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Is US making less progress than other countries in HT as a prime treatment of Prostate cancer?

VascodaGama's picture
VascodaGama
Posts: 1621
Joined: Nov 2010

Japan says yes.

According to a citation from a detailed Japanese study published in ASCO’s Journal of Clinical Oncology, patients in Japan are more often treated with hormonal therapy than in the USA, and the reasons behind are due to doctor’s “choice” rather than in view of the characteristics of the patient’s disease. The study indicates high rates of Progression-free survival in clinical stage II, III and IV patients treated with HT. This is an interesting finding for those diagnosed with Localized PCa, who may include HT as their prime treatment, instead of a radical approach.

Here is part of the document citations. For the full text and study visit this site;
http://jjco.oxfordjournals.org/content/37/10/775.full.pdf+html

“…The role played by endocrine therapy for localized prostate cancer in Japan differs markedly from that in Europe and the United States. According to the prostate registry operated by JUA (11), which included 4529 registered patients who were diagnosed with prostate cancer in 2000, ADT was selected as an initial treatment for 45.9% of the 2671 patients with stage T1c-T3N0M0 prostate cancer. In the United States, the number of cases with localized prostate cancer treated with ADT has also been increasing, according to the CaPSURE report and the SEER data, but the number in the United States is less than half of that in Japan.
A recent analysis made by CaPSURE yielded a noteworthy finding as to the background variables of patients for whom ADT was selected (12). In the existing guidelines pertaining to the treatment of localized prostate cancer, especially in the United States, there is hardly any statement that recommends the use of ADT. This may be explained by the following factors:
(1)ADT is viewed only as a means of conservative treatment of advanced cancer; and
(2)there is concern over androgen deprivation syndrome appearing as an adverse reaction to ADT.

In Europe and the United States, few high-quality clinical studies have been carried out on ADT used for the treatment of localized prostate cancer, and clinical evidence is absent. Then, why has the use of ADT for the treatment of localized prostate cancer been increasing in the United States in recent years? Shahinian et al. viewed selection of ADT as a Wennberg’s practice style hypothesis and explained that it is primarily dependent on the view of individual urologists.
A Wennberg’s hypothesis is that, when there is uncertainty about the optimal treatment course, use of medical interventions is determined by the characteristics of the physician. In other words, the treatment provided depends more on the physician who is treating the patient than on specific characteristics of the patient’s disease.
However, the analysis made by Kawakami et al., cited above, involved a comparison between radical therapy and palliative therapy and suggested that the selection of ADT was based on the relatively evident features of patient’s background and the results of recent clinical studies demonstrating the efficacy of this therapy, rather than being dependent on the personal preference of individual urologists. We expect that discussions over the involvement of ADT in the treatment of localized prostate cancer will increase in the future.”

The best to my comrades and newbies.
VGama

Kongo's picture
Kongo
Posts: 1167
Joined: Mar 2010

Vasco, this is an interesting study from several aspects and I'm sure from your experience living in Japan that you have greater insights into potential cultural and psychological factors that affect the course of treatment choices. Similar to "The China Study" this study looks at a homogenous population so the results tends to be self discriminating in screening potential other factors affecting treatment choices such as socio-economic class, race, access to health care, and so forth.

As you may know, in the United States one of the major influcences of treatment choices is whether or not it is covered by individual insurance companies or Medicare. Several years ago Medicare significantly reduced the amount of reimbursement doctors received for administering ADT and not surprisingly, the overall use of HT in the routine treatment of prostate cancer dropped significantly.

What this study does not address is the potential negative side effects of HT. While many men have relatively minor side effects and rebound quickly after treatment is discontinued many others are permanently affected with a loss of sexual potency, hot flashes, growth of the breasts, and even an increased risk for breast cancer, among others. Also, the study did not apparently address variances in HT protocols such as varying time on the drugs, intermittent use, and so forth.

