an informative site and here is a long shot at seeking your advice…

    My father was diagnosed with metastatic prostrate cancer after going to the doctors with back ache 5 weeks ago. Scans indicated that the cancer has spread to the bones in his spines and ribs but not his lungs. He has been put on Bicalutamide 150mg only and had his first consultation with the specialist yesterday who took a blood sample and told him his PSA is 2,215. The specialist told him to come back in 4 weeks for a biopsy and to move him on to an injection hormone therapy. Today my dad called the doctor who said that his blood test revealed that his PSA is now 703 after only 5 weeks on Bicalutamide.

    I would love to hear your opinion as to the most suitable treatment for someone in a similar case as my dad, i.e. what injection would be best? should he remain on the bicalutamide in combination with an injection. Will the injection be an LHRH agonist and do you think this would be a good option for him in your opinion? Do you think he should try for clinical trials now or leave for later and if so, what would be good options for a case like this?

    I hope you have the time to respond and if you do, thank you and if not, thank you for all of your information, it has been useful in my understanding…my dad won’t look at a thing so I am trying to get my head around it!!

  53. Richard Williams

    I have prostate cancer. In 2010 I was treated with Brachytherapy. Afterword my PSA dropped to 1.5. Today my PSA is 5.3. My doctor said best treatment for me is hormone therapy. I have heart disease and have 3 stents in my heart. I had a heart attack in 1995 and I really don’t want another one. Is there one drug or treatment that you would recommend? Would the hormones effect the blood thinners I am taking?

    • Dear Doctor my father is aged 75 and is recently been diagnosed with prostate cancer and undergoes medical treatment at a local hospital, as a family we were told that his cancer has reached uncurable stage, will horme therapy help him ?

  54. FARHAT FERCHIOU

    Dear Doctor,

    I have been recently ( 12/2014) diagnosed with “locally advanced Pca” ( T3N2M0, Bone Scan, Abdominal CT Scan, Chest Xr all clear). My doctor at MDAnderson started treatment with 1 SC injection of Degarelix(240mg)for 1rst month, then I am now on Lupron ( 1 Im inj/mo) in order to shrink the cancer and as a neo adjuvant therapy before surgery or Radiation Therapy. Do you agree with such a treatment? Is it a safe effective management?.Please be kind to give feed back.
    Best rgds,

    Farhat Ferchiou

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