Although I have visited Japan (and other Oriental countries frequently) I would not consider myself knowledgable enough to speculate on the psychological make up of the group of Japanese men who apparently followed their doctor's orders and did not choose other therapies. I don't know whether this is because of the stereotypical Western view that the Japanese tend to follow the directions of authority figures or whether this treatment is a nuance of the Japanese health care system, or even some other factor. Your background may provide a better perspective and I would be interested in what your thoughts are.

From my own personal point of view I am grateful for the wide variety of choices we have to treat prostate cancer in the United States although the plethora of choices is difficult for most laymen to sort out thoroughly enough to make truly informed decisons.

I studied the potential use of HT in conjunction with other treatment on the theory that since prostate cancer cells typically have a point of mitosis at 380 days (give or take), removing testosterone for say 18 month to 24 months improves the liklihood that another primary treatment such as surgery or radiation would be more effective. Although I still think that there is some merit to that course, my doctors persuaded me that with my relatively low risk diagnosis (PSA = 4.3, Gleason 3+3=6, 15% invovlement in one of 12 cores, and staged at T1c with a normal DRE and no history of PCa, that HT was unnecessary and potential benefits did not appreciably increase the efficacy of my primary course of treatment (CyberKnife Radiation).

I believe that most urologists and cancer specialists do not consider HT to be curative. It can certainly be pallative and most likely improves the efficacy of other treatments as studies have shown in the use of HT in conjunction with IMRT for intermediate to advanced PCa but it is not curative. In other words, in the absence of any other treatment, discontinuing HT and allowing testosterone to once again feed PCa cells, the cancer will begin growing again.

Best,

K

VascodaGama's picture
VascodaGama
Posts: 1621
Joined: Nov 2010

Kongo,

I knew that medical treatment in USA is very expensive (two times fold that of Japan) but never thought about the negative impact in the health care. I am surprised to learn about those cuts in the reimbursement of doctors handling ADT.
The above study was done within the Japanese Health Care system which is quite homogenous too. Every single citizen is obliged to be part of the social security (including foreigners with the “Resident” status) so that nobody worries about expenses. The impression that Japanese tend to follow “orders” is not in the sense as we westerns are used to think about. That discipline is part of Japanese culture with a meaning of “respect to the other and superiors”. (Sometimes not so respectful) Seniority is important and so it is expertise and status recognized in their society. The ones that lose respect, lose a status and commit suicide. There is always a sense in trusting a superior’s opinion because “fool play” is not expected to coexist. Everybody is thought to be doing their best.

Patients have access to any specialist or institution at its own choice (we pay 20% of small bills and there is a conservative maximum limit to be paid in costly treatments, RP, RT) and the same goes to the type of preferred treatment, but many just follow the suggestion of their doctor.
The best surgeons, radiologists or oncologists work usually in hospitals and universities, not in private clinics, and they do not need to compete for the business. They tend to show the best performance so that they stand out from the “crowd”. Institutions are the ones getting the acclaimed prize.

My experience in Japan was that the system allows to transparency. I was requested by my doctor to educate myself in my problem and to choose the treatment. It was quite scare for me and my wife without any medical background (maybe that is the reason why the majority prefer to follow “orders”). I consulted three other specialists in the different fields, in Japan and USA.

The study is credible and very detailed, and it is a good source for information. The protocol is standard as continuous with a variation in the type of hormonal; Single or Combined, breakdown by age, Gleason, stage, PSA, etc. The importance is that it “breaks” the myth that hormonal will stop being effective in short periods of administration, no matter what choice of modality are used. (LHRH agonist alone or together with antiagonist, or simple castration, etc.)

I think that the opportunity of HT as a prime treatment exists and that it can be successful in containing the cancer during many years before one commits to a radical approach. There are a big number of guys doing well over ten years. The side effects exist but they usually stop once withdrawal from the drugs (the intermittent approach), whether in radical approaches they may become permanent, if any. I am new in ADT so do not become an example to take, but so far nothing in particular grave as happen.
Newbies should know about this possibility when deciding in the treatment of their choice, knowing that HT is just a palliative form of controlling the cancer, maybe above AS. Radical treatments give a chance for cure.

Where is the “regular” Martini?
As the Japanese say “Kanpai” (cheers)

VGama

ob66
Posts: 218
Joined: Apr 2010

Both of you speak of HT, based on Japanese experience, with regards to an alternative to either surgery or radiation. And I know that is what the study addresses. But why not continue HT for extended periods of time after either RT or surgery? Would not the same logic prevail? Do we know if it works, or doesn't in prolonging life? You know hot flashes would not be the worst thing were one to live longer. Might even put up with breast enlargement. Flip as I am here, has it been looked into?

VascodaGama's picture
VascodaGama
Posts: 1621
Joined: Nov 2010

ob66

I never thought that HT in USA was regarded more as a “side” treatment than “prime”. In Europe and it seems that in Japan too, hormonal drugs are recommended on the same level as a radical treatment. Surely it does not cure but cancer of the prostate is also seen as a long lasting disease with more patients dying with it than from it, if not attended.
Why should the medical community “combat” indolent cases?

Hormonal therapy gives a chance of avoiding major radical treatments in older patients, but it also has proven to be equally effective in handling cases of younger patients. Cure is not considered but control on the progress.
Side effects are inevitable in all types of treatment. Nevertheless, some patients express worse cases from radical treatments than from HT. The protocol of choice from the 90th was/is a radical for cure and then HT for recurrence. However, we read more nowadays in this century that the protocol tend to be a palliative followed by a radical, if needed.

Still a word on the Japan’s theme, Japanese like to follow rules which have been established in reliable basic principles. This gives them a sort of “peace of mind” in life as guide lines for what is proper to do in their society. They are “unique” (generalists) more than individualists which makes people to see them as “robots”. Rarely do you see Japanese advocating his own thoughts.
In the medical world the same is seen. Doctors treat patients based in established medical practice guide lines than on the basis of their individual believes. I would say that the Japanese medical practice is typical of being delayed six month to the western when a new practice or drug is put into play.
The citation of Kawakami et al in the above post expresses exactly his cultural behaviour. He refers to Wennberg’s hypothesis as physician individualism in deciding on a treatment rather than a “standard/robotic” way based on the “…specific characteristics of the patient’s disease”.

I wish you a continuous good progress on your survival.
VGama

ob66
Posts: 218
Joined: Apr 2010

Thanks for the response VdG....HT, in America, to my knowledge, has never been a curative approach. It is not a "side" or "prime" treatment. It is a "carryover" (for lack of a better word---maybe, "staller"). It postpones. It gives those with PCa a short period of vacation, even though not a cure; a postponement of the inevitable, if you will. And then in the late stages, again a staller of the inevitable. I was just wondering why, if one were not adversely effected by the side effects, of say lupron, one could not stay on it forever (an intellectual reach, I admit) if it were working. If one were to quietly pass on while lupron it may be an easier demise. I guess I ask, has this been addressed? Seems logical, but all things logical are not necessarily workable. What say thee?

VascodaGama's picture
VascodaGama
Posts: 1621
Joined: Nov 2010

“Staller” is a new word to me. Couldn’t find it on my Portuguese dictionary.

Ob66, I agree with your comment that HT can be taken as a “staller”. However I do not know if you are aware of the abstracts published at PubMed with regards to the latest findings on hormonal treatment and their statistics. There are studies indicating the success of HT in long free survival periods on the same basis of other treatments.
My opinion is different of yours in regards of seeing HT as a “postponement of the inevitable” (recurrence or death?) or as a means for a “quietly pass on”.
Famous leading oncologists in prostate cancer cases for many years say that HT can cure as well.

When told of the “cancer” I was quite scaried and thought that I have been “flagged” for death. Later I reflected that death can be assumed only if one sees it growing and do nothing to hold it, (any kind of treatment is good). I see prostate cancer as a chronic disease that if caught earlier it can be cured or controlled for long periods of time, until we die from other causes.

We are aware that Cancer has no practical cure. The treatments available are not perfect enough to warrant an effective way of freedom from the disease and freedom from their side effects. To my knowledge there are four approaches to deal with the problem, all at the same level;
(1) By “cutting”-out a portion of our flesh expecting to have the whole cancer within it.
(2) By “burning” the cancer inside us expecting to get it whole in the target line of the rays.
(3) By “manipulating” our body enzymes and immune system expecting a natural or anti-bacterial type of kill.
(4) By “doing nothing” of the above.

If the radical approaches (1) and (2) are successful with no apparent recurrence, we may say that we are cured, otherwise we may call those approaches as “Stallers” too. And we read of the many cases of recurrences within the 10 years post treatment.

I think that Palliative treatments do not cure but they give a chance to “hold” the cancer and treat it as a chronic disease for long periods of time. It can be started as “prime” or after a radical. It all depends of one’s preferences and to which level we are prepared in accepting the side effects. Radical treatments may cause worse and permanent conditions, which take many guys to accept their “karma” and just do nothing.

RP, RT, HT or AS (WW) are not perfect; they give us a chance to be heroes of ourselves in the battle against cancer until “The end of our Existence”.

The best to your case,
VGama

ob66
Posts: 218
Joined: Apr 2010

Thanks for your thoughtful response. I hope you knew I was stretching the word "stall" into "staller", as I suspect you did. My question still remains. Having had surgery, RT, and now on lupron for just under a year, and doing wonderfully, why would I not stay on it forever. That assumes I can live with the side effects. Why is it usually used for 1-2 years then stopped, and then re-used when PSA rises unfavorably. My simple logic prefers hot flashed to the prospect of death. And I feel 100% (less hot flashes) on lupron. Anyone have an answer to "Why not?" Thanks.

VascodaGama's picture
VascodaGama
Posts: 1621
Joined: Nov 2010

Ob66
We are the crew of the same boat. My case is similar to yours’. I had RP then RT and now I am on Eligard 6-month shot since Nov’2010.
Back in 2000 (my diagnosis event) I researched about HT, just when the first results were published regarding treatment’s performance used as a prime option. I read about the possibility of having HT on a “intermittent” modality, and read the story of a patient doing well.

My opinion on the logical behind the interruption of treatment after 1-2 years and its restart as you describe, was posted by myself in another forum in discussions with Jim Waldenfels, a famous PCa survivor on IADT3 for eleven years. My search come from the trial commented in the book named “A Primer on Prostate Cancer” (by Strum & Pogliano), explaining in detail with graphs the first trial on intermittent ADT approach. Dr. Stephen Strum et al were the founders of the trial and they wanted to verify an “idea” in having patients OFF the treatment so that they could enjoy the full benefits of ADT in contrast with radical treatments. Meaning that they would see their potency return and have normal sexual performance with “wet” orgasms.

One of the benefits of the intermittent modality is logically the relief of menopause symptoms, as you comment, in exchange for a less control on the cancer. No drug effect equals to a “freedom for progressing” of the cancer, which I think is the basis of your question. However, intermittent seems to be required as well to extend that period of a “staller”. This is a way for avoiding mutations of cancer cells and therefore avoiding its adaptation to drugs effects.

I have found that in the last ten years from studies and trials done at the anatomy of cells, many theories have risen regarding the way cancer cells react to certain chemicals (enzymes), and a consensus was initiated as a cause for the hormone refractory prostate cancer.
Researchers found that in a cell, random genetic mutations occur within its genetic code. This can be explained by the so called “behavioral adaptation” of cancer cells in surviving on low testosterone (under the effects of the drugs).In such “adaptation” the beneficial mutations are preserved because they aid survival. This is a process known as "natural selection" from Darwin’s theory. If low testosterone is persistent, the cell to survive will mutate to adapt to the new environment. However, by tricking the cells in providing their survival intermittently (now you have it / now you don’t), they may become dormant. The length of this period is the key to avoid mutations, and therefore failure of ADT.

Intermittent modality also permits to verifying if cancer cells have been killed for-good, meaning “vacations” from the HT drugs forever. There are cases where patients have been seven and eight years without drugs and still maintaining stable PSAs.

I hope this insight helps you in understanding the principle.
Please ask if you want more details.

Regards
VGama

ob66
Posts: 218
Joined: Apr 2010

VGama: Wow, thank you so much for such a well thought out, lengthy and informative response. You could not have broached my questions better. The information given is apreciated more than you will ever know. I thank you, and best to you, Bob

guards
Posts: 72
Joined: Aug 2010

IMHO I believe there is a necessity for counsulers at the early stages of decision in treatment. I know at my original age 63, and stage T1c, with my health history taken into consideration, HT should have been the primary care of choice for some period. They FINALLY found a sample in my biopsies after doing the procedure 4 or 5 times in a 3 year period. Of course the Uro wanted to cut and the radiation oncologist was eager to cure me with brachy. Having known a brachy survivor I chose that. And the cancer appears to be currently clear. However 1 year after the treatment my life as I knew it ceased to exist.
There is much more to consider than just the cure sometimes the choice of quality of remaining life is much more important. I was a fairly active individual ,golf, biking, travel etc. then came the problems with strictures and incontinance that have literally made me homebound as it is too embarrassing and messy to get very far from my own bathroom.So I have sat in my room ,gained 40-50 lbs and watched the diabeties I worked so hard to control again go rampant so that I had to go back on insulin ( I was off it for 3 years prior) Is this all someone elses fault NO but the depression of losing the life I had worked so hard to establish and the retirement I had worked my whole life for go down the tubes was too hard to deal with for me. So I spent 3 years going to a Uro that gave me the shoulder shrug and asked what are we gonna do-- HOW THE HELL DO I KNOW YOU ASS. I think with my history ,diabetes, two heart stents and a heart attack. A rod in my leg from a Motor cycle Accident that never healed correctly that cost me a years work while I became able to walk again, should have been an indicator that at 63 ,not old but certainly not young , a psa that had been climbing slowly for about 8 years perhaps some type of HT and an attempt to maintain a quality of life for 8 or 10 years before any life altering actions were taken. Perhaps some form of HT even before the biopsies were finally found. It is now 4 years later and I am getting my diabeties back under control some what. and I switched doctors last fall and now have an AUS800 installed that will be energized in 4 weeks and I pray will restore my life. now if I can get out of this chair again and resume some sort of natural life I will rejoice. I am writing this in the hope that others in similar age/ health situations I was in will consider less invasive procedures such as HT to at least attempt to control the disease. I have missed the last 3 years of my life and I hope the Aus lets me return to some form of normallacy.

i

VascodaGama's picture
VascodaGama
Posts: 1621
Joined: Nov 2010

Ob66
You are welcome. I like to know that I could be of help.
I do not know your case’s chronology but hope you continue this “fight” successfully.

VG

VascodaGama's picture
VascodaGama
Posts: 1621
Joined: Nov 2010

Guards,
I am sorry to hear about your drastic if not disastrous outcome from treatment. You are getting into control of the case now so will finally find that Quality of Life you and we so much aspire for. I love golf (I will be teeing off in one hour from now) and oil painting. Travelling is a great pleasure and I believe very much that you too could accompany me in all of that. Just do some planning with your family and friends and enjoy retirement as you wished 4 years ago.
There are many cases similar to yours. I think that all patients should be informed of the possible side effects from treatments and given detailed information on each one. HT is very well “set” and can be the best choice for many to handle their PCa case.
Thanks for the comments.

Hope the best to you.
VGama

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